§ Mr. John Hannam (Exeter)
I welcome this important debate on a subject with which I have been associated for some 10 years. I congratulate the hon. Lady the Member for Wolverhampton, North-East (Mrs. Short) and her Committee on their work in producing such an excellent report.
I recall an occasion in the early 1970s when the present Secretary of State for Education and Science, who was then Secretary of State for Social Services came down to my constituency to open the Tree Tops centre for mentally handicapped children. It is a wonderful centre which has developed over the years. What sticks in my memory is that, when he entered the hall with all the dignatories and people gathered there, the music being played was Gilbert and Sullivan. As he came in, the song from the Mikardo which started up was "Behold the Lord High Executioner". I have reminded him of that on several occasions since. My right hon. Friend was responsible then for the launching of a major Government initiative for the mentally handicapped, and much of the progress made since then is due to his initiative at that time.
I should like to pay tribute to the record of my local health authority, Exeter health authority, because it is probably one of the leaders in the country in the progress being made in moving patients out of the old institutions and into new staffed hostels and local support units. The latest progress report which the authority has just sent me reads:All programmes are on target and entering a most interesting phase as the new community services open, offering a greater variety of help and support than was ever possible by the central hospitals.I am very proud of the authority's record and I keep in close contact with it. It is one of the authorities we can look to, and I am sure that the Select Committee found that when its members went there. I do not want to dwell on the overall situation and go back over points which have been raised by other hon. Members. However, I stress that there is a good working relationship between the health authority in Exeter and the local social services department. That seems to be why the financial resources and the staff can be switched across the resource fields. That has happened there, and it ought to be possible to achieve the same benefits and progress elsewhere.
I should like to raise three separate issues which concern us in the all-party disablement group and which require urgent answers and action from the Government. The first concerns children in long-stay hospitals and institutions; the second relates to emergency alarm systems, which are important to those who come out of institutions and require help in their own homes; and the third is my concern about board and lodging payments. Only a small number of children are in long-stay mental hospitals, but the matter is urgent in terms of the lives of those involved.
At a recent meeting of the all-party disablement group, representatives from Exodus came to speak to us. That is an organisation concerned entirely with getting children out of long-stay hospitals. Exodus has just produced a report called "Still There" which shows that in England and Wales 450 children are still living in hospitals with 25 1334 beds or more. Not only are children still living in the hospitals, but new admissions to those hospitals are still taking place. There were four admissions this year, and the last one was in May in the west midlands. Surely children should be receiving child care and not medical care in the sense of being in hospital institutions. It is quite wrong for them to be in hospital beds under institutionalised care.
Tremendous success has been achieved in recent years in moving children out of hospitals. In 1980 the then Secretary of State said that there were more than 2,000 children in long-stay hospitals. We are now down to 450, so I am not cavilling at the progress which has been made. One of the principal reasons which makes the statistics appalling is that many of the children have reached the age of 16 and are no longer counted in child statistics. The question must be asked, what happens to them when they reach the age of 16? Many of them have no alternative but to go back into hospital.
If we look at the statistics for those under the age of 16 living in hospitals with 25 or more beds, it is clear that there is a wide disparity between the regional health authorities that have successfully taken children out of hospitals and those that have not. For instance, Wessex and the North-West regional health authorities have all but completed the removal of children from their hospitals. On the other hand, the authorities in the west midlands, southeast Thames and Oxford each have more than 45 children living in hospitals. A number of health authorities have more than 10 children living in hospitals.
I should like to see a final onslaught by the Minister to remove the remaining children, to get it all over with. At the same time, we must look at the type of care they will be going into. The all-party disablement group accepted the recommendation by Exodus that there was a need for the Government to add emphasis to circulars already issued requesting action in this area. Prime responsibility for the care of children must lie with the Social Services Department, and the first step is to ensure that each child is reviewed by the social, health service and education authorities, and the second step is to ensure that the results of their reviews are implemented.
I should like to draw attention to early-day motion 844 which calls upon regional health authorities and the Government to take urgent action to remove these 450 children from long-stay mental handicap hospitals and to find them appropriate accommodation in the community. We want an immediate end to the admission of children to hospitals. The Government have achieved a great deal in the last few years, but in his summing up, I hope my right hon. and learned Friend will agree that the Government must take such action and add some impetus to the action which requires to be taken by the regional health authorities.
Another problem referred to the all-party disablement group concerns emergency alarm systems. Here I have a specific point to raise concerning the legislative provisions governing the grants and allowances for the installation and planning of alarm systems. For many people, particularly elderly people, an alarm system might prevent them from being rehoused in alternative accommodation. I should like to raise a number of points and ask my right hon. and learned Friend to look at them. However, I do not necessarily expect detailed answers tonight.
For example, do the housing benefit regulations of 1982, which allow for benefit to be paid to cover rental and running costs of an entry phone or intercom system for the 1335 proper enjoyment of the dwelling, include emergency alarm systems? Do the provisions in the Health Services and Public Health Act 1968 to allow local authorities to make financial provisions for "aids to daily living" cover emergency alarm systems?' Under the Supplementary Benefits (Single Payments) Regulations a benefit officer is able to grant a single payment if it is the only means by which serious damage or risk to health or safety can be prevented. Is there a case for giving more guidance about this regulation, as the typical user of an emergency alarm system would satisfy it?
These are just some of the areas that need clarification. I hope that they will be considered tonight and that answers will be given in due course.
The vexed question of board and lodging payments gives rise to concern because of the effect that they will have on residential care and nursing homes, and the implications of that for the provision of care in the community for the mentally handicapped and mentally ill. Many homes are finding it extremely difficult, if not impossible, to priovide good care within the new financial limits.
A number of glaring anomalies in the new regulations have led to the situation whereby those who require the most special care are unable to pay for it within the existing limit. The two anomalies are, first, that local authorities do not have the power to top up payments to people over pension age or in nursing homes and, secondly, that, while the new level is £170 a week for a person disabled under pension age, it is only £110 a week for someone who becomes disabled after pension age.
As to people over pension age who suffer from either a mental disorder or a mental handicap, it is not clear from the regulations whether they qualify for a slightly higher limit. I should be extremely grateful if the Minister would clarify that point. Even if they qualify, the rate for someone suffering from a mental disorder but not a mental handicap is £120 a week, but for someone suffering from a mental handicap it is £140 a week. These limits do not account for the additional care that many mentally handicapped and mentally ill people require.
If a home is unable to provide care for an elderly person at £110 a week, that person is unable to look to the local authority for topping up. Such people are therefore faced with a number of options. If they have been living at home, they can continue to live at home but presumably in inappropriate accommodation. Alternatively, they can look for a home that can accommodate them at the given price. That home is most unlikely to be able to provide them with the care that they require, and it is likely to be well away from where they have always lived. The third situation arises for someone who has been living in a hospital for the mentally handicapped. Those people have no alternative but to continue to live in the hospital because they are unable to pay to live in a residential or nursing home. The result is that appropriate care in the community is not being provided.
As to the different limits between those disabled before pension age and those disabled after pension age, it is highly likely that someone becoming disabled after pension age will have to remain in hospital much longer than should be necessary. Alternatively, such people may find a second-rate home, but again that is likely to be away from where they have always lived.
The limits are proving difficult anyway, but they are penalising most severely those homes that provide special 1336 facilities and place emphasis on rehabilitation. Their costs, and consequently their fees, are inevitably higher as they provide physiotherapy, occupational therapy and general welfare facilities. Basically, they are providing more than just board and lodging, and if we are looking for good practice for care in the community, we must look towards the provision of these additional facilities.
As well as hitting hardest the most severely disabled people, these regulations also hit the voluntary homes, because in the main the voluntary homes provide care for the most severely disabled people. Generally speaking, such care is not something that private homes wish to take on. The regulations are clobbering those homes that are providing genuine care at a genuine price for the sake of putting an end to those other homes that have been guilty of abusing the regulations in the past.
The regulations present us with a complete overhaul of the whole system of payments to people in residential and nursing care. It appears that very little consideration has been given to the mechanics of the system. The general understanding of the regulations is that local authorities will pay for residents and then claim back from the resident what he or she has claimed in supplementary benefit from the DHSS. For people under pensionable age, the difference in the charge and the money from the DHSS will be paid by the local authority, and that is the topping up to which I have already referred.
Reports have been coming through—in the last week such a report came through to the Royal Association for Disability and Rehabilitation—that local authorities are totally unable to work out exactly what their responsibilities are. They are reluctant to pay for a resident unless they can be sure that they will be able to recover the supplementary benefit from the resident. Therefore, the resident must apply for supplementary benefit from the DHSS, which will not award it until that resident has a place in a residential home. That is a bureaucratic nightmare that is most certainly slowing up the whole process for the person who needs to go into a residential home or nursing care.
I fully understand that these changes are being monitored very carefully and that the payments limits are being kept under review, but I cannot stress too emphatically that this is an extremely urgent problem. I know that the Minister is looking at representations from various organisations and that a number of them are collating information on how these residential care homes will be affected. But unless some immediate changes are made—and very soon—it will be too late, and many horrifying and distorting stories will reach the press, just as we have seen with the effect that the changes have had on young people under the age of 26.
I know that my right hon. and learned Friend is aware of these problems and that he and the Government wish to correct them as soon as possible. Until they are corrected, and until these other anomalies are wiped out, we shall not achieve our objective of real care in the community. I hope that these points will be taken seriously by my right hon. and learned Friend and that he will deal with some of them when he replies.
§ Mr. Tony Lloyd (Stretford)
The reference to Exeter by the hon. Member for Exeter (Mr. M. Hannam) were accurate, because the Select Committee, which visited that 1337 area, was impressed by the standard of care and facilities provided. But that contrasts markedly with some of the other things that members of the Select Committee saw.
My experience of that Select Committee was one of great personal learning, and to some extent profound horror, about some of the things that still exist, especially in our large and older mental institutions. It has been said on many occasions, and it is worth repeating, that as a society we have condemned many people to conditions that ought to be unacceptable in this day and age.
The Minister and all those who gave evidence to the Committee accepted and re-emphasised those comments. As a Parliament and as a society we have to shape up. We must not pay lip service to the idea of getting away from these institutions. We must first make sure that this is done in a proper and acceptable fashion. It must be recognised that we are talking about individuals coming out of institutions and not statistics. Secondly, we must ensure that we do not move people into new and smaller institutions which offer nothing in the spirit of community care. That is probably the single most important thing that I gained from the Committee's deliberations.
The point was hammered home time after time that there are many extremely worrying examples. For example, attempts have been made to establish structures which were not appropriate to the enhancement of the lives of individuals. The whole ethos of community care is so individual that it is virtually impossible to find global solutions or to operate from outright diktats from the centre. The Minister for Health has said on different occasions that it is necessary to give that type of discretion at local level. It involves a whole new ethos of attitudes to community care.
There is a need, for example, for very close coordination by different agencies. I am concerned, despite the comments of those who feel happier, that there is still dislocation between the health authorities and the Department of Health and Social Security and others who are the professional carers, such as general practitioners and those in society with responsibility. That sentiment was echoed by the response of the directors of the social services to the Select Committee report in which they drew attention to what they felt was a lack of co-ordination. I am worried that if that lack of co-ordination is allowed to continue and develop we shall end up, 40 years on, with everybody saying that we have failed as a society to cater for the mentally ill and the mentally handicapped and that it was not our fault but somebody else's.
A dispute has arisen between the North-Western regional health authority and almost all others concerned about the level of funding passed from the health authority to the local authorities when individuals are transferred from the care of one to the other. The North-Western regional health authority has been using the figure of £11,300 as the amount which should pass with each individual placement. I was interested in the comments of the hon. Member for Leeds, West (Mr. Meadowcroft), who pointed out that on Merseyside £14,000 was transferred from the health authority to MIND when it undertook such a task.
The city of Manchester has calculated that a figure of £19,000 would be more reasonable. The Minister raises his eyebrows, but the regional health authority is insisting upon a figure which the local health authorities and others 1338 concerned feel is inadequate. I know of a case within the Trafford local authority area where a considerable delay ensued before a person was accepted for transfer from an institution to a community-based structure. The result was that the quality of his life considerably deteriorated. The local authority could not afford to develop its own facilities fast enough because of lack of money from the health authority, which is also not happy with the situation.
When I raised the matter in a written question, the Minister made a very fair point and one which I would concede completely. He said:I am not convinced that the production of a centrally compiled account of funding arrangements within individual regions would be helpful without an equally detailed account of the service developments proposed."—[Official Report, 4 July 1985; Vol. 82, c. 246.]I accept the Minister's point about something that, by its very definition, if it is to be adequate community care, has to be so individually based that prescriptions cannot be given from the Elephant and Castle or any large area health authority.
Nevertheless, we have to accept that, even dealing with individually based services, it is necessary to take account of the central funding of resources. The difficulties of which I have spoken will show that the funding is inadequate. It is not satisfactory to allow one authority to blame another. In years to come, we should not be saying that it was a good change of concept but in practical terms had no impact because the different approaches would not, or could not, work together.
Health authorities feel themselves to be constrained by financing problems, and for obvious reasons are reluctant to pass across any more money than the minimum with which they can get away. That is not surprising, but it runs counter to the concept of community care. We should be asking about the individual, not whether he should be transferred out of the institution and into the community but what resources and facilities need to be made available within society to allow him to live an adequate, independent and fulfilled life. Inevitably, that means that we, as a society, have to accept the high resourcing cost. I fear that, the way that the funding of both local authorities and health services is going, we shall not see that.
It is important to draw attention to some of the things that the Select Committee said. My hon. Friend the Member for Ipswich (Mr. Weetch) spoke of the important matter of families and the resources given to them. He spoke about the needs of the family and the need for adequate support for family members caring for others in the family. One witness to the Committee pointed out that professional carers are caring within professional working hours, but members of a family care for 24 hours a day, seven days a week and even, sometimes, 52 weeks a year. We must do much more to make the role of family carers more simple.
Recommendation 36 says:We recommend that local authorities give priority to providing respite care sensitive to the varying needs of different people.They specifically means respite for those caring within the family structure.
The hon. Member for Exeter touched on the important new board and lodgings regulations. When the Minister attended the Select Committee's meetings, he was questioned closely about the position of people who were 1339 moved out into various hostels and houses in multiple occupation. The Committee pointed out that local authorities should be given power to designate as residential care private homes with more than a given proportion of dependent residents.
Many people move to such places from institutions. The standard of care, as far as the Committee could make out, is grossly inadequate. It is necessary that there should be some means of checking and some responsibility on the local authorities to guarantee that the interests of people in such accommodation is protected. That means that there must be adequate licensing and adequate inspection and monitoring arrangements to make such places work properly. The Committee said that community care is not a cheap option, as many hon. Members have already pointed out, and it is important that we recognise that.
I have quoted figures and the Minister might quote different figures. It is certain that the lower cost individuals— if that is not a too inappropriate way to describe human beings—are transferred from institutions first. However, the cost of care in the community is rising. If we are not merely to give lip service to the spirit of the report, we shall have to rethink our attitudes to social provision for all those who live devalued lives. I am referring not only to the mentally ill and the mentally handicapped, but to the homeless and young disaffected people. We shall have to rethink social provisions.
We have no cheap option. We cannot simply say, "Yes, we have a big heart." We must make resources available to ensure that we provide local services. The needs of individuals are not cheap to provide. Society will not find it cheap to provide facilities for all those involved in community care and community living—the families, the professional carers and the extended carers.
We have to make a commitment. I see no evidence of a movement towards making that commitment and I find that sad. If the Select Committee report is left to gather dust we shall miss a massive opportunity.
§ Mr. Roy Galley (Halifax)
The hon. Member for Wolverhampton, North-East (Mrs. Short) gave a competent précis of the Select Committee report. I began to wonder whether there would be anything left for anyone else to say. However, the hon. Lady used a slant of her own, with that brusque charm which we have come to know and cherish. In her exposition she did not start at square one of the Select Committee's deliberations.
I was pleased that my hon. Friend the Member for Oxford, East (Mr. Norris) referred to the definition of community care. One must first define it and then ask whether as defined it is right. There was much debate in the Select Committee, which has not been illustrated in tonight's debate, about whether the concept of community care was right. The debate continues in the country.
The oral and visual evidence given to the Select Committee overwhelmingly stated that the principles of a community-based, flexible response policy to the needs of mentally ill and mentally handicapped people was right. That is not a matter of administrative convenience or of cost, but a matter of the quality of life.
In the more personal nature of smaller treatment units, particularly family-sized units, there is a degree of self-reliance and responsibility which has a curative effect 1340 upon the majority of mentally ill and mentally handicapped people, and gives them a better quality of life.
In the last 15 years enormous strides have been made in the quality of life of physically disabled people, although much more remains to be done. We must now start to do the same for menially disabled people. Two or three years ago the Government set the ball rolling by giving priority within the Health Service to the mentally handicapped and mentally ill. The Select Committee report is another milestone in a crusade to improve the lot of mentally ill and mentally handicapped people.
Two key factors in the Select Committee report are vital — flexibility and individualism. Individual needs are important, and when one considers discharging a person from hospital and changing the method of care an individual care plan must be developed. This requires a host of alternative approaches, as we discovered as the Select Committee travelled in the United Kingdom and the United States. It may be a core and cluster arrangement—rare in practice, but common in theory—of extended family dwellings, small staffed homes, hospital-type establishments with 20 to 25 beds, or even larger establishments. That is why I say that there must be flexibility. Each area must develop its own policies, and it would be wrong to rule out the idea of a 50 or 100-bed unit, because in certain circumstances that may be an appropriate way of dealing with the problems of the mentally ill and mentally handicapped.
§ Mr. Weetch
The hon. Gentleman has made some interesting comments about the quality of life for the mentally ill. If it is to be a community-based policy, he must accept that the community is still suspicious of the mentally ill. If, therefore, a mentally ill person is discharged into a community in which suspicion is abroad, to put it no higher than that, because there is insufficient understanding of mental illness, his discharge may mean the reverse of increasing his quality of life.
§ Mr. Galley
From the units which he Select Committee visited, the weight of evidence seems to be that going into the community and having some self-reliance has a curative effect on the individuals concerned. There may have to be, at least initially, a large measure of staff support, cushioning the effects of a community which may not react well. However, as one sees, for example, wth drug misuse clinics and rehabilitation centres which are closely associated with the community, those barriers can quickly break down.
My right hon. and learned Friend may be bored with the same point being made to him. It is, however, important that points relating to discharge are made by hon. Members in all parts of the House, because it is among the most important issues that the Select Committee considered. There is no evidence from this country that people have been discharged into the community and then not properly looked after. In the United States, however, there was substantial evidence that that had happened there.
We must make sure, therefore, that an imaginative and flexible range of alternatives—from the small, family-sized unit to the larger unit — are available in the community before hospitals are closed. In other words, proper care plans must be developed before people are discharged into the community.
1341 Much has been said abut bridging finance. Joint finance, with people being taken into the community with a cost tag, as it were, attached to them, will not solve all the problems that will be presented as we develop the policy of discharge into the community.
It will be possible in my area of Calderdale to carry out an imaginative response to the discharge of such people only by the provision of considerable central finance. That finance, welcome though it will be, will not be available in all areas. Considerable capital consequences will arise from each change as it takes place, and that will arise before any savings are realised from closing large, impersonal hospital complexes.
Some flexible arrangements for bridging finance are helpful. They will have to be developed into a system with a more formalised central bridging fund, and that will involve initial money being provided by the Department of Health and Social Security. Out of such a fund, money can be donated for immediate needs, and gradually assets will accumulate which, in time, can be used to build up a network of community care facilities. In due course that network will be completed and the money that has accumulated will be available for other Health Service provision. I hope that my right hon. and learned Friend will give considerable and detailed thought to that approach.
There is a small proportion of the mentally ill and the mentally handicapped for whom radical change may not be appropriate. Some are suffering from multiple handicap or are so ill that they would not be able to cope with any sort of community facility. Such people form a small minority, but we must recognise that they exist. There are others who are old, and a change in their environment would be counter-productive. There may be a requirement to move from a large building to a small building, but we are discussing individuals for whom there cannot be change. These people will be unable to move from an environment that is essentially institutionalised to one that is community based.
As the process of change gathers pace there will be lessons to be learned. There will be a need for small adjustments to policy as time passes. In developing the strategy, the advice of the Select Committee is, "We agree that this approach is right, and let us get on with the job, but festina lente. Let us do so with sensitivity and care." There is a need for radical change, but it must be accompanied by careful thought and full preparation. The growing pace of community care provision will mean changes for staff in many disciplines. The staff will need new skills and attitudes. The change of focus from the hospital to the community will not always be easy. The development of multi-discipline approaches and the breaking down of rigid demarcations will be extremely important. The evidence suggests that the dedicated staff who run our mental illness and mental handicap services have embraced change with considerable enthusiasm. However, there are small groups that will be resistent to change. The Select Committee met a degree of resistance from psychiatrists and from other sources as its members visited various parts of the country. However, in practically every instance the professional bodies were supportive of the new policies and the change of focus.
Undoubtedly an element of caution is proper, especially among psychiatrists and the various shortage specialties 1342 that are involved in dealing with the mentally ill and the mentally handicapped. We need to balance the airing and resolution of anxieties with the need to make progress with successful change. The trend towards community care will be only one of the pressures that will lead to change in the work of general practice.
The presence of the mentally ill and the mentally handicapped in the community will place greater pressures on general practitioners. It is right that they should be involved closely in the treatment of people once they have been discharged from hospital. General practitioners must be deeply involved in the treatment of those who have never been in a hospital. One senses that at times general practitioners have been resistent and reluctant to be involved closely in the care of these people, but they have to co-operate with many others. The involvement of GPs will mean that they, the GPs, will need to manage their time more efficiently and optimise the use of their skills. They will need to free themselves from more minor asks that can be dealt with by nurses, or pharmacists, for example.
There will need to be flexibility. For example, GPs will have to be prepared to refer patients to community psychiatric nurses, and the role of the nurse will need to develop within a team approach. An excellent service is currently being provided. It is just beginning to grow and to make an impact upon us and we must give it considerable assistance. If we are to make the best use of CPN services, it will be necessary for more staff to move into that area. That will create a need for proper training and deployment and a more coherent approach to their terms and conditions of employment as compared with hospital-based staff. Within the development of CPNs and community nursing services, more parts of the country must place emphasis on developing community mental handicap teams.
The Select Committee was impressed by the amount of co-operation between a range of medical, nursing and social service professionals and stressed the need to strengthen that co-operation. Gone are the days when different professionals worked in their own tight little boxes. There is an increasing need for the co-operation of equals.
It is too easy to become involved in sterile arguments about administrative structures, but there may come a time when, as these services develop and barriers are broken down, we need to provide administratively as well as practically a combined health and social service system.
Greater co-operation, a reduction in barriers and increased sensitivity are needed by DHSS staff dealing with social security, because they become increasingly important when the mentally ill and mentally handicapped live in the community. The benefit entitlement of people moved out of hospital into local authority or NHS regulated accommodation is an important consideration. There seems to be an inconsistency in the operation of the various regulations when people change from one type of accommodation to another. Significant changes in accommodation may not be dealt with sensitively by social security staff.
Rigidity, whether in social security, social service or medical matters, is the wrong approach towards the mentally ill and mentally handicapped. I hope that we shall develop a flexible, individualised system. I was encouraged by the suggestions in the social security reviews that the social fund could be used flexibly to meet 1343 the need for community care as people are discharged into the community and that a sensitive evaluation should be made of the needs of the mentally ill and mentally handicapped to give a new quality to their lives.
§ Mr. Dafydd Wigley (Caernarfon)
I compliment the hon. Member for Halifax (Mr. Galley) on the sense of the points that he made which were drawn from his experience as a member of the Select Committee. I was not a member of that Committee, so my comments will be brief.
The Committee's report is excellent, featuring a number of practical challenges that face us and bringing us face to face with the question whether we have the commitment to carry out the programmes leading to the integration in the community of the mentally handicapped or mentally ill. I shall concentrate on mental handicap, because I have more knowledge of that aspect, but many of my points will relate to mental illness as well.
The Committee's brief was geared mainly to the position in England, but the Committee also went to Cardiff. The success or failure of the Welsh initiatives with respect to policies for the mentally handicapped is relevant to the thrust of the report. A few years ago, the "All Wales Strategy for the Development of Services for Mentally Handicapped People". suggested not long-stay hospitals but 36-bed or 48-bed hospitals as a means towards integration in the community of the mentally handicapped. The horrified reaction of many people not only in Wales but elsewhere led to the good strategy which we now have which was described in the November Mencap conference in Madrid, which I attended, as the best theoretical plan in western Europe. Unfortunately, theory and practice are not always the same, and we are experiencing considerable difficulties in turning many aspects of the plan into reality.
In the context of the Select Committee's report, it is worth noting three main principles of the "All Wales" strategy. It is important to note that it is written into the strategy thatthese general principles apply to all mentally handicapped people, however severe their handicaps.The first is:Mentally handicapped people should have a right to normal patterns of life within the community.That is also the main thrust of the Select Committee report. Secondly:Mentally handicapped people should have a right to be treated as individuals.This means that they and their families must play a full part in decisions intended to help them. Clearly, it is easier for the less acutely handicapped to take a meaningful part in decisions affecting them and to practise self-advocacy. For those who are not capable of personal direct involvement, the advocacy service must be developed to ensure that their needs and requirements are taken fully into account. In due course, we may need to address our minds to developing a structure to ensure that.
Thirdly, the strategy states:Mentally handicapped people require additional help from the communities in which they live and from professional services if they are to develop their maximum potential as individuals.That them has emerged time and again in today's debate. We are not talking about cut-price options. We are talking about what is right and gives people dignity and a meaningful life as opposed to the terrible existences that 1344 they have led in long-stay hospitals over the years. Making this system work is thus likely to require greater rather than smaller resources, especially during the interim period, and I am glad that the Select Committee report addresses itself to that aspect.
As the long-stay hospitals move out into the community, the patients most capable of doing so will go out while those who remain are likely to be those with the most problems and in need of the greatest resources. In any case, the overheads will remain to be met for a considerable period. Regrettably, some patients may never move out into the community, although we should aim to get as many as possible out of the long-stay hospitals and into suitable care.
There will thus be a parallel demand for community-based services and for continuity of the hospital services and it is important that the Government clearly accept that. The morale of many people in the Health Service is low because they are uncertain about what is to happen to the hospitals and to their own involvement as the emphasis shifts to the social services. I am sure that the Select Committee is right to state in recommendation No. 55:In the long-term, this inquiry has confirmed that the separation of health and social services for mentally disabled people is illogical and inimical to joint services. Some means of eventually bringing the two services together is desirable, which would not destroy the present degree of integration of social services with other local authority services, nor diminish the priority given by either the NHS or local authorities to mental disability services.It is important that that should be placed on the record. We must work towards that end, not by drawing social services away from local authorities but by bringing the Health Service at the sharp end — the local, consumer end — closer to the local government structure. If we are to make care in the community meaningful, we must develop locally based domiciliary services because the kind of service that is provided on an institutional basis in long-stay hospitals will be equally needed by people living in small groups or in their own homes. The services will be much more difficult to arrange, but they must be provided if people are not to miss out.
I take the example of medical services. Many general practitioners have no training and very little experience of handling mentally handicapped people, who occasionally become ill just as anyone else does. General practitioners may need some specialised knowledge to treat and respond to those patients. The same applies to nurses in ordinary hospitals into which mentally handicapped people may need to go for a few days. There needs to be an awareness of the training available for the staff who are dealing with them.
We heard from the hon. Member for Exeter (Mr. Hannam) of the need to turn off the tap as a first step towards integration, and to ensure that no young people under 16 go into long-stay hospitals. That has been the objective of successive Governments, but regrettably we are a long way from achieving it.
We heard some disturbing figures in the all-party disablement group last week. I subsequently tabled a question relating to Wales. I asked how many young people under 16 are resident in long-stay hospitals in Wales, and I find that there are 43 such persons there now in 20 long-stay hospitals or units to which they may go. I now have an update on the figures that were given last week, and apparently 10 such people have been admitted 1345 during 1985. If we are not getting things right at that end, we shall never get the integration into the community that we seek.
I am glad to say that integration is happening in some places. In my constituency last Friday, the Under-Secretary of State for Wales, the hon. Member for Conwy (Mr. Roberts), was present with me at the opening of a community-based facility. I think that the Minister and other hon. Members will be interested to hear about it.
A constituent and good friend of mine, Gwynn Davies, and his wife Mary, who have a mentally handicapped son who is now in his twenties, had determined to get a community-based facility for mentally handicapped people in their own village. They set up a non-profit-making company, with trustees, and with 200 villagers as shareholders in the company, to develop a small community home for three mentally handicapped people, a shop in which they can work, and a few acres of land in which they can do agricultural and horticultural work. They are getting the financial support that is necessary from the public sector through the Welsh Office and the "All Wales" strategy.
That is an example of enthusiasm on a voluntary basis within the community being tied together with the resources that are available only through the public sector and the state, to get development on a human level on a scale that is meaningful to the people that will benefit from it. Unfortunately, not every village in Wales or in England has a Gwynn and Mary Davies, but many of them have the boys and girls and the men and women who need that sort of initiative.
The challenge is, how do we get community-based services integrated into the community to grow with the enthusiasm and the flair that is seen in the sort of project that I mentioned without becoming bureaucratic on a small scale, in the same way that the long-stay hospitals are bureaucratic on a larger scale? It is not an easy aim to achieve, but it can be done. Three or four years ago I saw how people had succeeded in doing it in Sweden by making sure that the resources, the commitment and the determination were present.
If we are to turn the theory into practice, we need a tremendous commitment. We have to avoid the pitfalls of bureaucracy. We have to avoid putting people into jobs and thinking that by appointing more theoretical people behind desks we shall succeed. We must have people who are enthusiastic at the sharp end. It is a challenge to every Government, and one that is worthy of the effort.
§ Mrs. Edwina Currie (Derbyshire, South)
I think it would be wise to pay tribute to the Chairman of the Select Committee, the hon. Member for Wolverhampton, North-East (Mrs. Short). She will be leaving the House at the end of this Parliament and she will be greatly missed. She has held together in the Committee a very disparate bunch of people. Whatever our arguments and disagreements, we owe her a great deal for her deeds and commitment to social services and to the welfare of our disabled people thoroughout the country.
The hon. Lady said that the nub of the question is resources, and I hope that the House will recognise that the 1346 chance of getting those resources for the National Health Service and local authorities is much better under this Administration than under any previous one.
In the last decade, the cash allocated to the National Health Service — for example, the current money for England—has gone up by three times, but in real terms we have seen a steady rise since this Parliament took office in 1979, compared with a fall in real terms in the mid-1970s.
My hon. Friend the Member for Oxford, East (Mr. Norris) produced many figures. With everyone else, I have done 60 hours work this week already and, like him, I tend to find that figures start to become a little peculiar when one has not had much sleep. Therefore, I shall merely draw attention to the trends. The fall in real terms in the mid-1970s took place when the right hon. Member for Plymouth, Devonport (Dr. Owen) was the Labour Minister for Health. One wishes to put that on the record and say, so much for his comments about nurses during Prime Minister's Question Time this afternoon.
During Prime Minister's Question Time, questions were raised about whether the Conservative Government want more public expenditure and what our attitude is. The Prime Minister said that the key factor was the percentage of GDP represented by this public expenditure. We should put on record the fact that the allocation to the National Health Service under this Administration has consistently been about 2.9 per cent. of GDP, which compares with 2.5 per cent. or 2.6 per cent. under the Labour Government.
§ Mrs. Currie
It was not on a falling total — [Interruption.] I invite the hon. Gentleman to intervene.
§ Mr. Corbyn
The hon. Lady is talking about maintaining expenditure on the Health Service, which is not true. There have been significant cuts in many areas of the Health Service. Secondly, there have been massive cuts in other areas of public expenditure, which increase the proportion of expenditure on the National Health Service without improving patient care where it matters.
§ Mrs. Currie
I am talking about current expenditure in the National Health Service in England. My figures come from the Library. The hon. Gentleman is entitled to do as I did and ask the Library to give him the objective figures for expenditure. In real terms, in cash terms and in the percentage of GDP, this Government have done a great deal better than the Government of the party to which he claims to belong.
§ Mr. Corbyn
On a point of order, Mr. Deputy Speaker. Is it in order for an hon. Member to say that I claim to belong to a political party when I have been a member of that party for 19 years and intend to remain so?
§ Mrs. Currie
The hon. Gentleman has not been here for most of this debate. He is never here for other debates on the Health Service and social security matters. He might do better to listen to somebody who is.
§ Mr. Corbyn
On a point of order, Mr. Deputy Speaker. Is it in order for the hon. Member to mouth inaccuracies? I have been here for most of this debate and I attend almost every debate on health and social services as a spokesperson for my union, the National Union of Public Employees.
§ Mr. Deputy Speaker
Inaccuracies seem to be part of the daily diet here, although I must say that the hon. Gentleman has been here for most of the time that I have occupied the Chair.
§ Mrs. Currie
Apart from the rather silly comments that we have heard during the past few minutes, may I draw attention to the comments of the hon. Member for Oldham, West (Mr. Meacher) in the Daily Telegraph last Saturday. He said that the real growth in the NHS that has been provided by the Government is not real growth because it has been swallowed up by demography and by the increased costs of equipment and of pay. I would point out to the hon. Gentleman—who has not graced us with his presence today at all—that no rules said that we had to provide the extra money for demography. No rules say—
§ Mrs. Currie
In a minute. Sit down.
There are no rules which say that any Government must provide extra money for extra pay, for increased prices or for demography. The fact is that this Government have and the previous Government did not.
I have also heard it said that the percentage of GDP spent on health care in other countries is higher than it is here. Indeed, so it is in countries that finance their health care either privately or through the insurance system. They have to count into their GDP on health care the costs of the people who send out bills and invoices, the people involved in credit control and the credit ratings of those who must pay for the service, and all the people who must chase up the poor souls who cannot pay. As long as we have a Health Service financed through taxation, the percentage of GDP is likely to be lower in this country. Long may it remain financed in that way. Does the hon. Member for Holborn and St. Pancras (Mr. Dobson) wish to intervene now? No; he is busy writing his speech.
May I now turn to the specific topic of community care, in which I have a special interest, because there are eight hospitals in my constituency, of which seven are long-stay, dealing with mental illness, mental handicap and geriatrics.
It used to be the practice that Nottinghamshire dumped its long-stay patients in Derbyshire, particularly in south Derbyshire, and that Derbyshire dumped its long-stay patients in Nottinghamshire. I have a large number of constituents who are effectively rootless and completely cut off after many years in hospital from their communities. The regional health authorities plan to close most of those hospitals over the next 10 years and transfer the patients in one way or another to the communities around. All these hospitals have done excellent work over the past century. I single out Aston hall hospital and the Pastures hospital at Mickleover in Derby. Aston hall is blessed with £800,000 for a demonstration project to show the work that can be done with community care. It has got that money because it has a first-class record of moving 1348 people with dignity and compassion into the community and having them accepted in that community. I am glad to see that.
I have no doubt whatever that the staff, with the co-operation of local people, can ensure a smooth transition to more normal life styles for many of those patients and, perhaps even more important, for potential patients who might otherwise be obliged to go in. The health authorities' activities therefore have my full blessing. I shall do everything that I can to help them. Governments for many years have made the Cinderella groups of the elderly, the mentally handicapped and the mentally ill, a top priority. At least, that is what they have said. In the case of the elderly, I suspect that such a declaration has been almost unnecessary because the growth in numbers alone and the needs of the elderly have meant that they take up the bulk of the services. In the National Health Service, for example, they use about half of all the acute beds. We should recognise that this Government have consistently accepted the demographic imperative—if I may put it like that — and have made resources available.
As for the mentally handicapped, their status has improved dramatically over recent years. My right hon. and learned Friend will remember the battle of Amesbury road in Moseley in which I tried to construct an adult training centre for the mentally handicapped within a stone's throw of his house. The objections came, not from my right hon. and learned Friend but from one of his neighbours who was a surgeon at a local hospital. We managed to shame the man into accepting it. It was some years ago.
Even in 1970, mentally handicapped children were regarded as ineducable. Now, they are found all over the country in little units attached to normal schools and they are doing very well. I believe that once they, their families and their neighbours are used to their being in the community, that is where those children will tend to stay. Once this generation of mentally handicapped hospital patients has gone through the hospitals, I doubt if we shall ever again fill up the hospitals by "putting such people away".
The specific problems that 1 think we face and have not solved are those of the mentally ill. Mental illness is not a nice topic. It is not an easy topic to discuss. The main reactions that one gets in this area of work are ignorance, apathy, prejudice and hostility. I became aware of this problem of acceptance when I was chairman of the central Birmingham health authority. I was obliged to close a ward in the Queen Elizabeth hospital. It was a psychiatric ward, and it was on the top floor of the hospital and our patients started throwing themselves out of it. We eventually reopened it as an out-patients' department.
The first question that I asked was, "Why on earth did we put an acute psychiatric ward on the top floor of the hospital block in the first place?" The answer was that the professor of psychiatry had a battle royal to get psychiatric patients regarded by his own colleagues as ill, treatable, curable and appropriately placed in the teaching hospital, and therefore, the fifth floor ward which no one else wanted was the only one available.
Most psychiatry in the United Kingdom—the Select Committee saw this on its visits—does not take place in teaching hospitals; it does not take place in acute hospitals; it is not glamorous; there are vacancies for staff 1349 and very often the staff are untrained or undertrained. They are overworked, unsupported and unappreciated. That is a matter of fact.
What is missing is not so much resources. What is missing is not so much the Government commitment. What is missing is public understanding and the acceptance of mental illness. Just as the professor had no end of trouble persuading his colleagues in the medical profession to accept the presence of his patients in their hospital, so those of us who take an interest have a major task ahead of us persuading constituents and colleagues that the mentally ill are not different people to be segregated as if they have some disease that is catching. They are part of our community. Appropriate treatment, rehabilitation and research facilities are not an option but an absolute necessity.
Serving on the Select Committee on this topic was a depressing business in itself. The National Schizophrenia Fellowship presented us with many pages of evidence and I challenge anybody to read those case histories without feeling desperately sad. It is a heartbreaking business. The most noticeable feature of much of the evidence received was the anguish and bewilderment of many of the families, including families with the NHS in other contexts—such as those where the head of the household was a doctor — that there was no help available for such patients. They have found that, 40 years into the NHS, too often the attitude of public authorities consists of a mixture of stonewalling and buckpassing so that precious little progress can be made.
Mental illness is no respecter of persons. It is now just about three years since an hon. Member committed suicide. I hope that sufficient time has passed for us now to look at the matter a little objectively. Jocelyn Cadbury was my Member of Parliament. I was his senior councillor and twice running a member of the selection committee which invited him to fight the seat. I attended the inquest and we found that he had twice before tried to commit suicide. I do not think that it would have mattered very much if we had known because he had fought the illness successfully for 16 years and had no particular reason for feeling depressed. There was no reason, as far as we could discover, why he eventually succumbed.
I believe that, if Jocelyn Cadbury had suffered from a physical illness, he would readily have admitted it, sought help and expected to receive, and received, sympathy. Because it was a mental illness, he feared the stigma and was unable to ask for help in time.
We still have a desperately long way to go to change attitudes towards mental illness. The Government have shown themselves willing to face the expectations that we all put on the NHS. My right hon. and learned Friend has shown his capacity to follow public opinion and to lead it. I hope that he will take to heart the remarks of the Select Committee on this difficult area and continue his efforts to improve the care that we offer all of our people.
§ Mr. Jeremy Corbyn (Islington, North)
This is a timely and useful debate. I congratulate the Chair and membership of the Select Committee on producing a report which allows a debate such as this. Several of its observations are valuable and some of its recommendations should be taken up. As I am sponsored by the 1350 National Union of Public Employees, which has many members in the Health Service and local government, I must observe that they will be at the sharp end of any programme of continuing closure of large psychiatric institutions and the transfer of resources to borough councils.
As I was a borough councillor in Haringey, I am well aware of the enormous pressure on resources on a borough council's social services budget and the difficulty of arguing for sufficient funding for the mentally ill. Although I welcome the idea behind the Select Committee report and the work that it has put into the subject, we must remember that community care as many members of the Select Committee envisage it is extremely expensive. I am not convinced that the Government are prepared to put in the necessary sums of money. Nor am I convinced that they are prepared to lift restrictions on borough or county council expenditure to enable them to make provision for the mentally ill. I am alarmed that the Government are proposing community care on the cheap. That would entail grave dangers of privatisation, private homes and all that goes with them.
Many Conservative Members hold up for praise the great virtues of the north American health service. They often quote the alleged efficiencies of health care in the United States. Many studies have been done of the process which is known as deinstitutionalisation in the United States. They have found that deinstitutionalising the mentally ill and putting them into privately run and privately owned institutions does not guarantee their safety, a cure or help, but means that somebody makes a great deal of money. The motive is different: not to look after people but to make money out of them. The American Federation of Labour and Congress of Industrial Organisation conducted a survey on private care for the mentally ill and the concept of self-regulation. Its report said that self-regulation wasinadequate, unworkable and unacceptable as a substitute for strict government enforcement of standards.Although Conservative Members praise the American system as an example of the unfettered, free market economy, they should remember that there is another side to the coin.
There is severe understaffing in the institutions which provide care for those who are mentally ill or who need psychiatric care and insufficient resources are made available. Vast needs are not met by the large institutions. The Minister for Health should tell us how much money the Government are prepared to put into community care. Inadequate resources are being provided. Community care is far more expensive than institutional care, so much more money will be needed to enable a smooth transfer to community care. In 1979, the Jay committee reported that the number of staff working with the mentally handicapped needed to be more than doubled to 60,000. The Government have not responded to that recommendation and the number of places has decreased. Guidelines for local authority residential provision for the mentally ill suggest 0.33 places per 1,000 of the population. The present provision is one third of that number. Although the provision is increasing in some areas, there is still a long way to go.
Those who are physically or mentally handicapped are cared for not only by institutions, the social services and the National Health Service but by a large number of people who are forced to give up their jobs to look after 1351 relatives who are ill. Although Conservative Members praise the concept of community care for relatives and neighbours, in many cases it forces women to give up promising careers. The reason is that inadequate funds are made available. The Labour party is determined that they should not be forced to give up their careers. It will ensure that adequate public resources are made available. I know many people whose careers have ended because they have had to look after mentally or physicall ill relatives. It is a very serious problem, and I am surprised that Conservative Members are smirking.
§ Mr. Charles Kennedy (Ross, Cromarty and Skye)
The hon. Gentleman said that the Labour party would provide more resources for the care of the mentally and physically ill. How would it provide help for those people?
§ Mr. Corbyn
The hon. Gentleman has made a perfectly reasonable point. Financial remuneration could be provided for those who are forced to stay at home, and there could he more community nursing facilities and home helps. Nobody should be forced to give up a career simply because a relative is seriously ill. Nobody should be forced into financial hardship as a result.
There are many recommendations in the report. The principle of the financial atmosphere in which the report has been produced has to be examined. While some Conservative Members may choose as their bedtime reading Conservative Central Office or Department of Health and Social Security propaganda, the fact is that there is serious underfunding of the Health Service in general, serious underfunding of the social services and serious underpayment of many manual workers in the hospitals or social services departments.
The report refers to a serious problem in recommendation No. 55 — the relationship between the National Health Service and the local authorities. While the report is careful and specific in saying that there has to be a close relationship between the institutions in ensuring that community care is properly carried out and that individuals who are being looked after by the community are properly looked after and not put at risk, the report begs the question about the relationship between the Health Service and local government — with the democratic nature of local government and the essentially undemocratic and rather patronising nature of the Health Service structure.
In areas such as care for the mentally ill where there is a close overlap between the role of social services departments and that of the NHS, both institutions must be looked at again. I would favour bringing things closer to the local authority where there is a greater possibility of democratic control, or democratising the Health Service. The relationship between the two institutions must be brought closer together.
I should like to refer to several recommendations — [Interruption.] If Conservative Members cannot be bothered to listen, there are plenty of bars in the building that they can go to to continue their conversations.
The first recommendations to which I refer is where the report rightly refers to the high cost of community care. It states that it cannot be done on the cheap. If the Government pay lip service to the report, I hope that they will respect that recommendation and make the necessary financial provisions available.
The report also refers to individuals leaving mental institutions and making sure that an individual care plan 1352 is available for such people so that they are not lost in society or some plethora of so-called community support, but are genuinely looked after individually. That is extremely important.
Another important point concerns the need for a central bridging fund to ensure that sufficient money is available for the cost of closing psychiatric hospitals and the increased cost to the local authorities. Another particularly important recommendation, which shows that a great deal of work has been put into it, concerns the design of buildings for the mentally ill and the need for consultation on it. As one who has been involved in examining building design in the past, I believe that far too often architects' ideas tend to run away with them, as do local authorities, ideas. They do not take into sufficient account the needs of the people who will have to use the buildings.
There are social security problems for the residents in psychiatric institutions or mental hospitals. I hope that the Department is prepared to examine that seriously. Many relatives of people in mental hospitals have come to see me, who have been concerned about the way in which benefit payments are made to patients in those institutions and their understanding of the benefit payments to which they are entitled and which are being paid to them.
Recommendation No. 90 is about the disposal of sites after the closure of mental hospitals. People in my constituency are concerned about that. The regional health authority is proposing to close Friern Barnet hospital, which is in the Prime Minister's constituency. The Select Committee suggests that before such an institution is closed and the land or the buildings sold it must be offered for the maximum use of the service for which it was built. Many people are sceptical about the motive for closure and sale. They believe a lot of it is asset stripping and that sufficient funds are not being made available to the local authorities to undertake the necessary care for the psychiatrically ill.
I should like to make some specific points about the effect and thrust of the policy proposals on London from the DHSS. Virtually every social services department in London has been told by the Government that it is about 30 per cent. over the grant-related expenditure allocation formula. It must, therefore, be fairly obvious that if those social services departments are to have far greater responsibility for the mentally ill, they will require more resources.
I hope that the Minister will say tonight whether the GREA formulas will be adjusted to take account of the needs of those people who are to be cared for by the community, or whether the same punitive measures will be taken against those social services departments as have already been taken against eight London authorities through the rate-capping proposals last year. The operation of the resource allocation working party formula on Health Service expenditure means there is a continuing and long-term outflow of resources from inner city areas. Those of us who represent inner city areas are acutely aware of that every day. We are aware of the long-term plans for the closure of many hospitals and of the centralisation of health facilities in individual boroughs or health authority areas. I hope that the Minister will recognise that there has to be a serious change of attitude on this matter.
In my constituency, Islington borough council, as part of the local authority partnership agreement, is in discussion with the regional health authority and the Government about developing care in the community, and 1353 on the effects of the closure of the Friern Barnet institutions. At the present time, 300 Islington residents are patients at Friern Barnet. Of those, 100 are psychogeriatrics, 100 need medium to long-stay accommodation and 30 are acute psychiatric cases. The local authority has cut forward a detailed set of proposals on how those cases can be dealt with.
The real problem is whether there will be sufficient money available from the regional health authority to the local authority to meet the needs of those patients. It has not been made clear how much it will cost to care for a patient who is no longer in a mental institution but in some form of community institution. I know of no figures made available on this matter and, as I said earlier, the local authorities are still being penalised by the grant-related expenditure formula. The Government should come clean on this matter.
Many local authorities are in the same position as my own borough of Islington where a local institution is being closed. There will be an influx of mentally ill to that area, and enormous responsibility will fall on that social services department. If sufficient funds are not available, the effect will be further cuts in the social services received by other people or inadequate care for people leaving those mental institutions.
Many people are extremely worried and suspicious about the motives of the Government in promoting community care. They do not know whether it is to be a cost-cutting exercise or a genuine attempt to improve care for the mentally ill in our society. Exactly the same problem is faced by the neighbouring borough of Haringey where about 400 patients will be coming from Claybury Friern hospitals when they close. Exactly the same problems apply there about the operation of the GREA formula and the costings they have worked out for it.
Mental illness in society requires more discussion. A matter of importance that is completely missing from the report, which could perhaps be studied at further length by the Select Committee, is the causes of mental illness. Any cursory study will show that the incidence of mental illness is greater in areas of high stress, intense poverty and high unemployment, and if we return people to those communities we must be clear about what we are doing for them.
The growth in, and causes of, mental illness require serious research. It is not good enough simply to say, "We will do our best to look after the mentally ill." That is obviously the case, but we should also look at the causes of mental illness, its patterns and the possibilities of cure of the conditions and symptoms.
Many people who work in mental hospitals such as Friern Barnet and Claybury which are threatened with closure feel a sense of injustice and anger at what is happening. They have worked very hard for many years in those institutions often under-staffed and in very difficult conditions. They are doing jobs for which they are not paid enough, and quite often they have not received proper training because of the way in which those institutions have developed. Therefore, it does not seem fair that closure should be proposed when it is not clear what will happen to the staff. It is not clear what the staffing implications will be for the borough councils that will receive the patients from those hospitals, nor is it clear what will be the long-term future for those people.
1354 We require from the Government sufficient funding to pay for genuine community care, not care on the cheap. We also require a public education programme so that people understand the causes of mental illness and have respect for those who suffer from it. The mentally ill should no longer be put at the back of the queue either in terms of resources within local authorities or resources within the Health Service. If that continues, the mentally ill will continue to be shoved to the back, as a result of which we forget about them and pretend that they do not exist, as has happened for far too long.
§ Mr. Charles Kennedy (Ross, Cromarty and Skye)
I feel as if I am bringing up the rear before the House listens to the replies from the Front Bench.
I was not a member of the Select Committee that produced this commendable report on community care. However, it has been interesting, informative and educational to listen to the debate and, as it were, to have flesh put on the report. After all, this was a unanimous report, and hon. Members have tonight given their own views on various aspects of it.
As I have said, I take an interest in health matters, but in this case I represent a Scottish constituency in which this is an important issue. The two hospitals there — Craig Phadrig and Craig Dunain — are greatly affected by the thrust of the policy which the Select Committee has been examining.
The debate has been notable for its lack of partisan flavour, with the exception of the hon. Member for Derbyshire, South (Mrs. Currie), who in characteristic rumbustious fashion gave a spirited party political defence of the Government's spending programme and disciplines in relation to the Health Service. She seemed to antagonise several hon. Members in a quiet way, but I could not help but feel that with the recess approching we are about to implement our own form of care in the community. We are going to shut down this central institution and move Members round about the country back into the community. Perhaps the old adage is true that MPs are more effective and less like manure when they are not all piled up together in an odious group but when they are spread round the country and there is a chance that they might do some good.
§ Mrs. Edwina Currie (Derbyshire, South)
I am sorry if I hurt the hon. Member's feelings by being critical of his party leader in his previous incarnation as Labour Minister of Health. I merely wish to put on record one or two facts. Would the hon. Gentleman admit, having heard me speak many times in social services debates, that I can be exceedingly critical of the Government when I feel like it?
§ Mr. Kennedy
If so, it is in exceedingly coded terms. It is usually well padded by glowing remarks about the Minister, his spending record and his general demeanour. In fact, everything he is going is good, but.
We are getting off the subject, but on the point about spending, it is interesting to look at the figures when my right hon. Friend was Minister for Health. During that time the NHS had the largest ever sustained, in real terms, growth pattern.
§ Mr. Kennedy
I think he was practising some of the principles which still guide him in politics today. It has been agreed all round that the basic issue of concern is that of funding. It will come as no surprise to the Minister, speaking in the luxury of the Opposition Benches, when he hears me say that I am firmly in favour of more funding for community care.
There are some fairly cruel contradictions or some dilemmas for local authorities in this policy. They have been encouraged to enter into joint funding agreements. They now find that, because of another arm of Government policy, namely, rate capping, they are faced with the dilemma of perhaps having to maintain the statutory financial obligations, particularly as the taper effects begin to move the burden for joint funded projects away from central Government and back to the local authority. As they have to consider how they meet the challenges or the obligations, it is likely that they will fall foul of Government policies in other sectors.
I think the Minister, being reasonable, would agree that dilemmas are presented for health authorities and local authorities. The point made by several speakers on bridging finance is particularly pertinent in that context. The hon. Member for Oxford, East (Mr. Norris) quoted the Minister as saying that if some hospital facility has been greatly under funded and the function is transferred to community care the cost will go up. That is without doubt the case. There is no doubt that bridging finance and real pump priming are extremely important and additional pump priming is also important to make this whole shift in the balance and in the nature of care more effective and less crippling financially to local authorities than it has been or will yet be.
I should like to move to the role and position of the support services within the community. One of the commendable features about the report is the scope and the breadth with which it adopts its examination of the subject matter. There are two areas of particular concern. I mentioned the hospitals in my own constituency, but I am sure this applies to every Member who is in the Chamber. One is housing and one is transport. The Committee has done a good job in pointing to the need for more housing. It is right to look to the housing associations in particular as leading the way in the development of more housing geared specifically, certainly sympathetically, towards the needs of those with various forms of disability or handicap. That is welcome, and will obviously feed in well to a care in the community programme.
Some of us in the alliance have been spending a considerable amount of time in Wales recently. It made me laugh to hear everybody say what a big constituency Brecon and Radnor is. It is about 1,000 sq miles, whereas my constituency is 2,000 sq miles and involves several islands as well as the coast-to-coast mainland in the north of Scotland. Therefore, transport is close to our hearts. I was glad to see that the committee spent some time concentrating on transport. It said:Desperately little attention would seem to have been paid to the effects on transport services of community care policies.Everything should be done to examine that problem, particularly in the rural areas with scatttered populations. With the exception of the Western Isles and Orkney and Shetland, I could claim the constituency with the most scattered population. Not only is public transport essential 1356 in such areas, but the car is not a luxury but a necessity as well. Anything that can be done to focus on transport and its place in the community care policy is welcome.
The report is extremely interesting and points the way to the future when it recommends thatvoluntary bodies be approached with the idea of piloting service-contracting.That is just one aspect. There is an immense potential for the voluntary sector to be harnessed still more. I appreciate the anxieties of the hon Member for Islington, North (Mr. Corbyn). That need not mean that one is trying to offload on to the voluntary sector, much of whose work is unrecognised and unsupported, what should be the rightful duty of the state or the local authority. However, voluntary bodies have an enormous amount of good will and ability, and can make a big contribution to the community, as the hon. Member for Caernarfon (Mr. Wigley) made clear from his local example. The voluntary sector could and should be more involved.
Sometimes, the various statutory and professional groups tend to approach the so-called Cinderella services somewhat hesitantly. They do not wish to involve voluntary bodies too much because it might lead to additional difficulties. I appreciate that there may be problems with professionalism, but much more can be done.
If I am lucky, I may learn, more about the role of the voluntary and informal carer at Social Services questions next Tuesday. Assuming that the supplementary questions are somewhat shorter than the speeches that have been made tonight, we may reach try question. I shall be asking the Secretary of State whether he has any intention of introducing a specific carer's benefit which, if it were introduced, would go a long way to overcoming the problems that we have been discussing.
More can be done to encourage the local benefits office, the local housing office, the local social services departments and the local health authority to try to come together. This does not necessarily involve extra finance. We should try to provide some help for the person caring for the lady next door or the young couple keeping an eye on the mother-in-law or the elderly or dependent parent, uncle aunt or whatever. They should have a central point of access from which they can get more information about how they tap what is often the mystifying range of benefits that should be available to them but which they do not pick up. It could also tell them how some of the services, both statutory and voluntary, can be delivered in a more organised, cost-effective and professional way. Money could even be saved.
The report is generally welcome. I learnt a great deal from it and from tonight's debate. We can only hope that, after the publication of the report and tonight's debate, these ideas will circulate further, and stimulate more discussion and response. Whatever our differences in degree or on policy issues, we would all agree that this sector will become increasingly important as we go into the next century. I congratulate the Committee, and I look forward to the Minister's speech.
§ Mr. Frank Dobson (Holborn and St. Pancras)
It is normal to pay tribute to those who served on the Select Committee, and in particular to the Chairman of that Committee. Sometimes the compliments are nominal, but hon. Members throughout the House will agree that my 1357 hon. Friend the Member for Wolverhampton, North-East (Mrs. Short) has made a significant contribution over the years to the development of decent policies for health, social services and social security. The report is yet another of her contributions, and we look forward to many more.
We must pay tribute those who work in the old-fashioned, clapped-out, long-stay hospitals. They are usually overworked, underpaid, unappreciated and frequently unrecognised. Any criticism of those institutions is levelled, not at them, but at society in general, because we have allowed those institutions to fall into disrepair. We have not provided sufficient funds for the encouragement necessary for those workers to do their job properly. A major characteristic of the old institutions is that the people working in them are frequently out of sight and out of mind. That suits society. Most people agree that properly funded and organised care in the community is better for most people than care provided by the old institutions. Subject to a number of reservations expressed by the hon. Member for Oxford, East (Mr. Norris) and others, we all look forward to the day when most people are cared for outside institutions.
Before we can care properly in the community, we must ask why people were first cared for in the old institutions. We have all been shocked by spectacular mistakes. Some people should never have been housed in institutions, but once they were there they were not allowed out. Primarily, people were put in long-stay institutions because they could not cope outside on their own or because those who tried to look after them could not cope. Any change in the arrangements for people in those institutions must ensure that they can cope outside and that the people looking after them can cope with the problems. If we proceed willy nilly to move people out of the old institutions, those involved will not be able to cope. The danger is that we shall empty the old institutions and do nothing more. That will not be satisfactory.
To be realistic, we must accept that there is no evidence that "the community" cares. It has never cared much about people in institutions. We must ensure caring for the future, but that will not just happen. We must create the machinery. People living in the community now — people who are vaguely living and vaguely in the community — are not being cared for. For example, we do not know how many homeless people live in London. Estimates vary from 5,000 to 20,000. At least several thousand people are homeless in London. Many of them have medical problems. Many are addicts of one sort or another. Many suffer from physical or mental illnesses. "The community" has left them to doss down wherever they can, leaving the police to move them on, when they want only to settle down for the night. If the Government and society want to prove that they have the capacity to provide care in the community for people who are at present in institutions, the best way to carry conviction is to do something about the people who are not being looked after properly in the community now.
To cater for those concerned we shall have to provide many smaller units, some of which will have to give the full-time care — 24 hours a day, 52 weeks a year — which the old institutions have provided, but in a smaller and better environment. We shall need better places where people can go for shorter stays. We must make provision 1358 for day care and outpatient care. There will have to be a massive increase in domiciliary visiting, with improvements in primary care of all kinds. From most available evidence, it is clear that we shall have to provide much more training for general practitioners in mental health and mental handicap, which is not their forte at present. We shall need a vast structure of support for families, neighbours and friends, by whom a large part of the burden of community care will be carried.
In my view, a warm-hearted instinct has produced the revolution in thinking about the problems of the mentally handicapped and mentally but we must be practical and ask whether the resources to sustain the development of a high standard of care in the community are being provided. From an examination of the present position, or from a reading of the Select Committee's report, the answer is that the resources are not being made available to make care in the community work as well as it should.
Almost everybody agrees that the old institutions should go and that we need new units, but there is not much evidence that they are now being built on a sufficient scale. There is little evidence that sufficient additional day care units are being provided in places convenient to people living in the community. There has been some improvement in outpatient psychiatric treatment, but much remains to be done on that front, and we need much more training for doctors and others. I could give a litany of requirements, but if I did the answer would probably be, "No," "Not very much," "Not likely" or "Not on your life." We must change that situation.
In view of the resources that are being provided, it seems that the Government have not appreciated the scale on which they will be needed. In a speech to the Richmond Fellowship in July last year, the Parliamentary Under-Secretary of State for Health and Social Security, in my prescence, said:It may be the case that care in the community will be more expensive than care in the large institutions.There is no question but that it will be more expensive if good quality care is to be provided. The old institutions are being phased out because they do not provide care to a high enough standard. If we provide care to a higher standard, wherever we provide it, it is bound to cost more.
The old institutions provide bulk care, and the best parallel of which I can think is an old motor coach. It carries large numbers of people, it has not had enough spent on it over the years and it needs to be replaced. The only alternative that would be cheaper than the old, clapped-out motor coach would be for everybody to get out and walk, because no alternative provision has been made. If the old coach is replaced by small or individual forms of transport, that will cost more in total than squeezing everybody into the big old coach. So it is with new provision that will need to be made for care in the community. If we are talking in terms of individualised, tailor-made care for everybody who comes out, that is bound to be more expensive than the old institutions.
I find it difficult to obtain evidence that the additional resources will be provided. On 8 December 1983 I asked the Secretary of State for his estimatefor the current year and each of the next two years of the increased costs to local authorities of providing care in the community for people spending less time in acute hospital beds, the closure of convalescent homes, and homes for the elderly, the mentally-sick, the mentally-handicapped and disabled persons.1359 The Under-Secretary of State replied at some length, ending with the following:the information needed to make the requested estimates is not available centrally." — [Official Report, 8 December 1983; Vol. 50, c. 233–34.]I asked a further question on roughly the same lines on 16 July 1984. The question was directed to the number of people involved, and not finance. Again, the Department did not have estimates of the number likely to be moved out. In October 1984 I asked the Secretary of State what increase in joint finance allocations to certain London health districts he estimated would be required to promote the closure of old long-stay institutions and the development of community care. The Under-Secretary replied:No such estimates have been made centrally."—[Official Report, 23 October 1984; Vol. 65, c.573.]As I understand the British system of government, it is not possible to get money from the Treasury unless Estimates are produced. A Government who are not producing Estimates on the cost of community care are clearly not seriously into the business of getting the necessary funding. Underfunding will have two effects. First, it will bring the concept of care in the community into disrepute. Much worse than that,if community care is practised on the cheap, there will be disaster for those who need the care and also for the unofficial, unpaid carers —in other words, family, friends and neighbours—who take on the great burden of looking after those who come out of the institutions. We all know that the bulk of the burden will be borne by women. Unless we make adequate provision, a great burden will fall on many women who are not equipped to carry out that task of caring. Being born a woman does not necessarily provide the full equipment to look after a member of the family who is physically or mentally sick, despite our traditions.
Even if the additional resources are provided, many women will carry out the task because women have always done so in the past. I suspect that everyone present in the Chamber knows families where an amazing amount of love — there is no other word for it — is poured into looking after a mentally ill, mentally handicapped or physically ill relative. When I come across that in my constituency, I feel humble. That is my feeling when I come into contact with families who treasure one of their number in that way. It can be a terrible burden, and it is our duty in planning care in the community to ensure that the community does not consist of one family or even one person. Genuine care in the community means us all getting together and sustaining the carers as well as the cared for.
Members of the Select Committee will know that one of the greatest reliefs for a family that is caring for one of its number is respite care, when the person being cared for can go into a hospital while the rest of the family have a holiday. I am not saying that I have come across an example of that respite provision being withdrawn for the mentally handicapped or the mentally ill, but within my constituency I have encountered examples of the withdrawal of respite care for the physically handicapped because Stoke Mandeville hospital, which had formerly provided respite care, could no longer afford to do so.
Local authorities have a statutory duty to provide for the mentally ill, but they are allowed to make their own assessment of the level of need. The latest figures that I have been able to find show that, of the 32 London 1360 boroughs, seven provide no special accommodation and seven others provide no day care places for the mentally ill. They cannot claim that there is no need, because nearly all 14 place people in facilities which are provided either by other boroughs or by voluntary organisations. Even in what the Minister regards as relatively well resourced London, local authority provision is lacking.
The problems are shown by the figures on after-care for patients discharged from mental hospitals. I have not been able to obtain any national figures, but the latest figures for Greater London show that only 3 per cent. of the people discharged into inner London had definite arrangements made with their local social services to provide some care for them when they came out of hospital. That is a staggeringly low figure, yet these are the very local authorities which have been rate capped, which have already lost a gigantic amount of rate support grant and which can expect to lose even more when the arrangements are announced next week.
The Government will claim—I am sure that the hon. Member for Derbyshire, South (Mrs. Currie) will back them — that spending on social services has risen by more than 12 per cent. in real terms during the Conservative party's term in office. By subtracting the increases in spending which have been made by those councils which the Government vilify as prolifigate overspenders, we can see that there has been practically no increase. Many local authorities have scarcely increased their spending.
My hon. Friend the Member for Islington, North (Mr. Corbyn) referred to the relationship between poverty, a poor environment and the incidence of mental ill health and mental handicap. I think that every one accepts that there are social, class and income relationships. That means that, as the big old institutions are closed down, people will be discharged to the poorest parts of Britain, especially to our big cities. On the whole, the health authorities most likely to be affected by the discharges are those which, under the changes of the past few years which were so proudly introduced by the right hon. Member for Plymouth, Devonport (Dr. Owen), lost most funds and suffered most cuts. The four Thames authorities which serve Greater London are the most significant.
In October 1984 I asked the Secretary of State whetherthe resource allocation working party formula for capital allocations reflected the cost of replacing large long-stay institutions in outer London as part of the move to community care.The Minister replied:No. The RAWP formula does not specifically take account of the cost of replacing obsolete buildings."—[Official Report, 23 October 1984; Vol. 65, c. 572–73.]In other words, this magic formula which certain people think is so fine does not make any allowance for the need for inner London health authorities to provide new buildings to replace the old institutions in which the mentally ill, mentally handicapped and old are housed. I suspect that the effect is similar in other large cities.
Successive Governments have failed to find the resources necessary to bring about care in the community. "Care in the community" has a potent political appeal. It breaks down the concentration of care, as represented by the hospitals, and redistributes it over a much wider area. This redistribution does not solve the problem, but from the Treasury's point of view it has inestimable value in that it makes the problem harder to identify and consequently easier to ignore. One reason why the Government are so 1361 keen to mouth phrases about care in the community is that it allows them to adopt an attitude of "Out of the NHS accounts and out of mind". It is more difficult to identify the amount being spent in the regions through agencies, local authorities and voluntary organisations, than it is to make a simple check on the spending figures of a centraliesed National Health Service.
The old institutions will be with us for some time, even those that are gradually being emptied. One of our duties is to remain aware of how these institutions are functioning. It is generally accepted that institutions which are being run down find it extremely difficult to provide even their previous standard of service. There is a fall in morale among the staff and an awareness of the running down, which makes things difficult. We must ensure that the people still in the institutions do not suffer even more than they did in the past as a result of the run down.
I have written to every district health authority about attitudes to privatisation and the contracting out of ancillary services. The most significant response was anxiety that privatisation might spell danger for people in long-stay institutions. Many of the district health authorities replied that the domestic staff, especially in long-stay institutions make an essential contribution to life in the wards. They are able to spend time with patients and get to know them. They become familiar with the patients and the patients familiar with them. They will make cups of tea in their spare time and help old men fasten their flies when they come back from the lavatory. That is a contribution towards humanising the wards.
The health authorities are aware of the danger that once the clipboard and stopwatch approach is applied to domestic services on the wards that high standard of care will either disappear or nurses presently occupied with other duties will have to provide it. If that happens, more nurses will have to be appointed or some of the existing functions will not be carried out.
The Opposition strongly support the idea of care in the community, but we do not believe that any of the big old hospitals should be closed before people in the hospital and in the area that it serves and those who wish to provide care in the neighbourhood are satisfied that satisfactory alternative provision has been established. My experience suggests—this applies not just to mentally handicapped people—that some of the people who have been moved out of the big old lodging houses into homes of their own or group flats have suffered in the process because insufficient provision was made in advance to support them during that transition.
§ Mr. Corbyn
As there is declining provision of acute hospital beds in inner and city areas, and a great demand for geriatric, psychogeriatric and psychiatric provision, the long-term problem is often longer waiting lists of people trying to get acute beds because there is insufficient overall provision.
§ Mr. Dobson
I accept that, although I suspect that the Minister will not agree, and I shall deal with that aspect in a moment.
We should accept that the disappearance of the old institutions in any geographical area must not take place unless we are satisfied that adequate provision has been made in advance for those to be transferred. The important point is that it should be made in advance. If people are 1362 not caught by proper after-care arrangements from the moment they leave the old institutions, they will be lost to the system and will never by retrieved. It will be almost impossible to track them down and many people will actually die as a result of being moved out of the old institutions. For those who have been in institutions for a long time, the trauma of coming out will be the worst part of the process and we must look after them very carefully during the transitional period.
Many genuine mistakes are also likely to occur during the transitional period. It is vital that the people organising these things do not take an ideological view about moving people from one part of the spectrum of care to the next. They should not regard themselves as having failed if the part of the spectrum which they most favour turns out to be unsuitable for some of the people for whom it has been provided. Everyone involved must keep an open mind, or we may end up expecting some people to function in facilities which are still too institutional for them, while demanding that others survive in a non-institutional climate with which they cannot cope. If the Victorians did not have the moral right to put everyone in big institutions, no more have we the moral right to put people in any particular part of the new spectrum of arrangements if it does not suit their needs.
I do not believe that proper care for the people moved out into the community can or will be provided by people making money out of it. That has been one of the major thrusts of the Government's policy on care in the community, but we do not believe that the standards laid down are adequate or that health authorities have the resources or the will to do the necessary monitoring. When, predictably enough, the profiteering became too obvious even for the present Government, their response was not to step up control of standards and to distinguish between good and bad providers, but to introduce new lower limits on DHSS support, which has hit high quality voluntary and charitable provision as well as the profiteers who were allegedly the target.
In view of the time, I shall not take up any more of the points raised in the debate. I make just one final point, which no doubt will not commend itself to the Conservatives. I do not believe that care in the community can really work in a society based on he stressful and competitive philosophy of the modern Tory party. The Government believe that the engine of society is selfishness and competition, that life is a race in which the prizes not ony do but should go to the strongest, the fastest, the cleaverest and the most aggressive. That view is ultimately irreconcilable with the idea of looking after the mentally handicapped and the mentally ill.
The Victorians, who, as we all know, subscribed to the values which the Prime Minister claims to like, resolved the dilemma by taking the mentally and physically handicapped out of the race altogether and putting them in large institutions, partly to cocoon them from the struggle. People with handicaps cannot be cocooned in the same way in the community if the community is based on competition. Besides the requirements for proper care in the community which have been outlined by hon. Members on both sides of the House, there is one overwhelming requirement — to base our society on a recognition of our mutual dependence and our obligations one to another. That is not the Government's philosophy, but without that philosophy characterising our entire society, care in the community will never prosper.
§ The Minister for Health (Mr. Kenneth Clarke)
The hon. Member for Holborn and St. Pancras (Mr. Dobson) was his usual quiet and attentive self for most of the debate, but he perked up a little and his beard began to bristle when my hon. Friend the Member for Derbyshire, South (Mrs. Currie) began to inject some of the red meat of partisan politics into the debate. When he replied, he carried with me for most of the time as he made a reasoned and considered speech, but he ended with one of his slightly over-the-top pieces of party philosophy, which took him a little away from the subject.
I wish to begin — I hope that I shall end in more or less the same mood — by agreeing with as many of the hon. Gentleman's sentiments as I can. I join him in congratulating the hon. Member for Wolverhampton, North-East (Mrs. Short) and all the members of the Select Committee on the work that they put into producing this report. I agree with most of those who have spoken in the debate, including the hon. Member for Holborn and St. Pancras, that we should support the policy of care in the community, which the Select Committee report carefully defines, to make sure that we do not start using it as a slogan. I am especially glad that the Select Committee members managed to secure a debate on the report, so that we have had a protracted discussion on an extremely important subject. I have come to believe that this is an extremely important part of current health policy. It is also the part of health policy that is least understood by many members of the public, and it still arouses much unnecessary' controversy when authorities attempt to put it into practice.
When I became Minister for Health, I knew a fair amount about the care in the community policy, but I had little direct experience of the problems of putting it into practice. When I came to my present job, I shared some of the public's scepticism about some of the things that had happened in the past. I was certainly sceptical about some of the consequences of the so-called upgrading of mental hospitals which began more than a decade ago, which led to patients being turned onto the streets, because they were described as non-treatable, to reduce the numbers in the wards. Not long ago, I visited a Salvation Army hostel where the people there told me that they remembered ambulances corning up outside the hostel and turning out patients who had just been declared to be non-treatable by a psychiatrist at a nearby large mental hospital.
I knew when I started, and still know, that mistakes can be made. I know that people discharged from hospital can lose touch with the services that are meant to support them and can fall sometimes into sad and unpleasant conditions. I always have a fear that we should not add to the population living under the railway arches at Charing Cross and elsewhere by finding that, accidentally, we put discharged mental patients into that position.
However, having said that, and being aware of all those problems, I must say that, after only three and a half years in the job, I have become an enthusiast for the policy which underlies this changeover to care in the community. That is because I have seen good examples of what is happening as health authorities tackle the changeover that is required.
For instance, I have seen the enthusiasm, as my hon. Friend the Member for Exeter (Mr. Hannam) said, with which the leaders of the health authorities and the local 1364 authorities in that part of the country are making the change, and how they are collaborating to achieve it. My hon. Friend praised his health authority, and most hon. Members who have visited Exeter will agree with him that it has done much in this area. In other parts of the country, I have made a point of trying to see care in the community policies and have asked health authorities to show me what they have achieved. I have met patients of all ages and the staff who care for them, and I have heard first-hand descriptions of improvements in the quality of patients' lives that are being achieved now. I do not wish to generalise too much from the examples of individuals whom I have met, but I shall cite two which relate to long-stay patients who might be thought difficult to transfer out of an institution. In Eastbourne, I met a mentally handicapped man who I should say was in his 60s. He had spent 40 years in a nearby hospital for the mentally handicapped. For about 30 years of that time he had been mute and a disruptive patient — not seriously, but setting off fire alarms and fire appliances in the hospital. I met him in a converted couple of houses where he lived. He talked pleasantly in a relaxed way. He described his life in Eastbourne and was plainly enjoying it. He was clearly not highly intelligent, because he was mentally handicapped. He was able to talk and was enjoying a much fuller life than he had for all those years in his hospital.
In Derby I met a man who had been diagnosed as mentally ill. He had spent 40 years in a nearby large mental hospital. I met him living in a converted terrace house with a great deal of close support from the local social services department and the housing association which had provided the housing. He was slightly reticent, but he was not an unusual man. If I had met him outside the house I should never have realised that he had been a patient in a mental hospital. The only curious thing about his conversation was that his recollections of Derby all revolved around the second world war when he had worked making aircraft engines in the nearby Rolls-Royce factory. He had plainly been cut off from ordinary life in Derby from the second world war until a year previously, when he had gone into that new accommodation. I mention those cases, firstly, because it is always encouraging to meet such improvements being achieved in patients' lives, and, secondly, because they led me to the conclusion to which the hon. Member for Leeds, West (Mr. Meadowcroft) came. I agree with him that one goes to one part of the country and finds that there are many patients whose transfer into the community is regarded as impossible and yet one goes to the next place and finds that that has been achieved successfully.
There is plainly no way in which we can discharge all the acute mentally ill patients into the community, but with mentally handicapped patients the position is rather different. I do not see a future for large ward and large hospital care for them at all. A great deal can be achieved. It is easy to exaggerate the difficulties of moving long-stay patients into the community.
I do not just have the experience of this country. I attended a meeting recently of Ministers of Health from all the countries in the Council of Europe. I heard them all agree that a community-based model of care should replace an institution-based model. All those countries were adopting policies similar to ours. I am glad to say that in such an international gathering the United Kingdom is seen as something of a pioneer. That relates not just to this Government but previous Governments. We were also.
1365 regarded as having avoided so far some of the worst dangers of going too fast in an ill-considered way, as I fear has happened in Italy, or scarcely moving at all, as appears to be the case in Greece.
Despite the mistakes and the difficulties, by and large the process of change has been reasonably well managed here.
It is rather unfortunate that the Select Committee went to the United States and that it cites the United States and Italy as the international comparisons because—with no disrespect to the general health care in those countries—they are widely regarded as two of the poorest examples, with especially unfortunate mistakes having been made in Italy. I do not think they resemble anything that has happened here.
We should realise that we are achieving a great deal and that we are in line with international practice. I hope that the few hon. Members, such as the hon. Member for Islington, North (Mr. Corbyn), who say that many people suspect that the change is just part of saving money, realise that they are out of step with the majority of Members of the House who realise that our objectives are shared by the vast majority of those genuinely interested in the mentally ill and mentally handicapped patients.
We must restate the aims of the policy to a sceptical public. We ought all to agree about the need to change from an old-fashioned and unsatisfactory pattern of care in which most of the patients were unwilling long-stay patients in large wards in large hospitals. We must replace that with better, more civilised and humane care for patients that keeps them in closer touch with the community and allows them to live in their own homes or near centres of population.
We need smaller units of all kinds, including small hospital units, with nursing staff trained in community skills. We need sheltered housing with resident staff. We need day services and domiciliary help for family carers, to whom the hon. Member for Ross, Cromarty and Skye (Mr. Kennedy) paid tribute, and for those patients who are capable of self-sufficiency in their own homes.
In my visits around the country, I have seen remarkable cases of severely disabled people living alone in their own house or living in twos or threes. With the right support, people who the average layman would think could not possibly cope are living in their own homes. That is the objective of the policy. It ought not to be controversial.
I cannot emphasise too often that the Government are not changing the pattern of care to make cuts or to save money. That is not our objective and it would be a mistake for anyone to think that it is a credible objective. We are shifting resources with the patients. We will have to retrain and prepare staff. Sometimes it will cost more on balance and sometimes it will cost less.
I quite agree that, in changing to a more modern and humane pattern of care, we must concentrate on the needs of patients. Each patient will require individual assessment of needs. The transition for each patient, as well as for whole blocks of the service, will require careful joint planning, joint approaches from health and local authorities and co-operation between all the health care professions. It is a pity that, in just one or two speeches today, hints of rivalry between the professions began to creep in. There were suggestions about which authority 1366 might dominate in the provision of care and which unions or professions might get the bulk of the staff and provide care.
I agree with the hon. Member for Ross, Cromarty and Skye that it is important to take advantage of voluntary bodies and what they can contribute. Care must be provided by those who are best able to provide it. That might be the health authority, the local authority or a well-run voluntary body. We must not discriminate between the three, but decide in patients' interests which of those bodies will get the finance and deliver the service.
Our aim is to improve the quality of life of the patients in our care. We want to improve their environment. We must put them in a less frustrating setting than large wards, give them more stimulus and less boredom, protect them and retain the best elements of the word "asylum". That policy has the backing, as I am sure the Select Committee found, of most of the leading interested voluntary bodies.
MENCAP and MIND — the largest bodies with an interest in mental handicap and mental illness respectively — are fully committed to this approach. I try to keep in touch with both as frequently as possible. The only criticisms that I get from them are that we are not going fast enough. They also always argue about finance. The Select Committee report endorses that policy and praises what has been achieved in some places.
I must say, however, that I find the report a little like the curate's egg. Although I welcome its support for its less institutionalised approach, if I am allowed to criticise the members of the Committee, who have fairly criticised the Government in various ways, I must say that the report lays heavy emphasis on the difficulties, having described its support for the policy. The report shows signs of having been influenced by many complaints, and on one or two occasions it proposes some curious arrangements. The Select Committee has paid far too much attention to those who say that it cannot happen until larger additional resources are made available to a particular witness's department in his locality.
The report acknowledges that sometimes excuses are made, but in each locality community care has got to be made to work, sometimes against the grain of local prejudices and by changing local practices, within realistic expectations of resources. The state priorities of the local authorities and the regional health authorities match those of the Government and of successive Governments on health care and social policy. Those priorities are the former so-called Cinderella services for the elderly, the mentally ill and the mentally handicapped.
One should find that, when increased resources are made available, generally they go to the priority areas. One is considering the activities of statutory bodies whose spending has increased briskly during the last six years. My hon. Friend the Member for Derbyshire, South reminded us of the figures. The spending of those authorities which provide hospital and community health services has increased by 15 per cent. over and above the general level of inflation during the last five years, and the spending of the social services committees of local authorities has increased by 17 per cent. over and above the general level of inflation in the same period. As they are spending so much money, they should pay more than lip service to the priority services. That is where the bulk of the money should be going. We give growth money to the health authorities to enable them to make changes in practice and meet rising demand.
1367 Whenever a debate is held either about finance or about policy in the National Health Service, the Government are able to point to the vastly increased amounts of money that are given generally to the authorities, which we leave them to disburse, and to the policy priorities. The debate is then turned round on the Government. We are asked: if those are the priorities, where is the extra money? The point of providing more money for the coffers of the health authorities is to enable them to improve their services in the stated priority areas.
Given that we are not devoid of resources for this priority area, one looks at the pace of change, upon which the report placed much more emphasis than any of the speeches to which we have listened today. The Select Committee's report urges a substantial slow down in the pace of change. It suggests that any idiot could close a large hospital. If so, during the last few decades we have been rather short of successful idiots. No authority has ever succeeded in carrying out its stated intention of closing a large hospital. This is not a new idea, anyway. The report refers to the 1962 hospital plan when the Minister of Health became quite lyrical about the need to close down large numbers of mental hospitals. Twenty-three years later, not a single large mental hospital has been closed. Therefore, I cannot agree with the emphasis that the Select Committee has placed upon the Government avoiding undue haste.
Although the aim of the policy is not to close hospitals — that in itself is a pointless aim — nevertheless it is worth considering whether we can replace some of these institutions with something better. Most regions have one or two hospitals that they ought to have closed many years ago. I fear that some of them are a disgrace to a modern, civilised country. They are very old, and since the hospital plan was published they have become older, more expensive and emptier. The hon. Member for Stretford (Mr. Lloyd) described his experiences of visiting some of our larger mental hospitals. I have been as moved as he was by some of the conditions that one sees there. The hon. Member for Holborn and St. Pancras described some of them as clapped out. Some are dank, inhospitable dumps as buildings. I agree that the amazing thing is that the quality of care has been raised so much by the dedication of all the staff wo have to work in those inhospitable surroundings. I join the hon. Member for Holborn and St. Pancras in paying tribute to the staff who have done so.
One has to ask: why have many of those hospitals, long earmarked for closure, never closed? One of the main problems is the difficulty of planning the replacement services and making sure that thy are there for the patients to move out. There have been other reasons as well. We all know that there have been if we have local experience of trying to plan that change. Once the closure of a large hospital is proposed it is usual to encounter resistance to that proposal from friends of the patients and the staff. Friends and relatives tend to fear any change from a setting that they may think is not attractive, but where the problems of the patient appear to be relieved to some extent.
Whatever the Confederation of Health Service Employees say nationally — it is in favour of the policy generally — locally, trade union leaders and large numbers of the staff tend to resist the loss of jobs. The local population often receive an inadequate expiation of what is likely to replace the hospital, so they are induced 1368 to campaign against the closure, which is presented to them by the National Union of Public Employees or other unions as all part of a policy of health cuts. That slows down the changes and adds to the difficulty of making them.
No doubt the hon. Member for Oldham, West (Mr. Meacher), who has joined us, if we ever succeeded in closing the large mental hospitals, would add the lost beds to the ludicrous figures that he produces to try to show that bed closures are a measure of the state of the Health Service. That all underlines the difficulties that are faced in practice in closing large hospitals. I have my own experience. Saxondale hospital was cited by the hon. Member for Wolverhampton, North-East. It was first mooted for closure when the right hon. Member for South Down (Mr. Powell) was the Minister responsible for health. We still have not got round to it. Most local people will believe it when it happens and will accept it once they are satisfied that better services will replace the hospital.
§ Mrs. Renée Short
Does the Minister accept that during our inquiry we did not have representations from any hospital union, from either individual workers or groups that we met, complaining about the possible loss of jobs if large mental institutions were closed? Will the right hon. and learned Gentleman put that out of his argument? We said in our report that after the closure of the large institutions staff would be deployed, working with smaller groups of patients in different circumstances and different settings, but the jobs would still be there.
§ Mr. Clarke
I am grateful to the hon. Lady for making that point. It is the same point that I made. I have encountered leaflets issued by local union branches trying to organise resistance to a closure on the grounds of resisting health cuts and saving jobs. I accept that the hon. Lady may not have encountered that, but I have done so, not least in my part of the country.
We therefore have decided to set early dates — we have already set some — for the closure of those redundant hospitals. The reason for setting dates is that that will provoke the start of the serious planning process, and where that process is well advanced, it will concentrate people's minds on maintaining a set timetable in implementing it. Provoking the planning process sets in train a difficult series of measures that the authorities have to handle if mistakes are not to be made or kept to a minimum. Those involved need to explain to relatives that by the date set better care will be provided. They need to explain to the staff the retraining that they will require and their future in the system, as the hon. Lady said. They need to explain to the local population the type of patients who will move into the community and avoid planning rows and unreasonable fears. I am tempted to defend my neighbours against the attack of my hon. Friend the Member for Derbyshire, South; but I am glad to say that there were no objections in the part of the world that she described. Objections can be avoided if the nature of the movement into the community that is taking place is explained to the population.
We must provide better services outside before anyone is transferred. Everyone is agreed upon that. Every patient must be individually assessed and moved to a setting that suits his or her personal situation. That is an extremely difficult process, but it is important for the Government to keep up the pressure to make sure that people concentrate 1369 their minds on it and accept it is going to be necessary to do those things, because the large hospital is finally going to be closed. I do not regret the pressure we are putting on to make everything proceed.
Not all hospital care will be replaced. Many of those suffering from mental illness will need some hospital care. I agree with my hon. Friend the Member for Oxford, East (Mr. Norris), who said that there is a slight danger, if one is not careful, that people will concentrate on community care, which is easily arranged for the mildly neurotic, and forget that the first call upon the hospital service must be, in the case of mental illness, to care for the seriously disturbed and acutely ill patient. From time to time schizophrenics certainly may need hospital care.
For the future, the small local unit on the district general hospital site is the best model. A few months ago I attended the opening — not the formal opening, but very nearly the actual opening — of one in the Queen's medical centre in Nottingham. There I met staff members who were extremely enthusiastic about what they were going to do, and they were nurses transferring from Saxondale. they could see they were moving into a better hospital environment. We also need hospital hostels; small homely units.
We must guard against hospital units being provided which are merely transferring patients from one hospital institution to another. It I had time, I would answer the complaints made about Oxford. I will go away and find out again about the situation in Barnsley about which I have heard complaints before, and try to make sure that hospital authorities are not going to reproduce institutions.
These things are going on at the moment. It is good practice and it is working up and down the country. It is being assessed and spread by the Health Advisory Service, Good Practice in Mental Health, the National Development Team for Mentally Handicapped People, and Kent Community Care Project Assessments. Those are various groups which know an great deal about what has been achieved already and are disseminating good ideas to those who are getting started.
Having tried to persuade all those who have spoken, except for the hon. Member for Islington, North, who insisted on carping about community care, that the objectives are common objectives, I will turn to the matter of finance, because the other message for the Select Committee is that we will support this policy with more enthusiasm so long as we are satisfied that the finance is going to be there to provide better services.
My hon. Friend the Member for Oxford, East said that he did not believe this was going to be a cost-neutral policy. I am not sure why it is believed that cost-neutral is really the basis upon which the change is being made. In our detailed evidence to the Social Services Committee on Public Expenditure, we showed that expenditure has increased in real terms on the mental illness and mental handicap services. Spending by health and local authorities on these services rose by 19 per cent. in real terms between 1978–79 and 1983–84. Unit costs have risen more substantially, and in this area I accept that unit costs can be taken as reflecting rising standards where previously one had low-cost hospital facilities.
The figures now no longer reflect the total resources employed in the care of these groups because they are going over increasingly to general community health 1370 services expenditure and the amount going on mental illness and mental health cannot be precisely identified. But there is more money going to this area all the time and that is not cost-neutral expenditure. When it comes to transferring the hospital to community, one cannot always tell whether one is going to spend more in that locality or less. I will not go in great detail into the engaging description by the hon. Member for Holborn and St. Pancras of the old coach being replaced.
Before assuming that it is automatically more expensive outside for the great majority of patients, I ask hon. Members to remember that about 40 per cent. of the expenditure in a large hospital is not in direct patient care. That percentage is the cost of the maintenance of the buildings and support services and so on. If the ratio of one to one staff attention required in the community is going to be greater, a certain amount of money which may have been wasted on old fabric, will be released to finance personal care.
§ Mr. Norris
Given that 40 per cent. of the cost of institutional care is not directly related to patients, surely the relevant point is that bridging finance is not merely the provision of capital to buy small houses before the receipt from the old institution. It must also take account of the fact that diminishing numbers in a large institution will still have to be catered for while adequate services are provided in the community, and that will be a substantially longer bridging operation which will have a substantial ramp on both sides.
§ Mr. Clarke
The bridging argument entered my exchanges with the Select Committee and is again reflected in the report. I accept that in the loosest sense of the term, bridging must look at the capital and revenue needs. We need a mechanism that can cope with that.
I know that the Select Committee feels strongly about this, and I should like to explain what the regions are now doing about it. The role of the regions is to allocate resources to the change in policy. The purpose in allocating resources should be to enable the health authorities to close down the institutions, disperse the patients and to buy the service required for those patients from whichever area is best. One must therefore decide how much money will be transferred with each patient.
In a sense, that will be a patient's entitlement to cover care in the community. One will have to decide how much money will be transferred to another district health authority, if that is where the patient comes from; to a local authority, if its social services department is to provide the care; or to a voluntary body, such as MIND. That will enable those organisations to buy the service required.
As far as I can see, all regional health authorities are now beginning to build up their own arrangements for precisely that mechanism of transferring funds in order to buy the services that patients require. I do not have time to describe what each and every region has done, but the hon. Member for Leeds, West cited the example of the £14,000 per place being given to MIND.
The hon. Member for Stretford (Mr. Lloyd) criticised the amount being contemplated by the north-west region. That region appears to have an extremely good system of transferring funds with the patient, and it will pay a local authority, such as Manchester city, for providing services. At the moment, it is paying £11,300 for each patient, because that is the average cost incurred. That may not be 1371 right, and the average cost may not be sufficient for a heavily-dependent patient. What is needed — I believe that the north-west region will look at this with the local authorities — is a more sophisticated mechanism for deciding how much each patient will cost in each place.
That much is already being done by regions. If we have a central bridging fund, and given that the Government will build it up presumably by putting money into it out of the total Health Service allocation, one is really saying that centrally we shall try to achieve this bridging over and above what the regions are already doing. I am not sure whether that is desirable.
I did not close my mind about that, and I do not do so now. For the last three or more years since I have been Minister, I have been saying that I would look at any cast iron proposal that demonstrated that bridging finance was required for capital or revenue. But that must be a well thought-out scheme requiring genuine bridging finance where money was needed up front to complete the closure of an institution. That would release the funds which would pick up the finance in the future, thereby enabling central finance to go down.
I more or less told the Select Committee and others that by some means or other we would find the finance for such a well-presented scheme. No such scheme has ever been presented to the Government, and no locality is cited by the Select Committee where such a proposal is thought to be necessary or possible.
I shall look at any such proposal to see whether the claim is justified or excessive, but it is important that the central contribution should fall away at the end just as it builds up at the front. I shall also see why the present regional mechanisms are not coping with this, although I believe that most regional health authorities would claim that they could cope over the strategic planning period. I do not reject the idea outright.
I remain to be persuaded that a worthwhile use for such a scheme is likely to be forthcoming. I have not left myself time to deal with all the other finance we are providing: the huge increase in the funds going to joint finance; the opportunity we have taken to enable care-in-the community money to be transferred timelessly to local authorities; our initiative on getting mentally handicapped children out of hospital, a matter on which I feel as strongly as the hon. Member for Caernarfon (Mr. Wigley) and my hon. Friend the Member for Exeter. We must complete the job on which there has been a great deal of achievement over the last three years.
I remain enthusiastic about care in the community. I trust that the Select Committee will propagate the policy, point out its advantage to the public, campaign for it with enthusiasm and combine that with their criticism and their scepticism. I think we will all find that we will make worthwhile advances on behalf of the patients in our hospitals.
§ It being half-past Eleven o'clock, the Question was deferred, pursuant to Order [4 July].
§ MR. DEPUTY SPEAKER then proceeded to put forthwith the deferred Questions and the other Questions necessary to dispose of the remaining Estimates appointed for consideration this day.