§ Mr. Richard Spring (Bury St. Edmunds)I am grateful for the opportunity to speak this morning. I am also most grateful to my hon. Friend the Minister for being here today to reply to the debate.
Last summer, I was contacted by very distressed parents in my constituency. What was revealed to me then and continues today is an example of human tragedy and suffering which moved me considerably. It would be helpful if I summarised my constituent's difficulties. As a teenager she became pregnant and had an abortion, after which she exhibited previously non-existent behavioural difficulties. In the United States the phenomenon has been identified and described as post-abortion shock syndrome. That may have been the cause of what followed. Seven years on, her parents contacted me. They were desperate. Their daughter had been a patient in the psychiatric ward of West Suffolk hospital in Bury St. Edmunds—a ward which gives the highest standards of psychiatric care and to which I pay unqualified tribute this morning.
In the opinion of the senior psychiatrist at the hospital, and, indeed, of outside independent psychiatric assessors, my constituent did not essentially have a psychiatric disorder. Furthermore, there had been violence directed against ward staff, which caused them concern and consternation. Psychiatric opinion indicated that her condition was behavioural rather than psychiatric. As she was diagnosed as suffering from an untreatable personality disorder rather than a treatable illness, it was not possible to detain her under section 3 of the Mental Health Act 1984.
My constituent was transferred to the region's medium secure unit for those with mental illness, the Norvic clinic in Norwich, which I have visited. Under the stricter regime there, she exhibited more restrained behavioural patterns. However, on discharge to a hostel, symptoms of chronic disorder reappeared and she returned to live with her parents. At home her actions including crying and wailing and banging her head incessantly against a wall. Where could she go? The psychiatric ward declined to take her because her condition was not considered pyschiatrically treatable. The district health authority was unable to help either for that reason, although it was very willing to do so.
I was advised that the criminal justice route should be explored. A previous move had simply resulted in my constituent being sent home with a fine. At this point, I should perhaps stop to say that all the routes that I explored on my constituent's behalf last summer seemed closed. My constituent has now had a baby. I am grateful to Suffolk social services for the concern that they have shown in helping her during this difficult time.
The nub of the issue is clearly this: where does someone who is not psychiatrically assessible go? Clearly, for the layman like myself and other hon. Members, there is no tangible difference between someone who appears to be psychiatrically or behaviourally disturbed and someone who is. The manifestations appear similar. Tragically, such an individual may commit an act of violence against another person, so there is clearly a public safety aspect.
My great fear is that our prisons contain people who have similar problems, when prison is clearly as inappropriate response to this tragic human disorder. I have taken the advice of several forensic psychiatrists and 754 I have to tell the House that my constituent is not alone in her ghastly dilemma. There are many in our country for whom there is no clear provision, because they fall outside certain definitions of mental disorder.
There is, of course, rising concern and awareness about mental illness. Indeed, that was highlighted as a key objective in "The Health of the Nation". Moreover, one of its strategic elements is the development of comprehensive local services, with local purchasing and planning arrangements which ensure continuity of health and personal care. A start has been made in Suffolk.
I have alluded to the Norvic clinic in Norwich, which is the only provider of medium secure beds in the East Anglian region. Districts do not, for example, have psychiatric teams whose specific responsibility is to provide more local services for mentally disordered patients. Indeed, at the core of the Reedport's recommendations is the view that district health authorities should be responsible for purchasing a more comprehensive spectrum of psychiatric provision for mentally disordered offenders. Clearly without the support of her parents and family, my constituent might well now be in prison herself.
The thrust of what the Reed committee reported was that mentally disordered offenders who need care and treatment should receive it from the health and social services rather than the criminal justice system. That theme and focus is not new. In 1975 the Butler report noted:
In the face of the widely acknowledged and urgent need, we have been disturbed to learn that little progress has as yet been made in establishing needs, or even in providing temporary arrangements".Indeed, the thread in the Reed report of last year of a multi-agency review had been taken up by the Aarvold committee in 1972. It recommended that a patient leaving a special hospital should not normally be discharged direct to his family or to casual lodgings, but, wherever practicable, should go first to a local psychiatric hospital or a hostel for an initial period of rehabilitation.All those learned reports have grappled with the same problem and all have highlighted the inadequacy of bed spaces in medium secure provision. Reed's targets of 1,000 beds by 1995 and 1,500 beds as a final target was originally set at 2,000 as long ago as 1974. The present figure is some 635, considerably below recommended levels. In my region, that would suggest that another 20 bed spaces are required in the medium secure unit.
"The Health of the Nation" noted that mental illness accounted for 14 per cent. of certificated sickness absence; 3 to 6 per cent. of adults over 16 may suffere depressive disorders; 2 to 7 per cent. suffer anxiety states. Others, of course, suffer from schizophrenia and dementia. In 1991, there were 5,567 suicides, with a notable rise among younger men. Mental illness has a wide range of manifestations.
The figures involve substantial numbers of our fellow citizens and the number will surely rise. But I cannot stress sufficiently that clinical needs and public safety are inextricably bound together. Of course, I accept that it is difficult to make clinical distinctions about the mentally disordered. However, in cases such as that of my constituent, it has been confirmed by many conversations with psychiatrists that there appears to be a grey area which current arrangements do not satisfactorily address.
755 I realise that the Reed report's recommendations that the number of spaces in medium secure units be substantially increased will be expensive. I shall explore that later. Clearly, we also need to examine how care for mentally disturbed patients can be enhanced for both existing mental patients and those who might be moved from prison to hospital. My hon. Friend will know that the Reed committee recommended a substantial transfer of prisoners into appropriate hospitals. Of course, there are dangers. For all its imperfections in this context, the criminal justice system at least offers the opportunity of a trial or, indeed, redress to an offender. Being sent to a hospital cannot and should not be undertaken without taking into account the interests of public safety. It cannot be seen as an alternative to remand in custody.
Therefore, in responding to mentally disordered offenders, the actual offence has to be responded to. A co-operative approach is needed to ensure an appropriate response. When, in the instance of my constituent, the consultant psychiatrist who took her case offered to stay in touch with the police if she was arrested, it was a generous and helpful offer, but a one-off response to my intervention. What we are talking about is a much higher level of co-ordination.
I should like to dwell on the ways in which to address that problem, accepting, as Reed recommended, an increase in the number of regional secure units with bed spaces of fewer than 100, as at the Norvic in Norwich. The reason for that is that the psychiatric ward at West Suffolk hospital and other similar wards undertake treatment for mentally ill patients without physical restraint and under conditions of minimum security. Violent, aggressive or disruptive patients cannot be restrained in such an open environment. My constituent, however, was not regarded as treatable anyway. In those circumstances, therefore, all that can be done is to resort to heavy tranquillisation rather than therapy.
In 1991, the East Anglian regional health authority established a working party to investigate the problem of providing for patients with mental disorders. As a result, there is a possibility that sub-regional units could be established. From my many conversations with psychiatrists, however, I know that they would be reluctant to use them. They want a network of small, intensively staffed units in each district. The expense would be high, but current ECRs—extra contractual referrals—for mentally disordered patients are costing up to £200 per in-patient week in the private sector. The cost of processing the individual through the criminal justice system and keeping that person in prison is extremely high.
Larger institutions, such as medium secure units, have an important role to play, especially for the real offender, potential or otherwise. There still remains, however., the challenging behaviour of individuals such as my constituent. The criminal justice route is not appropriate and such individuals do not respond to psychiatric treatment either.
I have consulted a number of psychiatrists, particularly in my constituency. Individuals with behavioural difficulties require a separate unit where they can be treated with appropriate behaviour therapy. In a county such as Suffolk that would imply the provision of a unit with about 10 beds, probably located on a hospital site. Obviously, there would have to be some element of security, aided by appropriately trained staff. After 756 behaviour therapy of perhaps six months or up to two years, individuals could then be discharged or transferred to a suitable residential place.
By definition, the focus would be narrow, but we are talking not about a large number of people, but about a sufficient number who have no place to go and whose lives are often marred by personal tragedy in consequence. Hope would be offered and the use of non-improving drugs could be avoided.
The whole issue of mental illness in its various manifestations is no longer something which is pushed under the carpet. The White Paper "The Health of the Nation" recognised that admirably. The Reed report has focused attention on the needs of those with mental difficulties. I greatly welcome both reports and the spotlight that they have thrown on the blighted lives of many thousands of our fellow citizens.
§ The Parliamentary Under-Secretary of State for Health (Mr. Tom Sackville)I congratulate my hon. Friend the Member for Bury St. Edmunds (Mr. Spring) on securing time to debate the important topic of behaviourally disturbed people. I also congratulate him on doing so in such an eloquent and moving way.
This aspect of health and social care is truly multi-disciplinary and it is right that health and social care professionals, patients, people in the community and politicians regularly take stock to see whether the right sort of care is being delivered to mentally ill and emotionally disturbed people.
My hon. Friend has clearly explained the circumstances of his constituents, their adult daughter and their difficulty in securing help. Their case is tragic and he has asked, quite rightly, what our policy is for caring for mentally ill people and how we prevent people from falling through the net.
The Government fully recognise the burden carried by carers who look after sick relatives. I pay tribute to all their hard work and dedication in standing by so steadfastly members of their families who are mentally ill. It is not an easy task and, quite rightly, those carers look to the statutory and voluntary agencies for help. I should explain that, for some years, the Government have provided grant support to a number of voluntary organisations which, directly or indirectly, represent the interests of mentally ill people and their carers. If my hon. Friend would find it helpful, I can let him have the appropriate names and addresses so that his constituents can get in touch with them for support and advice.
As the House will know, we have a large agenda before us. About one person in 10 suffers from some form of mental illness in the course of a year and mental illness is as common as heart disease and perhaps three times as common as cancer. About seven people in 1,000 of the population will suffer from schizophrenia at some point in their lives and currently it affects an estimated quarter of a million people.
So what is our policy? Quite simply, it is to continue to encourage the development of locally based health and social services to meet the needs of people of all ages suffering from mental illness. The aim is to have a range of services that are local, comprehensive and sensible.
The components of such a service must be principally effective assessment of need; community mental health 757 teams supporting mentally ill people in their own homes; an adequate range of day care services; adequate short and long-term hospital provision; and an adequate range of health and local authority respite services.
This policy, which is to be taken forward within the general framework of responsibilities for community care can be delivered successfully only by health and local authorities working together, in collaboration with the relevant voluntary organisations and the private sector.
The NHS's responsibilities for providing continuing care have been clearly set out in the White Paper "Caring For People" and were strongly reiterated last year in letters to regional health authorities and social service departments from the deputy chief executive of the NHS management executive and the chief inspector of social services. The form that this continuing care should take and the number of places provided must be a matter for local decision. While central Government can set the scene and establish a framework for mental illness and community care policies, it is the local agencies which will need to turn those intentions into firm positive action for the benefit of patients and carers.
Of course, at the heart of 'all concerns are those users and carers mentioned by my hon. Friend. The first key component for community care identified in the White Paper was services that respond flexibly and sensitively to the needs of individuals and carers. The second key component was to ensure that service providers make practical support for carers a high priority. To do that, we must all listen closely to what users and carers have to say about the services they receive so that we can learn from their experiences and develop more appropriate provision of care. I believe that we are doing this and today's debate reflects that, but, to encourage the process still further, we are setting up a national users and carers group with representatives from a wide range of clients, including mentally ill people as well as the appropriate voluntary organisations.
The purpose of the group will be to give direct regular feedback to Ministers through the Department about the experience of care in the community, particularly during the early period of the new arrangements. Its remit will cover both health and social services and we will expect to hear about services provided by the independent sector as well as the statutory authorities.
The group would be able to give the centre some first-hand feedback about what is going on regionally and what the effects are for particular user groups. It could share experiences and advise us on how services can be made more responsive and how systems and management can be improved. It could also act as a focal point for advice and good practice on how service users and carers might be more effectively involved in the planning and development of community care services. It will give us at the centre a much more direct feel of how we can continue to go about achieving the central aim of community care.
None of this can be achieved without the right level of resources and the Government are firmly committed to improving services for mentally ill people. This is demonstrated by the fact that, including secure provision, about £2 billion is being spent each year on mental illness. That figure, although impressive, does not tell the whole story, because it does not show the 37 per cent. increase in 758 real terms in gross expenditure on hospital and community health services since 1979 and an 86 per cent. increase in real terms in gross expenditure on local authority social services. Those figures demonstrate quite clearly that the Government are committed to policies for the mentall ill.
However, we recognise that the provision of services can be patchy and that is why we have taken a number of initiatives to improve the overall level of care. These include the introduction of the care programme approach in April 1991, two years in advance of the National Health Service and Community Care Act 1990, introducing the idea of needs assessment and care management to the care of mentally ill people.
Based on the best professional practice, it is intended to cover all patients being considered for discharge from mental illness hospitals and all new patients accepted by the specialist psychiatric services. The needs of each patient, both for continuing health and social care and for accommodation, should be systematically assessed and effective systems put in place for ensuring that agreed health and, where necessary, social care services are provided to those patients who can be treated in the community. Explicit, individually tailored care programmes are drawn up and a key worker is identified to keep in close touch with the patient and to ensure that the agreed package of health and social care is being delivered.
We have also introduced the mental illness specific grant available to local authorities which has brought about significant improvements in the social care provided to people with a mental illness In 1993–94, the grant will be £34 million in support of expenditure of some £47 million by local authorities.
In addition, we have helped to raise the awareness of mental health and push forward action by the relevant agencies by including it as one of the five key areas in "The Health of the Nation" White Paper. The main objective is to reduce ill-health and death caused by mental illness and there are specific targets to reduce suicide by 15 per cent. in the national rate and 33 per cent. for the severely mentally ill by the year 2000.
We have recently issued a mental illness handbook to put flesh on the bones of the White Paper and to help health and local authorities develop local strategies for reducing mortality and morbidity caused by mental illness. Although the information in the handbook is meant to be illustrative rather than prescriptive, it represents the most detailed description we have ever set out of what we would like to see developed in the field and how. As such, it is likely to be a major resource for many years to come.
There is a particular task in "The Health of the Nation" relating to mentally disordered offenders. Health authorities are required to include a range of secure and non-secure services for this group in their strategic and purchasing plans. The development of those plans will be influenced by the work of the Department of Health/ Home Office review of services for mentally disordered offenders—the so-called Reed review to which my hon. Friend referred, whose final report we published last November.
We are still considering many recommendations made during the review, but we have already endorsed a set of principles for the future provision of services and we have greatly increased the amount of capital available centrally for medium secure services—from £3 million in 1991–92 to £17 million in 1992–93 and £22 million next year. We are also awaiting the outcome of the working groups, under 759 the chairmanship of Dr. John Reed, which are looking at personality disorders and high security services. That work will be completed shortly.
To help in following up the review and in maintaining the good co-operation between agencies which it has fostered, we have established a new advisory committee on mentally disordered offenders. That committee is being formed for three years and, among other things, it will advise the Department of Health and the Home Office on follow-up action to the review.
Clearly, there is always a lot more that we could do. We still need to unlock resources from the old long-stay institutions in developing services further in the community and, to help tackle this, we set up a mental health task force in 1992 to help build up a balanced range of locally based services.
Also, it is apparent that implementation of the care programme approach is patchy and people can fall through the net. There is the problem of a small minority of mentally ill people who refuse to participate voluntarily in their care programmes. The Government are very concerned about the position of patients who slip through the net of community care and this is why we are taking a fresh look at the existing legal powers and considering whether changes are needed to the mental health legislation. A team has been set up to take this forward and a report will be made in the summer.
One point that is not always appreciated is that the Mental Health Act allows a patient to be detained in the interests of his or her own health. It is not necessary to show that they represent a danger to themselves or others. We are considering further changes to the Mental Health Act code of practice that are aimed at removing any misunderstanding about the admission criteria under the Act.
I am grateful for the opportunity to respond to my hon. Friend and I congratulate him on raising the topic. It is an unfortunate fact that everyone is aware of acute services and hospital services and the problems that they are in, but fewer people are aware, or are willing to be aware, of the problems of mental health. Too many people would like to brush it under the carpet, but there is an enormous need and one which must be met. We are determined to do that.
I hope that I have been able to show what measures we are already taking to provide a high-quality service for mentally ill people and the resources that we are putting in to support this. We will continue to do all that we can to make improvements and to ensure that mental illness is given a high priority by both health and local authorities.