Mentally Handicapped Patients (Surrey) (Hansard, 27 July 1981)

§ Mr. George Gardiner (Reigate)

I wish to raise the question of the funding for psychiatric and mentally handicapped patients within the responsibility of the Surrey area health authority—a matter that is causing considerable concern throughout the county, including my own Reigate constituency.

However, may I assure my hon. Friend that I do not do so in any carping spirit. Indeed, I believe that he and his departmental colleagues deserve to be commended for the manner in which they have sustained and strengthened our National Health Service generally during these times of acute economic difficulty. I note that last year he and his colleagues spent more in real terms on the National Health Service than was spent in any single year under the previous Administration, that the numbers on the waiting lists to enter hospital have been reduced by about 111,000, and that at least 1,000 more doctors and dentists are being employed. These are achievements in the Health Service as a whole of which he and his ministerial colleagues can feel justly proud.

It is in this context that anxiety is felt in Surrey about the resources available to maintain necessary standards of care for mentally ill and mentally handicapped patients in our hospitals—and of course in this International Year of Disabled People our interest and concern also embraces those who suffer mental disability. Our anxiety is also that his Department is not making full allowance for the unusual additional burden that the county of Surrey has to bear. The historical roots of that situation are already known to my hon. Friend. During the last century and the early decades of this century, it was public policy to build asylums, as they were then called, in the green fields beyond London. Surrey presented ideal sites for these institutions, and so today has come not only to have many within its boundaries, but to receive a great number of the patients in them from London and other counties.

At the time of our last Surrey area census in 1977, our major psychiatric hospitals—Brookwood, West Park and Netherne—took on average no fewer than 45 per cent. of their patients from outside the Surrey area. In the case of our major mental handicap hospitals—Botleys Park, The Manor, Royal Earlswood and Farmfield—the average was even higher at 69 per cent. There is no reason to think that those proportions have changed much since then. Indeed, the number of extra-territorial residents in those hospitals is expected to remain significantly high for the rest of this decade. It should also be stressed that most of those would be patients requiring almost continuous care. The issue that I am raising tonight is whether proper allowance is being made for that large number of patients from outside Surrey in those hospitals in calculating the funds to be made available to our area health authority—which, as I am sure my hon. Friend will agree, has been something of a pathfinder in identifying desirable levels of provision for mental illness and mental handicap.

Surrey's position was drawn starkly to the Secretary of State's attention in a letter from the chairman of the health authority, Dr. Ivan Clout, in March of this year. In it Dr. 959 Clout took the sums available under the resource allocation working party formula, and set them against first, the standards that apply in the top ten hospitals in the national league tables for such hospitals—to which I shall return in a minute—and secondly, the standards that derived from the Minister's own Departmental norms. From that exercise Dr. Clout concluded that if the present calculations continued to apply, standards in our mental illness and mental handicap hospitals would inevitably fall below those that my right hon. Friend's own Department insists should be reached, and to a point so low that patient care could sink to what he described as hazardous levels.

The reply sent to Dr. Clout at the end of April by the Minister for Health did not appear to address itself to the real problem, which prompted a further detailed letter from Dr. Clout in June. In this he pointed out that the sums being paid to Surrey were national average amounts—approximately £5,400 per annum for a mentally handicapped patient, and £6,050 fo one suffering mental illness. Both these figures represent standards of care below those laid down by the Department for minimal safe working.

Perhaps at this point I could refer to the national survey of large hospitals for the mentally ill and for the mentally handicapped that are carried out annually, comparing in particular the ratios between the number of nursing staff and patients. It is as a result of this annual survey that league tables are drawn up. I shall draw an example of each kind of hospital from those in my constituency. Of the 47 mental illness hospitals surveyed, Netherne hospital in my constituency came 45th. And of the 47 mental handicap hospitals surveyed, the Royal Earlswood hospital in my constituency came 40th. Obviously in any league table some must be at the top, and some at the bottom. But surely my hon. Friend must take note of the fact that by this test not one large hospital in Surrey comes higher than 39th, in either category. This is a measure of the funding crisis that we face in this sector.

From personal experience I pay tribute to the staff working at every level in these hospitals, and the results that they manage to achieve in these very difficult circumstances. But a time comes when they feel that they are nearing breaking point. The case was put well in a letter to Dr. Clout from the Parents and Guardians Action Group for the Royal Earlswood hospital for the mentally handicapped. This stated that: The present staff is only sufficient to cope with the basic essential tasks of living, and cannot possibly cope with long-term training and activity programmes to supplement the efforts of schools, training centres and occupational therapy. The miracle is that under these pressures the staff have maintained such relatively high standards and morale without cracking up. However, this cannot be expected to last for ever.

I ask my hon. Friend to appreciate that our anxiety on this score is all the keener when we contemplate the change in organisation in the administration of the Health Service due to take place next April, when the duties of the area health authority will pass to new district health authorities. Let me stress that this is a change which, in all other circumstances, we would welcome. However, we are fearful of the colossal burden that will be put upon certain of these new authorities in trying to maintain standards in their mental illness and mental handicap hospitals unless some change is made in the manner of funding what are currently described as "extra-territorial 960 patients". The new Mid-Surrey and East Surrey district authorities, both covering parts of my constituency, will be in particular danger as we see it. Unless the sums allocated for out-of-county patients are increased substantially, and passed on in full to the new district authorities, some, such as those that I have mentioned, will find either that the service they can provide to such patients will be dangerously inadequate, or that these services will have to be subsidised from general hospital and community service budget that are already fairly over-stretched.

I conclude by endorsing the plea that has already gone to the Minister from my county—that the Government should reconsider very carefully the calculations and assumptions upon which this funding is based, to allow for the unique extra burden that the new district authorities will have to carry, and to enable them to provide a level of service which, in Dr. Clout's words, both these unfortunate patients and humanity require.

§ The Under-Secretary of State for Health and Social Security (Sir George Young)

My hon. Friend the Member for Reigate (Mr. Gardiner) has taken this opportunity to raise in the House a subject that is of concern not only to him but to many who work in the health services in Surrey. He began his remarks with some kind words about the stewardship of myself and my colleagues, for which I am grateful. It demonstrates the high priority that the Conservative Party attaches to the nation's health.

I shall need to concentrate my remarks on the general question of the funding of services for the mentally ill and mentally handicapped patients in Surrey. I could not fault my hon. Friend's historical analysis of how the problem arose.

Surrey is almost unique in having such a high concentration of hospitals for the mentally ill and the mentally handicapped within its boundaries—well in excess of 5,000 beds in all. That has presented both the Surrey area health authority and the South-West Thames regional health authority with particular problems, since a high proportion of those beds are in large, outdated institutions approaching the end of their useful life.

When I did some research, it was, however, gratifying to note the efforts that have been made to overcome those problems. The Surrey area health authority has succeeded in closing the Holloway sanatorium, a large Victorian hospital for the mentally ill, and transferring patients elsewhere in the area. That was a major exercise, carried through with great care and concern for both the patients and the staff concerned. Putting the issue in perspective, there has, of course, been a steady decline in the number of patients receiving treatment in mental illness hospitals. In the last 10 years the number of mental illness patients in hospitals managed by Surrey AHA has fallen by 40 per cent.

The mentally handicapped patient population has similarly decreased by about 50 per cent. Reflecting that trend, the area health authority has also been considering the future of Brookwood hospital, near Woking. No decisions are likely for some time but among the possibilities is the provision of a locally based service in each of the three districts, which would be in line with our general policy on community care; the reorganisation of the present hospital to take account of the reduced number 961 of patients; or the provision of a new hospital on the site to serve the three districts that Brookwood serves at present. I mention that, because it is a clear demonstration of an area health authority actively seeking to solve one of the major problems that it faces, and behind all that there is a clear wish to provide an improved service for the patient and to make better use of the available resources. I endorse what my hon. Friend said about the staff in the hospitals in his constituency and in the other districts in Surrey.

The question resolves itself into a debate about resources. It is the availability of those resources and the funding of the services for the mentally ill and the mentally handicapped in Surrey about which my hon. Friend is concerned. I know how strongly he and the Surrey area health authority feel about what they regard as serious under-funding of the services that must be provided. I have read the exchange of correspondence between Dr. Ivan Clout and my hon. Friend the Minister of State. The heart of the problem appears to be the calculation of the resources to be made available to regional health authorities, based on the formula of the Resource Allocation Working Party—RAWP—the number of patients treated in the Surrey hospitals but who reside outside the county's boundaries and, included in that, the disproportionate number of long-stay patients. I do not quibble with the figures produced by my hon. Friend.

The distribution of revenue resources for the hospital and community health services is based on the recommendations of the Resource Allocation Working Party in its report published in 1976. It sought to establish a method of assessing the relative need for health care resources, that would not be biased by variations in the availability of health care facilities. The RAWP formula relies on population weighting to reflect the varying needs of different age-sex groups. The formula produces a series of target allocations, representing a notional fair share for each region. The objective is that over a number of years the allocations of the most deprived regions should be brought up to their target level.

The mechanics of the formula are somewhat complex, but essentially the target is an aggregation of a set of components, representing the major blocks of health service expenditure. One of those blocks is mental illness in-patient services and another is mental handicap inpatient services; they represent nationally 12 per cent. and 6 per cent. of the total. The component parts are weighted in accordance with the patterns of the use made of those particular services by different age-sex groups.

Within the in-patient services components of the formula, adjustments are made to allow for patients who are treated outside their region of residence. The South-West Thames region treats a number of patients from outside its boundaries and the region's target is accordingly enhanced. The case costs at November 1980 price levels are £3,000 for a mental illness patient and over £9,000 for a mental handicap patient. Those figures reflect the fact that some patients will stay in hospital for over a year. That is why they are slightly different from the figures that my hon. Friend produced. Regions are expected to make similar adjustments between areas for cross-boundary flow patients.

In respect of the psychiatric services a further problem is that there are a number of long-stay residents, admitted many years ago, whose original homes are in many cases no longer known. They are distributed unevenly across the 962 country, partly because of past patient flows between regions. The RAWP proposed a method of taking account of "old long-stay" patients within the formula, and its method, which compares the actual numbers with an "expected" pattern of distribution, has been followed by the Department. It so happens that the South-West Thames region, in which the Surrey AHA finds itself, is the region whose target share benefits most from this adjustment, which in 1981–82 was estimated to correspond to over 300 mental illness patients and just over 2,000 mental handicap patients.

The costing of these adjustments is made at nationally average costs, and I realise that this is a particular bone of contention with the area health authority. National criteria are, however, the basis for all adjustments in the formula, and the working party decided this was the most equitable and objective approach. The use of subjective cost norms would not increase the total amount of revenue available. It would, of course, affect the distribution of what was available, but not necessarily to the advantage of South-West Thames—or, indeed, Surrey—since cost norms for other services might easily outweigh those for the psychiatric services; and, as I hope my hon. Friend would agree, there could be no justification in an objective system of resource allocation for treating one set of data in an ad hoc fashion.

However, in response to my hon. Friend's strong plea I shall ask my Department to go through the figures again carefully to make sure that they have been calculated correctly and that both the RHA and, so far as possible, the AHA are getting the extra funds that they are entitled to because of the cross-boundary flows.

Perhaps I could emphasise what my hon. Friend the Minister for Health said in his letter to the chairman of the Surrey AHA. The RAWP targets are necessarily calculated within the total amount of money available. They are not, and probably never will be, a statement of what should actually be spent on total health care for a particular population. Much less are they a guide to what ought to be spent on particular services or client groups. They are basically derived from existing national patterns of expenditure, applied to demographic profiles of particular localities. They are, in turn, no more than an expression of the relative health care need of different regions or areas within the total of resources available.

It is accepted that the RAWP formula achieves that objective in a rather robust way by taking into account not only the expected demands of the resident population but, as I said, the extent to which in-patients cross boundaries for treatment and—for the psychiatric services—the relative numbers of old long-stay patients. All these statistics and cost data are revised annually. The target for South-West Thames is enhanced considerably by these adjustments, which represent about 5 per cent. of the region's target.

None the less, the target is still lower than the actual allocation to the region. This is not to say that the region should not spend more on some of its services; it is saying no more than that, overall, the region is spending more per head of the weighted population it serves than the national average. While this state of affairs persists, it will receive a smaller share of any growth addition for the NHS than those regions below their target.

I am very keen, as are my colleagues, that we should improve the quality of services for the mentally ill and the mentally handicapped, but the RAWP formula is not an 963 instrument for allocating resources for particular kinds of provision. It is for the health authorities to make their decisions on priorities within national and regional guidelines. Savings achieved by the better use of resources and by the decline in the numbers of the mentally ill and the mentally handicapped in hospital should be deployed to improve the services for these client groups—and, as I indicated earlier, the Surrey AHA has not been slow to achieve these aims.

In the current financial situation it is difficult to raise standards. I appreciate that the revenue allocations by the South-West Thames regional health authority to Surrey have meant that the Surrey AHA has remained marginally below its target allocation. However, the redistribution of resources from those areas in the South-West Thames region which are relatively over-provided to those which are under-provided is slower than many of us would wish. It is a fact of life—brought forcefully home to us all by the London Advisory Group's report—that there is a serious over-provision of acute services in many parts of London.

It is not easy to correct this imbalance overnight, particularly where it is clear that the primary care services are also in need of improvement in many parts of London. But against the background of the limited development money available to the South-West Thames region it has to be accepted that securing the necessary improvements in the services for the mentally ill and the mentally handicapped must depend not only on the better use of resources but on the release of resources from parts of the acute sector that are demonstrably over-provided.

I recognise the concern that has been expressed about the level of resources to be provided for the hospitals in Surrey after the NHS reorganisation next year. It would not be right for me to comment on this at this stage; but I can assure my hon. Friend that the South-West Thames regional health authority, which is responsible for allocating funds to the new district health authorities, will be prepared to consider any representations on this issue from the districts. Indeed, I shall bring my hon. Friend's speech to its attention.

Despite the difficulties of raising standards in the current financial situation, we believe there is still a great deal of scope for the development of services outside the large hospitals. We are maintaining the health capital programme and the amount for joint funding is being increased. On 16 July, we also published a consultative document entitled "Care in the Community" about moving resources for care in England, and invited comments by the end of November. We drew that up after informal discussion with interested people in the health and personal social services field and it explores a wide range of possible approaches. What we are certain about is the important implications that the document has for mentally handicapped and mentally ill patients in hospital. The 964 document estimates that about 15,000 mentally handicapped people at present in hospital—about one-third of the total number—could be discharged if appropriate services in the community were available. Their needs for support are unlikely to change and once discharged into social services care they would probably not have to return to hospital.

Turning to services for the mentally ill, the document recognises that nearly all seriously mentally ill people need help from both the NHS and the personal social services, and collaboration between the two is particularly important for them. Most people discharged from hospital psychiatric care have had only a short period as in-patients and do not need long-term help after leaving. Other people have spent many years in hospital and could no longer live outside it. There may, however, be up to 5,000 people now in hospital who fall in between these two groups and may be capable of leading more independent lives. Some would not be best placed in local authority residential care but might need a local authority day centre. It is important to develop personal social services to meet this need as part of the pattern of integrated, district-based services. That requires the development of health as well as social services.

Surrey's social services department has already made much progress in this field. The provision for mentally handicapped children is well up to the Government guidelines. There are three hostels with 70 places and 17 "out-of-county" placements. For adults, there are six local authority hostels providing 110 places and a seventh is being built. There are 146 "out-of-county" placements. The provision of centres for the mentally handicapped is also good. However, there is room for improvement. For example, we estimate that there are 720 mentally handicapped adults in Surrey who need residential care and that demand exceeds placements.

The mentally ill are catered for in two hostels and there are six informal day centres provided. The Surrey mental health council is extremely active with seven local groups attached to it. In the Reigate and Banstead districts, a specialist team caters for the needs of the mentally handicapped and the mentally ill.

"Care in the Community"—the document to which I referred earlier—suggests a number of ways for shifting resources to the community services and invites other suggestions. I look forward to receiving the comments from all interested parties, and every constructive suggestion will be considered most carefully. If the aims and objectives set out in the document can be achieved I am convinced that this will represent a major breakthrough in the development of those services for the mentally ill and handicapped in Surrey that my hon. Friend raised so sensitively.