Motion made, and Question proposed,
That a further sum not exceeding £5,168,144,000 be granted to Her Majesty out of the Consolidated Fund to defray the charges which will come in course of payment during the year ending on 31st March 1986 for expenditure by the Department of Health and Social Security on the provision of services under the national health service in England, on other health services including a grant in aid and on certain other services including research and services for the disabled. — [Mr. Kenneth Clarke.]
§ Mrs. Renée Short (Wolverhampton, North-East)
I am glad to have the opportunity to debate the report of the Social Services Committee on the care of the mentally ill and mentally handicapped, as, I am sure, are other members of the Select Committee. I am disappointed that, although the report was presented four and half months ago, we have not yet had a ministerial response. I hope that that gap will be filled. The Committee was well served by its expert advisers. I should like to thank David Plank, John Wing and Joy Young for all their work, help, advice and enthusiasm. The Committee is most grateful to them.
The Select Committee is now engaged on the social security reviews. We do not yet know about the effects of the reviews on the mentally disabled. Paragraph 147 of the report states that the analysis should showthe benefit entitlements of mentally handicapped and mentally ill people.I hope that the Minister for Health will fill that gap.
The Committee paid tribute to the great care given by doctors, nurses and other doing a multiplicity of jobs in the huge hospitals, often in isolated positions, during the last century. We saw huge hospitals in the United States with 20,000 patients. It is possible to move ahead too quickly. It is easy to move patients to cheaper, less well-motivated and less well-staffed places. If community care is to work, there must be locally based facilities which are well staffed by redeploying thousands of skilled, partly skilled and unskilled staff, as well as money. Unless that happens, community care will fail. If it is to work, there must he locally based psychiatric care, workshops and a rejigging of the social security system and taxation to encourage people if they find work. The clear lesson to be learned from our American visit is that we cannot close down one set of facilities, however imperfect, until the alternatives are firmly established.
It is fairly easy to shift patients from a state hospital to a less well-motivated and well-staffed "community facility", whatever it is. Large mental institutions can then he closed, but that does not help the patients. As the committee's report states:Any fool can close a hospital but it depends how you do it." That statement has been widely reported in the press.
§ The Minister for Health (Mr. Kenneth Clarke)
In case the hon. Lady gives a misleading impression, will she give one example of where we have closed a large mental hospital without providing alternative facilities? I think the hon. Lady will agree that there is no such example in this country, although there may be examples in the United States or Italy, to which the Committee travelled.
§ Mrs. Short
If the Minister has the patience to bear with me, I hope to give some examples later.
1316 Our present provision for mentally ill and mentally handicapped patients is underfunded and understaffed. If we are to transfer patients to the community, local authority expenditure will have to increase. That is the point that we are trying to put forward in this debate. Expenditure on housing, education and transport must increase. Unless we do so, an even greater burden will be imposed on the voluntary services. The only money that many patients will have will be their social security entitlements.
We must understand that many mentally ill and mentally handicapped people are already being cared for in the community in their own homes, or, if not, they are being cared for in group homes, hostels and lodgings. Better facilities will be needed for them. The Committee heard of many parents who were coping with their mentally handicapped children. These parents criticised the present inadequate provision. The careing professions made known their great concern during every visit that the Committee made.
There are, of course, day centres, group homes and sheltered workshops run by immensely dedicated people, but there is also great concern. We must bear in mind that mental illness hospitals scheduled for closure some years ago still have patients in them, some of whom are very old and frail. Some of those hospitals contain 1,000 or more patients. There is a danger that the Government are putting pressure on hospital authorities to close mental illness hospitals within certain time limits. This makes it difficult for psychologists, nurses and community mental health nurses to think about what should be provided for their patients.
The Committee's report states that the community psychiatric nurse is a key pail of the new mental illness service. The director of the Health Advisory Service calls the CPNprobably the most important single professional in the process of moving care of mental illness into the community".I am glad that there are now more CPNs in primary health care teams. During the Committee's visit to Blackburn and Tiverton we heard of general practitioners' increased confidence in referring patients to CPNs and of the confidence of CPNs able to work relatively independently. That is a very good development.
The Royal College of Psychiatrists favours that, but is anxious that it should be achieved by expanding the service rather than by redeploying those nurses who are already caring for more disabled psychiatric patients in the community. In 1977, the Trethowan report on the role of clinical psychologists recommended the employment of a minimum of 1,100. There are now 1,300, but they are unevenly spread throughout the community. There are half as many proportionately in Trent, Oxford and Wessex as in the north-western region. Those people should be training the therapists, nurses, care officers and assistants. Indeed, they should be training the relatives, giving them help and guidance when careing for their relations in their homes. In some areas the clinical psychologists are doing that, as Committee members saw on some of their vistis. I hope that the Committee will review the Trethowan report and encourage the leadership and potential of clinical psychologists.
The Committee has drawn attention to the fact that general practitioners are not always willing or able to care for mentally disabled patients. The Royal College of General Practitioners agreed that general practitioner 1317 training was inadequate for the job which the doctors were expected to do in caring for mentally disabled people in the community. I understand that the Royal College of Psychiatrists would be happy to help with general practitioner training. If the Minister for Health is willing to provide encouragement, this link between the two branches of the profession could be developed, and that would be helpful.
The president of the Royal College of Psychiatrists told the Committee:during the period since the 1950s, there has been a very radical change in the way in which psychiatrists have come outside the mental hospitals and have become more heavily involved with the community in a variety of ways"—notably with the concept of treatment and rehabilitation close to the patient's own home.
Not enough time is being given to the psychiatrists to plan acceptable alternatives. Public attitudes in the community must be considered. We are saying that the Minister for Health cannot turn people out of hospital before adequate community services have been provided for them. On discharge too many patients rely on seedy bed-and-breakfast lodgings, doss houses, park benches or even prison. The Select Committee is about to start an investigation into prison medical services, and I suppose that we shall come up against this problem again during that inquiry. Many private homes are springing up. There is no proper inspection, many charge large fees and no follow-up is provided by hospitals or social services. That is a serious gap in the present system of transfer from hospital care into the community.
It is possible to provide good care in ordinary domestic surroundings with sufficient resources and one-to-one staffing as the Committee saw in Nebraska as well as in Cardiff and elsewhere in the United Kingdom. The best form of accommodation is ordinary housing with staff with the necessary expertise providing for small groups of mentally ill people in the community. If the mentally ill are to be housed in the community, there must be a change of heart by their neighbours. We learned how to tackle that problem in Cardiff. It is important to talk to the neighbours about the project before the patients arrive.
Sheltered village-type communities can also provide an excellent environment for certain mentally ill patients. We visited a splendid Rudolf Steiner community overlooking the sea near Belfast where 60 mentally handicapped children and 30 mentally handicapped adults are cared for in a self-supporting community. They performed various interesting activities and ran a productive farm, breeding cattle and growing crops.
How will the Government carry out such a massive and diverse exercise in their present mood of cutting and skimping on the social services? The method of financing a successful programme of community care is crucial. The Minister for Health seemed confident when he told the House that the Government had sufficient financial mechanisms to encourage the discharge of long-stay patients and to establish matching services in the community, but the Select Committee for Social Services, health authorities, local authorities, voluntary organisa-tions, parents and clients do not share the Minister's optimism.
Regional strategic plans for the next 10 years are now appearing. Many of the regional plans for mental illness 1318 and mental handicap are sound. They are full of the right sentiments. The real action, however, takes place in the districts. There are many vague proposals for National Health Service community mental handicap units and mental health centres, but there is little evidence that the districts have any clear notion of how the new long-stay chronically mentally ill will be cared for. Some patients will remain in the big old mental institutions which look as though they are to be closed, but which will close only in the sense that the Italians close their hospitals by changing their names.
Those Victorian hospitals will lose many of their staff, but they will retain a core of patients. Mapperley hospital in the Minister's area has 350 beds and is supposed to close by 1991. There will be a large 150-plus bed district psychiatric centre on that site. Middlewood hospital in Sheffield has 775 beds and is to close, but a new 120-bed unit is proposed on the edge of the existing site. The fear is that those patients will be conveniently forgotten. People will think that St. John's, Mapperley, Middlewood and Powick have been closed and attention will be concentrated on the more interesting community services.
The Select Committee recommended that at least the same proportion of resources should continue to be devoted to the most severely mentally disabled in the future. It also discussed the new long-stay provisions—the asylum function—in hostels or refuges rather than in new units built in the grounds of the old hospitals. It is essential that we do not neglect the chronically mentally disturbed.
Paragraphs 161 to 167 of the Select Committee report give the numbers of mentally disabled people in prisons or who are homeless or living in shelters. The Committee recommended a departmental inquiry into the care of homeless mentally ill people. Perhaps the Minister will tell us whether that is to take place. Over the past few months we have been monitoring the Government's policy on resettlement units and we intend to examine Ministers on that in the autumn, but perhaps the Minister will tell us today what consultation has taken place on replacing the local units and how far Camberwell will have been replaced when it closes its doors in September. In the autumn we shall also be examining the prison medical service. The British Medical Association has warned us that prisons could become the "sump" for caring for the mentally disabled.
With regard to mental handicap, it is disturbing to see the extent to which some of the old hospitals are being retained to an undesirable extent and that new institutions are being created. Barnsley is building a new mini-mental handicap hospital. Oxfordshire and Berkshire authorities are planning to build more than 12 large new units, generally of 25 beds, but including a 50-bed unit in Reading. The Government are not closing the large hospitals. The Select Committee went into this question in detail in paragraphs 55 to 58 of the report and concluded that new units on this scale were to be deprecated. Ministers must use the accountability review process to discover why authorities are still building so-called "Wessex units", which were a great advance in their day, when Wessex is moving rapidly towards the use of ordinary houses for six or seven people at a time.
Some plans show proposals for the transfer of patients from one institution to another. This is sometimes called relocation. In America it is called "transinstitutionalisation"—a marvellous word for Scrabble players, but a 1319 barely acceptable practice, as paragraphs 153 to 156 of the report observe. We warned that traffic of dependent people between institutions was in danger of developing. We believe that to be undesirable. We saw examples of this when we visited Powick outside Worcester. As it is European Music Year, I remind hon. Members that Powick was the hospital where Elgar had his first job as a music master. Powick was supposed to have closed, but we have been to see it and have seen the patients there. There are approximately 100 patients left at Powick. They will be dumped elsewhere to enable the authority to make millions of pounds from the sale of that beautiful site overlooking the Malvern hills for private development or whatever.
Trent is planning to move 100 Saxondale patients to the site of Ransom mental handicap hospital. Northampton is planning to move 100 St. Crispin's patients to Princess Marina mental handicap hospital and 45 patients from St. John's Aylesbury to Manor House mental handicap hospital. It would be possible on this basis to close all long-stay hospitals, but they are not really being closed —the patients are simply being juggled around.
The nub of the problem is resources. The Select Committee's first and broadest conclusion is that at present mental disability services are underfinanced and understaffed. It is impossible to achieve the level of community care that everyone wants without some increase in resources. The Select Committee is not just asking for more money. If there were no community care policies, we could not continue for much longer with the kind of hospital service that we have. The Victorian asylum type of hospital is now inadequate. The Select Committee saw some very grim conditions, as I have described to the House. The press is understandably more interested in exposing the shortcomings of community care —the lodging house problem. We should not forget the alternative. The Select Committee report states in paragraph 21:The relative neglect in mental illness and mental handicap hospitals has only been tolerable (if barely so) because of the promise of a major shift in the locus of care.The particular problem to which I want to draw attention in the context of an Estimates debate is the difficulty of transferring resources from one area of public expenditure to another, from one ministerial Department to another. We spend over £2 billion on health and personal social services, a further considerable sum on social security payments for mentally disabled people, and there is further expenditure by education and housing departments. Money does not flow as easily between those structures as it does between patients.
The Committee expects to see an eventual reduction in NHS expenditure and an increase in local authority expenditure, as we describe in paragraph 22, flowing primarily from our recommendation that while the National Health Service should not be constrained in the short term from providing community residential services for mentally handicapped people, in the long term all social care—that is, non-clinical care—mental handicap services should be financed and administered by local authorities. That is already happening in some districts, but not in all. It is a question of the transfer of resources.
The Committee looked at the Government's care in the community initiatives, and they are very welcome. We look forward to their evaluation by the personal social services research unit in Kent, so long as that unit 1320 concentrates on what happens to patients and not just on the book-keeping exercise, because it is what happens to patients that is important. The Committee concluded that they did not at present offer a persuasive solution to the permanent transfer of resources. The very fact that the DHSS is funding them with bridging money means that they cannot easily be repeated. What is more, because they quite properly concentrate an getting specific people out of hospital, there is no certainty as to who will fund the services once those people no longer need them. Also, the services concentrate on getting people out of hospital rather than on the maintenance of the majority of mentally disabled people who are already in the community anyway. We must not overlook that.
The Committee made several recommendations in that connection and in paragraph 68 we recommendthat Ministers create means of bringing about the necessary permanent transfer of resources to local authorities so that by the end of the century they will be in a position to take over prime responsibility for non-medical services for mentally handicapped people.That is a clear recommendation.
We also make several recommendations which are designed to improve joint planning between health and local authorities and to toughen up regional and departmental oversight. We think that the recently published strategic plans are rather thin on the nitty-gritty of joint planning. Perhaps the Minister will say what he intends to do about that.
We call for a central bridging fund to enable resources to be released to build up a new style of mental illness and mental handicap service before the hospitals are fully closed, with the resultant savings. In paragraphs 111 to 116 we explain why we think that is necessary, as do most experts. Much of the per capita cost of a patient is tied up in fixed costs and ancillary staff, so that the discharge of a few patients does not itself produce any savings, because the staff who are already there have to remain to look after the patients who are left behind.
Mrs. Major of the National Schizophrenia Fellowship, who gave us some very good evidence, put the matter well when she said:Patients should not be removed until the alternative facilities actually exist in the community. It seems to me that it is like asking a passenger to jump off an elderly ship into the stormy sea with the assurance that the lifeboat will be along in a few months' time.By then, of course, there will not be any patients to pick up.
Some regions have apparently managed to close long-stay hospitals, or at least to run them down. We say in paragraph 115:the fact of discharge, of bed reduction does not reveal anything of the quality of community services provided. Some authorities have followed a path of either racing ahead and damning the consequences or of simply dismantling their existing services and rebuilding them in local wards still under NHS control.Somewhere new buildings are to be put up to do precisely that.
Some regions do not have anything like sufficient funds for such reserves. We gave as an example south-west Thames and the huge Epsom cluster. The same is likely to be true of north-west Thames and the Hertfordshire hospitals. The Committee has just received a very useful and full response from west Lambeth health authority. That is a district authority which is a RAWP-losing district within a RAWP-losing region. Its budget is being severely cut over 10 years. It is obliged to race ahead with the 1321 closure of Tooting Bec. We refer to that in paragraph 218 of our report. The local authority is rate-capped, penalised and generally restricted.
The Committee visited Friern hospital in the Prime Minster's constituency. It serves districts which are also RAWP losers, and boroughs in north-east London which have no funds to spare. No doubt some authorities can manage more easily. The Committee concluded, in paragraph 116:There are excuses as well as reasons for the lack of action.But for many some sort of centrally provided short-term funding is essential to bridge the gap. The Minister and the Government have to find some ways of getting over that problem.
Between 1979 and 1984 a financial gain of over £101 million has been made by the sale of hospital land. Much of that may well have been land attached to mental illness or mental handicap hospitals. What does the Minister intend to do with that money? What has happened to it so far? I know that the figure is correct, because the Minister gave it to me in reply to a parliamentary question.
I see from today's evening press that we have won over the Chancellor of the Exchequer to the view expressed from the Opposition Benches that defence expenditure should be reduced, and a figure of £500 million is being suggested. Perhaps the Minister will get his eye on some of that money.
The message from the Select Committee is that resources must be found if the Government's declared policy is to succeed. It cannot be done otherwise. I hope that the Minister will bear in mind the good advice that we give him.
§ Mr. Michael Meadowcroft (Leeds, West)
May I add my thanks and tribute to the Select Committee's advisers and say what a pleasure it was to serve as a member of the Committee, under the urbane leadership of the hon. Member for Wolverhampton, North-East (Mrs. Short). As I have experience of only one Select Committee, I have nothing with which to compare it, but if the experience of members of the Social Services Committee is anything to go by, I suspect that the Select Committee is a useful and helpful part of our procedures and our democracy in this Parliament.
The report of the Select Committee is unanimous. There was an intense effort to ensure that what we reported was supported by all members of the Committee. The membership of the Committee covers a wide spectrum not only of politics but of personalities. It ranges from the quiet, genteel members to the not so quiet and genteel. [HON. MEMBERS: "Which are you?"] I think that I join hands with the hon. Member for Macclesfield (Mr. Winterton).
It would be discourteous to other hon. Members to concentrate on more than a few aspects of the subject in the time that is available, so I want to emphasise one or two of the points that appear to me to be significant in the various visits that we made and evidence that we took.
Throughout our work, I was interested to find that what one area told us was impossible was being done in other areas. On many occasions we were told that it was impossible to move certain patients out of an institution, but the next day one found that it was being done at some 1322 other place. There is a terrible danger that not only the patients in institutions but the staff become used to what they have and, without malevolence, cannot see beyond that. Those who are charged with the political responsibility for policy-making in the Health Service and the social services, as well as in the House, must grapple with the problem of what level of paternalism should be allowed.
The type of paternalism that seems to be beneficial is when experts say that they know what is best for their elderly mentally handicapped patients, and that is to show them what it is like outside the institution. Unless that is done, patients will be unable to decide what they want; they will always decide that they want what they already have. That sort of paternalism can be valuable. The worrying side of paternalism is when patients are guarded because, it is said, it is too frightening for them to leave the institution. Again, that is done not out of malevolence but from a desire to care for those who are fragile and vulnerable.
In our inquiries, the matter of philosophy of risk was very striking. I have come to realise more and more that the risk that we allow, not only to the patients, but to those whom they might harm, is a political decision. Too often, we shelter behind the experts charged with the care of those people. If something goes wrong, we turn our back and ask, "Why did the social services allow this to happen? Why did the health authority not do more?" We must realise that if we are to encourage the flow into the community of those who have disorders, are vulnerable mentally, or perhaps have behavioural problems which may influence others, there is a risk attached.
We must grapple with the problem of risk. I was impressed by the director of a mental health institute in America, who said that he could sedate the patients for 12 months of the year and remove all risk. However, he also said that we would lose the benefit to the community of many of the patients, who are splendid members of society for nine months of the year and have much to contribute, but who are disturbed for perhaps three months. He said that it was our choice and that we could decide.
At the lowest level it applies if we wish people to live in as normal conditions as possible. As the hon. Member for Wolverhampton, North-East (Mrs. Short) said earlier, the best option is an ordinary house in an ordinary street. But fire officers insist that if there is a group of people living communally, the fire regulations require that extras such as fire doors and fire escapes must be added to the house. The property ceases to be an ordinary house in an ordinary street. That is a vivid aspect of the problems of normality and risk. We must be shrewd and decide whether to put up with the risk and not shelter behind authorities when something goes wrong, because somewhere at some time something is sure to go wrong.
Although some would say that we were brave or perhaps foolhardy, we touched on the delicate matter of sexuality. We tend to shy away from the problem of the rights of those who cannot guard their emotions and vulnerability in the same way as others. We asked those with legal minds to consider carefully the responsibility of those who care for such people and to consider the rights regarding contraception and other matters relating to sexuality.
There is a danger in thinking that if only we get all the practical steps right, people will enter the community without problems. The longer I remain in politics, the 1323 more I become convinced that we cannot change people's hearts and minds simply by changing policies. The context in which we develop policies is just as important as the pragmatic decisions. Although we should discuss the practical points to which the hon. Lady drew attention and which the report details at great length and, I hope, powerfully, it is just as important for us to argue with our constituents and our communities about the need to accept people whose behaviour may seem to be abnormal and who may appear to pose an extra burden on the community. Their behaviour should be regarded within the very broad spectrum of behaviour and personality. Without that understanding or acceptance, policies are empty and might, in some respects, be provocative.
It is important to recognise that the stress may be greatest in our urban communities, where many such people are sent to live because of the tremendous care that can be offered by urban organisations. Those who are struggling to survive on old estates or with unemployment— or whatever social conditions impact greatly upon them—may believe, alas, that they could do without the extra burden of having people in the community to whom they must give more attention. It behoves us all to recognise that the context of the community is desperately important if the good policies outlined in the report are to succeed.
Although the hon. Lady rightly drew attention to the need for more resources, I would not wish the House to believe that that is the only solution. We do not always consider the links between the voluntary sector and the different aspects of the Health Service, social services and the social security system. The total resources that can be provided by all those organisations may mean much less to an individual than institutional care. We cannot say that one solution—perhaps that of social security income support—is better than drawing the services together. It would be unwise to believe that the report asks only for vastly increased resources. We need a host of other services, too.
I should emphasise to the Minister that the bridging facilities between institutional care and the community are expensive. We cannot make large savings by closing an institution and disposing of the buildings and land until it is entirely closed. There is a serious problem in providing a bridge between what we have now and what we want. I hope that the Minister will take on board the crucial point that each area may need funds to provide such bridging facilities.
An adviser to the Committee drew to its attention an interesting paradox in the financial resources committed to this area of care. Although we are anxious to close some institutions, because the concept of the asylum is now completely anachronistic, paradoxically, the people of 100 years ago committed more resources to those buildings, in real terms, than we are committing today. They were splendidly built; they would not have survived for so long if they were not. Many of them are situated in vast acres of beautiful land. We saw an institution in Surrey that was advanced for its time. It had separate buildings with wonderful facilities among them, and the resources committed to it were probably more in real terms than the resources about which we are talking today.
If we consider the cost of keeping an individual in an institution or caring for him in the community, the difference may not be as significant as we might have 1324 thought. Roughly, it costs about £11,000 per person a year in an institution, and £13,000 to £14,000 a year outside. Community care is dearer, but not much more so.
We should commend the organisations that have not waited for the Government's response to the report or for this debate, but have used the report as a lever in their areas to do something about the problem. They have used the report's recommendations to set up a dialogue with the health authorities. I was interested to hear that, on Merseyside, MIND has already entered into a contract with the health authority, under which, for each individual that MIND takes into its care from an institution, the health authority will pay £14,000 for his or her place. So far as I am aware, the scheme relates to places rather than to people. As the Minister is aware, there is a problem with the money ending with the death of the patient, because the organisation has a continuing expense, so I commend that type of deal. We should be seeking to ensure that organisations can undertake different forms of individual care, innovation and experimentation.
§ Mr. Nicholas Winterton (Macclesfield)
May I refer the hon. Gentleman to my area health authority, which is closing the Mary Dendy hospital for the mentally disabled? It has first-class facilities such as a hydrotherapy pool. The care which will be available once the hospital is closed will not include such facilities nor those available in the Parkside hospital which is due to close during the next 10 years. Those two hospitals have sheltered workshops and many other excellent features which will not be replaced when they are closed. Will the patients have as good a standard of living and accommodation when they are discharged into the community as they had in the hospitals? Is that factor riot important? Is it not vital that additional resources are made available to ensure that the facilities now provided in hospitals are provided when those patients go into the community?
§ Mr. Meadowcroft
I am grateful for the hon. Gentleman's comments. I recognise his interest and his anxiety about the difference between facilities available in institutions and in the community.
The problem is whether we should consider the quality of life as opposed to freedom, which cannot necessarily be measured by objects. That is a difficulty. In some ways it is not dissimilar from the way in which some people consider facilities for prisoners when they ask why they have four-star hotel accommodation while we suffer outside. None of those people would wish to be locked up behind doors. In a sense, people prefer the poverty of freedom to the wealth of slavery. People may prefer the quality of life in the community to the facilities provided for them in institutions. I accept what the hon. Gentleman said. We must find a balance. We have the task, which at times is not easy, of finding the right solution.
It was a pleasure to serve on the Select Committee. I hope that the Minister will take note of the fact that the report was unanimous. I am glad to see that it has been hailed as valuable by nearly all the specialist organisations. I hope that we shall see the proper, caring and sensitive dispatch of people with proper support out of the institutions into the community.
§ 8.2 pm
§ Mr. Steve Norris (Oxford, East)
Although I was a late joiner to the Select Committee, I should like to join in 1325 congratulating the Committee's advisers, who, I think both sides of the Committee felt, provided an excellent service.
I take as my starting point the definitive statement by the Select Committee in paragraph 29:Community care for mentally ill and mentally handicapped people is not a subject for partisan politics.I believe that you will have observed, Mr. Deputy Speaker, that that is the spirit in which the debate has taken place so far, and I hope that it will so continue.
I congratulate the Government on having, first, endorsed and supported the concept of community care and on having devoted substantially increased funds to that principle. Since 1978, 51 per cent. more funds in real terms have been made available for the joint finance which is vital to the transfer of facilities from the hospital service to the community. The fact that year-on-year increases in schemes to which the health authority is also contributing are disregarded in terms of grant holdback is of additional benefit to hard-pressed local authorities. Those are useful steps towards financing community care.
Local authorities' personal social services expenditure has increased, not just in cash terms, but in real terms. In contrast to what is often held to be the case outside the House, the reality is a 15 per cent. increase in real terms on home helps, 9 per cent. in real terms on meals served in the home, more than 25 per cent. extra day centre places, not for the elderly, but for those who fall within the category of people with whom we are dealing, and a 26 per cent. increase in the provision for adult training centres. Those are achievements of which the Government should be proud.
The increases in expenditure are mirrored by service improvements. In 1983, 10 per cent. more people were visited at home by district nurses and health visitors, and nearly 25 per cent. more elderly people were treated by district nurses than when the Government came into office. What is more important, there are 51,000 places in day centres for the category of patient with whom we are dealing this evening. That is an increase of 18 per cent. since the Government took office. There are more places for mentally handicapped people at adult training centres.
The Government have provided special intiatives for community care. They have made £16 million available for a programme of special projects to provide alternatives to long-stay hospital care. The "Helping the Community to Care" initiative has been provided with £10.5 million. This is designed to help people care for elderly or handicapped people within the community. Local services for mentally ill elderly people have been given £6 million extra.
Support for the voluntary sector has increased from £7.5 million in 1978 to well in excess of £23 million. We must frame our observations to the Government in the light of an acceptance that they have devoted real extra resources to community care.
Having said that, we must acknowledge that the standard which the Government have set themselves is high. When the Select Committee sought a definition of community care which would describe what was meant by the concept, which is often quoted differently, it said:Appropriate care should be provided for individuals in such a way as to enable them to lead as normal an existence as possible given their particular disabilities and to minimise disruption of life within their community.1326 That is no easy task. It is no cheap task.
Having acknowledged what the Government have already done and are continuing to do, I believe that we should all be aware of the warning that the Select Committee sounded in paragraph 21, when it said:A decent community-based service for mentally ill or mentally-handicapped people cannot be provided at the same overall cost as present services. The proposition that community care could be cost-neutral is untenable.The Committee continued, I believe correctly, more strongly when it said:Proceeding with a policy of community care on a cost-neutral assumption is not simply naive: it is positively inhumane. Community care on the cheap would prove worse in many respects than the pattern of services to date. The Minister of Health admitted— 'If you have some hospital facility in the past which has been greatly underfunded, if you transfer the function to community care, the cost will go up.'Surely that is the background against which we must consider what community care means for the Health Service and social services.
We must beware of a number of pitfalls which potentially lie before us. I speak as a member of a health authority and as one interested in advancing the concept of community care. Other hon. Members will no doubt deal with other aspects of the report. I suggest to my right hon. and learned Friend that we should, for example, be careful to ensure that in the process of returning to the community those who are clearly able to return, we do not leave the worst disabled as a rump of patients in hospital, thus in a sense dedicating our asylum facilities, not by design, but by accident and by a process of attrition. That would be unfortunate and unhelpful. We should also beware that we do not become obsessed with those who are in hospital whom we are trying to get out.
One of the most significant observations made by the Select Committee was that we tend to think of the subject in terms of closing long-stay hospitals and putting people into the community. The speeches that we have heard so far have taken that course and talked about the closure of large institutions. The Committee noted an observation, which struck me at the time as singularly appropriate and important to remember—that 90 per cent. of the care is being provided in hospitals while 90 per cent. of the patients are living in the community.
We will have misunderstood the concept if we think that community care means only closing down the big long-stay institution to transfer people into the community. Community care is about the care of those who are already out of hospital and those who have never had the opportunity to be catered for even within the National Health Service.
We should be equally concerned to respect the concept of asylum. I was worried when the hon. Member for Wolverhampton, North-East (Mrs. Short) suggested that it was wrong for a health authority to say that it would close a long-stay institution but leave a facility on site for a reduced number of people. It would be wrong to leave a rump of patients who are difficult and for whom it is not convenient to make arrangements, but we have to come to terms with the concept of asylum for a limited number of people.
In west Berkshire we make a point of holding our health authority meetings in our long-stay mentally handicapped hospital because we are conscious of the fact that it is a Cinderella service. It is important that we go there. It is a good discipline because, once a month, we are able to walk around and see what is happening. I know the 1327 christian names of patients who could have walked out of that hospital 20 years ago to start the process of becoming members of society with occasional outpatient visits. As it is, they are incapable of ever making that transition. There are patients in that hospital, Borocourt hospital, who under no circumstances could be returned to the community.
§ Mr. Norris
I am grateful to the hon. Lady for clarifying her earlier remarks. We must not assume that community care means that nobody is allowed the protection of genuine asylum in the literal sense of that word, which the National Health Service ought to be able to afford.
§ Mr. Nicholas Winterton
As my hon. Friend serves on a health authority, can he give us an assurance, from his own experience or from his experience of other authorities, that such provision is being made for the future and that there will be long-stay care and asylum care for a limited number of mentally ill patients?
§ Mr. Norris
My hon. Friend must direct his comments in another direction. I cannot give him any guarantees about what my right hon. and learned Friend may offer us at the conclusion of this debate. My authority recognises that the concept of asylum is vital, but we do not allow that to become a convenience for not making every effort to return the obvious patients, and perhaps the less obvious, to the community. I suspect that that is where the decision is important and where the veil needs to be parted. I am speaking about only a small number of people. I am convinced that, for the vast majority, the general thrust of the community care philosophy is right.
§ Mr. Meadowcroft
I accept what the hon. Gentleman says, but does he agree that there is a danger that the more we talk about the people who are unable to be returned to the community the more we exaggerate their number? When the Select Committee went to see a project called Nimrod in Cardiff, we were told that people are selected for community care from a list and not according to their condition. We saw people who had been in an institution for 28 years and who are now living in the community. Nobody was prepared to admit that there was anybody in the institution who was not capable of being returned to the community. Intellectually, however, I accept the hon. Gentleman's contention that there must be some people who cannot be returned to the community.
§ Mr. Norris
I am grateful for the hon. Gentleman's observations. He is right constantly to re-examine the criteria used for retaining patients in an institution. It is possible to treat any patient, in any circumstances, in a private house if that is the aim. That cannot be the aim, however. It is vital that we get away from the idea that the private house is some kind of end in itself. We can use the private house for the vast majority of mental illness and mental handicap patients in the normalisation process, but the asylum concept remains valid for a small number of patients.
We have got past the easy side of community care. When it is obvious that patients can be returned to the community, most health authorities have developed plans to do that. We are now discussing the more difficult cases, and there are two things of which we must be extremely careful. The first is that we must not close facilities before 1328 we open others. My right hon. and learned Friend the Minister has rightly reminded the House that that has not happened. I am worried that as large institutions begin to have fewer people the pressures on health authorities to speed up the process to get the last few dozen patients out will increase. We must protect those patients against the economic advantages of closing a facility too early.
When my right hon. and learned Friend gave evidence to the Select Committee, he spoke of the bridging arrangements in regard to the closure of our large institutions. My idea of bridging arrangements is not confined to capital bridging—the purchase of a house or several houses before selling the land and buildings of an institution. That is the conventional concept of a bridge, and I am most grateful for the fact that my right hon. and learned Friend recognises the need for such a facility.
More important for community care, however, is the following process. If a facility houses 400 patients and costs £400,000 a year to run, that represents £1,000 per patient. If one takes away 200 patients, that makes it £2,000 per year for each patient. If one is left with 20 patients, the deduction is obvious. It is also clear that my mathematics are at fault, but one adds many more noughts to the cost as the number of patients declines. The lesson is that as the number of patients retained in an institution drops, almost the same amount of money has to be spent as when a greater number of patients were housed in there. A major increase in resources is needed to tide us over a transitional period which will not last for one year, or two years, or even for 10.
Hospital care for the mentally handicapped and those who are mentally ill has not always been as good as it ought to be. If community care is to succeed, it must be done well. It is better not to do it at all than to do it badly. To do it well means that long-term extra expense will be involved. Extra costs will be incurred, not because it is more expensive to maintain a series of private houses than it is to maintain one large institution, but because we are saying that we will not allow Cinderella services to exist. Staffing ratios will have to be improved. A massive increase in resources will need to be allocated to day centres, adult training centres and occupational therapy departments.
Paragraph 28 of the Select Committee's report praises the staff of hospitals for the mentally ill and the mentally handicapped. It says:There are not words powerful enough to praise the dedication of thousands of people who care for their mentally disabled fellows.I have the privilege of seeing them just once a month. I am also privileged to be able to walk in and then walk out again. They are unable to do that. They have to stay in the Borocourt, Fairmile and Wayland hospitals in my constituency and in similar hospitals in the constituencies of right hon. and hon. Members.
In this unglamorous specialty, on very many occasions doctors work many more hours than their contracts stipulate. The nurses, both male and female, provide constant care, despite the almost intolerable frustration of lack of progress in their patients. Progress is usually made centimetre by centimetre. In many cases they work in less than ideal conditions. The Select Committee salutes them. They are an example to us all. They are entitled to know that this House cares about them and about the patients in their care. This debate is to be welcomed for this group of 1329 people, if for no other. I look forward to hearing what right hon. and hon. Friends have to say on this important subject.
§ Mr. Ken Weetch (Ipswich)
The Select Committee has provided a valuable service to the House, for its report contains a great deal of constructive thought and comment upon some difficult policy issues and it throws light on mainly difficult and sensitive areas. Since I am the first hon. Member who is not a member of the Select Committee to speak, I should put it on record that the Committee has provided a valuable source of reference on this subject.
My remarks will concentrate upon mental illness and the psychiatric services in which I have a special interest. In the East Suffolk district health authority there are two large, old-style mental hospitals: St. Clement's and St. Audrey's. How to deal with these matters often comes full circle. In the 1870s, the person in charge of St. Audrey's hospital wrote down his thoughts on mental illness and the way in which the service should be organised. In a thoughtful memorandum, which officially has not seen the light of day, he said that he believed that psychiatric services and services for the mentally ill should be dispersed in the community and that professional services should be dispersed in local areas, because this would be of far more benefit to those whom the services are designed to help. That only goes to show there are no new ideas and that old ideas are revamped.
I have to declare an interest as a sponsored member of the Confederation of Health Service Employees. Many of its members are in the front line of the provision of those services. It recruits heavily from ancillaries and nurses in the psychiatric sector. My comments are the result of what I have seen and heard. I recommend to the House a recent working party report by COHSE: the Mallinson report on the future of psychiatric services. It is a very important piece of research into the subject.
The term "community care" is not defined. A number of reports on community care have been published but none of them defines community care in detail. The professional recommendations about the best way forward vary greatly. There are major differences of professional opinion about the best way forward and about the ultimate shape of psychiatric care. However, a rough and ready definition involves the phasing out of the large, long-stay, old-style mental health hospitals. They have come in for a great deal of flak, but the work that is being done in two large hospitals in east Suffolk is of a very high order. It is often done in daunting circumstances.
On the other side of the coin, community care means that most people who need appropriate long-term care can and should be looked after in the community. I am advised that other features of community care will include multidisciplinary community support, the relocation of specialist services in local settings, and the co-operation of the local authorities and personal social services. Of course, the whole structure will be underpinned by a framework of joint financial arrangements. However, I want to express some reservations about the concept of community care.
On the one hand a good deal must be said for such policies because the aim of all psychiatric therapy is to 1330 equip the individual to cope in the community. The ability to cope in the framework of everyday life is the measure of whether the person is improving and whether his mental condition is improving. That is an important principle, which I wholeheartedly accept. The other assumption is that the needs of the individual are best catered for in the community, within an integrated network of different professional services. Another advantage is that the support of families and voluntary support groups can be harnessed, and I think that that is a very valuable princple.
I think that most hon. Members will accept that far too many people have spent far too long in institutions of one sort or another. If one cannot cope very well and one goes into an institution, that institution and its framework become a crutch as time goes by, and people who have been institutionalised for a long time find the transition back to community life difficult.
While I have every sympathy with the aims of community care policies, and while I accept the proposition that, as a society, we must mobilise community resources in a structured way to help those who are mentally ill, I have reservations on the way in which they are being put into operation. In the first place, community care is not a cheap, but an expensive option. To provide a framework of support services is potentially expensive. There were certain economies of scale—if I can put it in economic terms—in having people under one roof in the old-style mental hospitals. That cost option is no longer available as the old hospitals are closed. To echo the words of the hon. Member for Oxford, East (Mr. Norris), who served on the Select Committee, there is no possibility that the Government will be able to get away with that policy at a reduced cost. In my view that is not possible. Such a view has long been on the record. For instance, the Nodder report of 1980 said that the advantages of community care were doubtful if no extra resources in real terms were to be provided. That has long been realised by people in the profession.
An important point is that when people are released into the community they then become the partial responsibility of the families concerned and there is sometimes an intolerable strain on family life if the support services are not properly organised. I have encountered cases in my constituency where families are having a job to cope. I notice from paragraph 45 of the Select Committee report that a general practitioner said:I have never been asked for my opinion in 27 years of practice as to whether somebody's family could cope with them if they were discharged, let alone invited to a case conference.That is a serious point to make. There is no point in discharging people into the community if the burden on the individual families is intolerable.
If the responsibilities for those services are divided between local authorities and the NHS, there is a very great danger of a confusion of responsibility and no clear line of authority as to the development of those services. I accept what the Minister of Health said when he challenged my hon. Friend the Member for Wolverhampton, North-East (Mrs. Short) to quote an example of a hospital having been closed too quickly before the existing services could take over and cope. Nevertheless that danger should be borne in mind. If there is any rush to close those large hospitals before the framework has been adequately prepared in the community, significant problems will be thrown up.
1331 In my view, if we are looking at the future shape of the framework, psychiatric services and services for mental illness should continue to be an NHS responsibility. In 1979 the Royal Commission on the Health Service said:The capacity of local authorities to develop services and in particular residential accommodation for those who are considerably mentally disturbed may have been overestimated.In the polite diplomatic language of a Royal Commission, that meant that it is casting serious doubt upon the capacity of some local authorities to take the strain of that problem when the difficulties start to accumulate. I believe that the Royal Commission was right. Leaving the responsibility with the NHS is the only way to prevent considerable variations in the quality of community services up and down the country. That is a well-established point. When services are left to local authorities, they vary considerably in quality from place to place. We should not take such a risk with mental illness and psychiatric health. Therefore, I should be most doubtful that in some cases that was the right way forward.
I did not stand up to speak in the debate prepared to argue about finance. I am simply not an expert on that, so I could not sustain the argument. Even on a prime facie observation, local authorities themselves have been the object of quite complex financial constraints. I am not debating the merits of that one way or the other, but the point must be made that fundamental objections can be made to a system of finance for psychiatric services that depends on a redistribution of funding between the NHS and personal social services. I do not see that as a coherent financial way forward.
Funding community care can be too easily disguised so that one is not increasing real resources but merely shifting current resources through complicated book-keeping and 1332 the mechanism of joint funding. If we are not careful, community care can turn into community neglect where people get lost.
Already there is great concern among those who have spent a lifetime with mentally ill patients—people who are mentally ill to one degree or another—that there might be dire consequences if mistakes are made in the policy. At time of rate-capping, financial targets, and financial penalties, together with the progressive reductions in the rate support grant, is not a good time to be talking of increased local responsibility for the critical service for the mentally ill.
The burdens of mental illness will increase as elderly people form a bigger proportion of the community, and the psychogeriatric services will come under much strain. A few years ago the audit inspectorate reported that there were wide variations between one local authority and another, and their abilities to cope with the problems that I have described are in many cases limited. Local authorities are too proud to abdicate their responsibilities to private institutions which are often of a doubtful quality.
The needs of patients and those who suffer from mental illness should be paramount and should not be subject to considerations of lowering costs and closing old hostels as quickly as possible. The services should be firmly and emphatically under the control of the National Health Service because only that kind of control can ensure equality of provision and, I hope, a high standard of provision between one area and another. These services should not be left to local authority backwoodsmen. There should be a fully integrated service within the context of the National Health Service. One hopes that in the long run the psychiatric service can lose the stigma and, indeed, the reality of having been for too long a Cinderella service.