§ Motion made, and Question proposed, That this House do now adjourn.—[Mr. Alan Howarth.]
§ 10.3 pm
§ Mrs. Gillian Shephard (Norfolk, South-West)Hon. Members will be aware that the second biennial report of the Mental Health Act Commission was laid before Parliament at the end of October. The commission, of which I was a member until April, is a special health authority set up by the Mental Health Act 1983 and it has a range of powers, duties and responsibilities with regard to detained and restricted psychiatric patients.
The second biennial report, which I commend to the House, describes the commission's work in the past two years and raises a number of concerns. I shall draw the attention of the House to some of these concerns about the special hospitals at Broadmoor, Rampton, Moss Side and Park Lane which between them have about 1,700 detained patients at any one time. These patients are among the most disturbed and difficult people in the country. Many of them will have to remain in secure hospitals for the rest of their lives.
To care for such patients is one of the most demanding tasks in the whole of the health care field, and our society is indebted to the doctors, nurses and other staff who undertake the work, not least because society is at best ambivalent about its expectations of the special hospitals. Public opinion, as we all know, veers from the shock-horror treatment of so-called revelations of abuses—[Interruption.]
§ Mr. Deputy Speaker (Mr. Harold Walker)Order. I must tell the House that the Chair cannot tolerate hon. Members approaching the Chair and seeking to debate the selection of speakers in the debate. If hon. Members persist in doing that, the Chair will have no alternative but to exercise the disciplinary powers vested in it. I apologise to the hon. Lady.
§ Mrs. ShephardI repeat that public opinion veers from the shock-horror treatment of so-called revelation of abuses in the special hospitals to baying condemnation when a patient absconds or is discharged, only to reoffend. Frankly, the public would prefer that the problem did not exist and that the staff were left to cope with keeping the difficult balance between security and care. Precisely because the public has that ambivalence, because the problems of working with those patients are so great and because the patients—[Interruption.]
§ Mr. Deputy SpeakerOrder. I must instruct the hon. Member for Caernarfon (Mr. Wigley) to leave the Chamber for the remainder of this day's sitting. As the hon. Member refuses to obey my instruction, I have no alternative but to name him.
§ Motion made, and Question,
§ That Mr. Dafydd Wigley be suspended from the service of the House.—[Mr. Alan Howarth.]
§ put and agreed to.
§ Mrs. ShephardThe public would prefer that the problem of the special hospitals and those in them did not exist and that the staff were left to cope with the difficult balance between security and care.
§ Mr. Deputy SpeakerOrder. I have to tell the House that the hon. Member refuses to withdraw from the House 233 in accordance with the decision and wishes of the House. I must, therefore, ask the Serjeant at Arms to escort him from the House.
§ Mrs. ShephardI hope that I get a bit of injury time.
Because the public are ambivalent, because the problems of working with those patients are so great, and because those patients are particularly vulnerable, being ill and disturbed and liable to long years of detention, I wish to draw the attention of the House to some of the issues that are raised in the report. They can be summed up in the word "management".
I will deal with two aspects of management—in the Griffiths sense of running the hospitals, and in the technical sense as defined in the Mental Health Act 1983 as to the powers and duties of managers. Until recently, the day-to-day management responsibility for the special hospitals lay with the DHSS special hospitals office committee, which to all intents and purposes delegated it to the local hospital management teams. For the past few years, Rampton has had a management board.
The DHSS special hospitals office committee on behalf of the Secretary of State for Social Services has acted as manager in the technical sense of the word under the Mental Health Act 1983. Since 1 January of this year, new hospital boards have come into being at Broadmoor, Park Lane and Moss Side, bringing them into line with Rampton. Why have the Secretary of State and the DHSS chosen not to apply the Griffiths principles of management to the special hospitals with general and unit managers that they introduced in the rest of the Health Service and which have been very successful?
Let us recall why the Griffiths reforms were introduced. They were introduced to sweep away the accretions of decades of half-reorganisations in the National Health Service and introduce the concept of accountability at regional, district and unit level to enable effective decisions to be made at local level with a minimum of bureaucratic fuss and ensure that the public, and above all the patients, knew where the buck stopped.
What is the position now at the special hospitals? We have an interesting palimpsest of all forms of organisation known to the NHS since its inception and in some respects dating back even earlier, possibly to the Boer war. In each hospital there is a medical director. His Boer war predecessor was known as a medical superintendent. What are his duties and responsibilities? Does he operate on the 1968 cog-wheel principle of co-operation with his consultant colleagues or on the consensus management principle introduced in 1974? Each hospital has a hospital management team consisting of doctor, nurse and administrator.
New hospital boards have the status of special health authorities. What does that involve? Are they any more than a giant leap back to 1948? How helpful will they be in solving the acute problems of those hospitals? Will they speed up decision-making? Can they hire and fire? How will they help patients and staff? It is certain that the boards add an extra layer. The answer to those questions will be that the boards are in their early days. My reply to that is that there is no time to waste and some of the problems highlighted in the commission's report illustrate my point. In passing, it is interesting to note that the 234 statutory instrument setting up the boards which was laid before the House is innocent of any mention of the word "management".
Some of the issues raised in the report, as I have said, illustrate the problem of management. One of the problems which looms large involves the investigation of complaints. Procedures for investigating complaints, including those made by and on behalf of detained patients, are set out in memorandum HC(81)5. That circular, as I understand it, does not apply to special hospitals and neither does the clinical complaints procedure set out in circular HN(83)31.
The statutory instrument covering the boards gives them
functions in relation to the operation of an adequate procedure for the investigation of complaints made by, or on behalf of any person who is a patient in the hospital in respect of any service provided at the hospital.Those functions may have as their aim the bringing into line of the special hospitals under the Hospital Complaints Procedure Act 1985.I do not know whether that is so, but if so it would not be before time. There is no agreed procedure for dealing with serious complaints at any of the four special hospitals. That point was made as long ago as 1980 in the report of the review of Rampton hospital which was presented to the House.The Mental Health Act Commission has been very concerned about what appears to be uneven practice and policy on patient complaints at the special hospitals. For a complaints procedure to work, it is essential that patients and their relatives should know what the procedure consists of and how it works and that they should regard it as fair. There is as yet no definitive written complaints procedure for the special hospitals. The commission has experienced consistent difficulties in establishing the procedures. Consider then how much worse it must be for the patient, who may well feel not only that it is useless to make a complaint, but that to make one might jeopardize his progress in the hospital.
The difficulties of dealing with complaints from very disturbed and ill patients are obvious. The very fact of their illness may cast doubt on the quality of their evidence. Nevertheless, they have the right of access to a fair, impartial and respected complaints procedure. They have the right to be interviewed in private and the right to feel that they can make a complaint with impunity. That is not the current position, as the commission report makes plain. I would welcome clarification from my hon. Friend the Minister about the progress or otherwise of the DHSS scrutiny of the draft procedure submitted by the special hospitals. I would like clarification on the likely time scale and the degree to which the new boards will be empowered to act on complaints that are upheld.
I refer the House to the draft code of practice for the Mental Health Act 1983, which was issued by the DHSS in August 1987. Section 171 laid down that health authorities should set up procedures for dealing with complaints from patients, that they must be in accordance with DHSS advice in the famous health circular (81)85, and that they should be explained clearly to patients, relatives and staff. I hope that that advice will be implemented with the utmost speed for the sake of all patients in the special hospitals, who are presently the only people who do not benefit from such procedures.
The Mental Health Act Commission's report cites in its complaints section an example called case B of a patient's 235 complaint and the unsatisfactory way in which it was dealt with. The patient was not interviewed by the hospital management team; the nursing staff concerned eventually, after a delay of seven months, declined to be interviewed, and it therefore proved impossible to reach any firm conclusions on whether the original complaints were justified. However, the commission was able to uphold the patient's dissatisfaction with the hospital investigation.
That case clearly illustrates the need for strong local management that is able to grasp and deal with a difficult problem. I should welcome any assurance from my hon. Friend that the new hospital boards will improve that highly anomalous problem. The DHSS as manager, in the technical sense of the word, under the Act does not observe the guidance on complaints procedures that it issues to others and expects them to observe.
The complexities of running a large residential unit, which must be as secure as a prison, where some patients will have to remain for life and which is nevertheless a hospital with expectations of carrying out rehabilitation work, are immense. Let us consider, for example, the apparently very simple problem of patients' possessions and how and where they are stored and accounted for. In theory, on admission, a patient might own a house full of furniture with some valuable items—perhaps a grand piano, a car and so on. Those items cannot be disposed of if there is any expectation that the patient might be discharged. If he has no relatives, or they are unable or unwilling to take responsibility for the items, the hospital has to dispose of such items. On occasion some of the possessions might be returned to the patient—obviously not the grand piano—for use on the ward. The bureaucratic nightmare of dockets, records and interim storage places is made more difficult because the patient, due to his illness or medication, may forget or mislay his property. The problem is compounded because the management responsibility is diffused over several fronts.
Special hospitals, with their combination of problems and complexities, should have the benefit of the general management principles that have been introduced elsewhere in the Health Service. I apply a simple test of accountability whether in the private or public sector— who does one telephone when one wants to know something? In the case of the National Health Service, the health authorities, Marks and Spencer or Sainsburys, one rings up the manager. However, is it so clear in special hospitals? Does one ring the medical director or his Boer War predecessor, the superintendent, the nursing officer, the secretary of the Prison Officers' Association, the chairman of the hospital board, the office committee—if so, which member—or does one ring the porter's lodge, which would be most likely to give you the answer?
I hope that the hospital boards will do a good job, but I question, for the sake of patients and staff in special hospitals, the decision that has applied to this management problem a solution that is more appropriate to the early 20th century, when the 1980s solution—which is already working well in the National Health Service—might have brought better results for all concerned.
§ Mr. Deputy SpeakerOrder. Does the hon. Gentleman have the leave of the hon. Member for Norfolk, South-West (Mrs. Shephard) and of the Minister?
§ Mr. KirkhopeYes, Mr. Deputy Speaker. I shall not detain the House. I know that the Minister is pressed for time.
I support everything said by my hon. Friend the Member for Norfolk, South-West (Mrs. Shephard). As a colleague of hers on the Mental Health Act Commission during its early years I can say that the concern of many of us, which is shown in the second biennial report, is that there should be complete consistency when dealing with complaints in special hospitals. I am sure that the Minister will have that matter in mind.
The only other issue that I shall mention, which is related to what my hon. Friend said, refers to the provisions of section 120 of the Mental Health Act 1983. I urge the Minister to consider the possibility of an amendment to allow a friend or relative of a mentally ill patient to be able to assist more fully in a complaint on behalf of the patient. Such actions would greatly assist those who, perhaps, are particularly disadvantaged through illness and perhaps need the extra help that would be available to them in such circumstances.
§ The Parliamentary Under-Secretary of State for Health and Social Security (Mrs. Edwina Currie)I congratulate my hon. Friend the Member for Norfolk, South-West (Mrs. Shephard) on her success in the ballot and on raising with such intelligence and lucidity this important topic for debate. The House will also wish to mark her dignity and forbearance in the alarums earlier this evening, which must have been an unpleasant experience for a new hon. Member.
I thank also my hon. Friend the Member for Leeds, North-East (Mr. Kirkhope) for his remarks.
The mental health legislation was updated in 1983 for the first time in nearly a quarter of a century. Its objective was to protect the rights of patients who had been detained under the existing legislation. Much of the emphasis was on patients' civil liberties. It would be fair to say that, by the early 1980s there was concern that patients' interests had perhaps been somewhat neglected. The Act clarified the procedures for consent to treatment, and the Mental Health Act Commission was charged with the statutory task of monitoring the powers under the Act. It was set up as my hon. Friend the Member for Norfolk, South-West described. It has been chaired with great distinction from the beginning by Lord Colville, to whom the nation owes a considerable debt of gratitude. My hon. Friend was appointed as one of the first Mental Health Act commissioners—one of about 90 in England and Wales—and served until her adoption and election to the House.
I should like to put on record the deepest and most heartfelt thanks to my hon. Friend and all her colleagues for the painstaking and professional work that they have done. As a result, our mental health institutions are certainly that much more civilised, humane, and, I hope, successful than they might otherwise have been.
The commissioners have the following key tasks: to protect the interests of patients who are detained in hospital under the Mental Health Act, by visiting and interviewing them, by investigating complaints—a large section of their current report reflects that work—by 237 keeping under review the way in which the Act operates, and by requiring the second opinions that the Act requires before certain types of treatment can be given to patients.
The commission also prepared the first draft of a code of practice on admission to hospital and treatment of mentally disordered patients, which is described in section 8 of its report. The final version of the code will be laid before Parliament next year, following consultation with statutory professional and voluntary bodies. That is part of the answer to one of my hon. Friend's questions.
The commission is required to publish a report every two years, and the Secretary of State is required to lay it before Parliament. I have it here. My hon. Friend referred to the commission's second biannual report, which was laid before the House on 28 October. The reports are a mine of information on the practice and treatment of our most seriously ill mental patients who, without our care and control, would be a danger to themselves and the public. They are also written in a sensible manner that is comprehensible to the lay public, and I commend them to the House. They make interesting reading. The report raises many important issues. Obviously, it goes much wider than special hospitals. We are studying it closely and we shall discuss many of the detailed points that it raises with the commission.
My hon. Friend raised some specific points relating to special hospitals. As she knows, the Mental Health Act Commission covers all detained mental patients, wherever they are. Those who require special security are found in the four special hospitals—Broadmoor, Rampton, Park Lane and Moss Side. I share her considerable admiration for the staff who work in those hospitals, notwithstanding recent difficulties at Moss Side. They have a most difficult job to do.
My hon. Friend spoke about changes in management and asked some pertinent questions about some management issues, which we shall take into account. She will know of the commission's unqualified welcome for local management boards, which is most encouraging.
Since the beginning of this year local boards have been placed at all the hospitals, with a single board for Moss Side and Park Lane hospitals. The boards now have delegated responsibility for the management of the hospitals and we are extremely fortunate in having for each of the boards a chairman and members with a wide range of background experience drawn from the local community and the professions.
Before the boards were set up—the first was set up in Rampton in 1981—the special hospitals were managed directly by the Department of Health and Social Security. Ministers now see the boards as providing strengthened local leadership and achieving precisely the kind of improved management efficiency and effectiveness and the improved patient care that my hon. Friends seek. The boards do not have an employment function, because the staff are civil servants and they do not control admission which is still done centrally by the DHSS admissions panel, which deals with about 200 admissions per year.
Nevertheless, the local boards exercise four important functions. First, they are responsible for the provision of all services at the hospitals, including professional services. In practice, that means giving support and advice as 238 required to hospital staff at all levels and developing policies and programmes to maintain and improve the care of patients.
Secondly, the boards will determine priorities in relation to the use of manpower resources, revenue and capital funds. In essence, that means that they decide how the available money can best be spent, and I shall come to the sum that is available in a moment. It is the boards' job to ensure that value for money is obtained by improving efficiency wherever possible. That was also the major purpose behind the Griffiths management reforms.
Thirdly, the boards are charged specifically with ensuring that adequate procedures for the investigation of complaints made by or on behalf of patients are indeed in operation. Fourthly, the boards will act as managers of the hospitals in the context of the Mental Health Act 1983—for example, in carrying out the requirement in respect of renewals of detention.
On all the matters that have been delegated to them, the local management boards, with the support of the hospital management teams, will be directly accountable to Ministers. I am sure that that will be a firm basis on which to meet the challenges to come, and I hope that my hon. Friend will allow the boards just a little more time, given that they have had only a few months, before passing judgment on them. Nevertheless, my hon. Friend's comments were most useful.
My hon. Friend asked about the complaints procedure. As she will know, we are now well advanced with draft proposals for a standard policy and procedure for the handling of patients' complaints, and these are currently the subject of consultations with the local management boards. The proposals reflect the key requirements laid on the Health Service by the Hospital Complaints Procedure Act 1985. They also take into account the fundamental principles that are now outlined in the commissioners' report, including the need to interview patients—a point upon which the commissioners' report laid particular emphasis. The Department's draft—it is the responsibility of the Secretary of State alone to produce the draft—also takes account of the local procedure currently being operated in each of the four hospitals. That is why we have not formally endorsed the procedure drawn up by the Broadmoor hospital ethics committee.
Local management boards will be responsible for ensuring that the policy and procedure that is finally negotiated and agreed with the hospitals and the staff side representatives is operated properly. The fact that the DHSS retains the employment function should not affect the boards' ability to exercise those responsibilities.
The Prison Officers Association, which represents a large part of the staff concerned, has repeatedly made clear its view that complaints leading to allegations of a criminal nature against staff should be referred to the police and that no pre-emptive action should be taken by management against the member of staff involved. That view has never been accepted by my Department or local management, which will continue to exercise its right to take action in advance of the outcome of police inquiries if the facts of the case make that appropriate.
Any staff member who is charged by the police is suspended from duty until the outcome of a police investigation and any subsequent prosecution that might take place is known. We agree with the commission that nothing should stand in the way of management pursuing its own disciplinary action if necessary, and this is done.
239 If management issues alone are involved, my Department expects the hospitals to mount their own management inquiry.
My hon. Friend cited an illustrative case study—that of patient B. I would not wish to say whether the facts as given were right or wrong, but we would have to agree that for anyone to have to wait for such an extraordinarily long time to be told the outcome is indefensible.
I turn to money and manpower. Psychiatry in general is a priority service for development money and has been for some time. There have been substantial increases in staff but, nevertheless, mental illness is the second biggest burden on the Health Service after heart disease. Recognition by successive Ministers of the need to improve and develop patient treatment and care has led to a substantial build-up in resources for the special hospitals in recent years. Annual increases in revenue funding have been consistently higher than those of the Health Service as a whole. Since 1980–81 actual spending has increased from £28 million to £54.6 million in 1986–87—an increase of 95 per cent, in cash, as compared with Health Service growth as a whole of 57 per cent, over the same period. After allowing for pay and price movements, the comparable figures are 23.9 per cent, and 11.5 per cent, respectively. Therefore, special hospitals funding has grown twice as fast.
Spending per patient has increased in the special hospitals from £14,461 a year to £32,257 a year. Since 1980, staffing levels have increased from 2,604 to 3,249 currently, an increase of just under 25 per cent. At the same time, there has been a reduction in patient numbers from 1,937 to just over 1,700. Those trends have combined to result in a notable improvement in patient-staff ratios from 1.3 staff per patient to two staff per patient. Regional secure units are even more generous in their funding. In 240 the past two years, the rate of growth in revenue funding in real terms has slowed down, reflecting the progress that has already been made in improving levels of staffing and service. The current year has seen a modest further increase in staffing of about 27 posts.
There is also an extensive building programme that is managed directly by DHSS headquarters and represents a substantial investment in redeveloping and modernising the hospitals. The current spend is in excess of £10 million a year and that level of spending is projected well into the 1990s. As an illustration, stage one of the Broadmoor rebuild has cost us £30 million and the current estimated total cost of the four-stage development at that one hospital is £69 million. Completion is expected within about 10 years.
As well as the Broadmoor rebuild, the programme provides for extensive upgrading of the infrastructure at Rampton, and there are extensive works at Park Lane. The new Park Lane hospital in Liverpool has been built to provide up-to-date single room accommodation with modern supporting facilities for up to 400 patients. In that way, patients who may well spend the rest of their lives in hospital at least may have some privacy and some individuality, and working conditions for staff can be noticeably improved. However, it is an expensive business.
I hope that what I have said has shown that Ministers and officials are addressing themselves to the concerns raised by my hon. Friends. I will write to them in more detail, if I may, on some of the other points raised and I am pleased to have had an opportunity to air this important subject.
§ Question put and agreed to.
§ Adjourned accordingly at twenty-eight minutes to eleven o 'clock.