Mental Illness

HC Deb 10 May 1995 vol 259 cc661-81

Motion made and Question proposed, That this House do now adjourn—[Mr. Kirkhope.]

10.4 am

Mr. John Marshall (Hendon, South)

The tradition in debates in this House is that one begins by declaring an interest. I declare an interest in that I am a member of the advisory council of the Jewish Association for the Mentally Ill, although I suspect that I receive much more advice than I give.

This debate is in the interest of the thousands of mentally ill individuals who are inadequately treated under the present system; of parents who see their sons and daughters suffer and, all too often, cannot influence the psychiatrists who treat them; of preventing the avoidable suicides and murders which take place because of failures in treatment.

I last raised the subject of the mentally ill in an Adjournment debate in December 1993. Although I have been silent in the House on the matter since then, I have frequently written to Ministers questioning the principles of the Government's policy, and have pointed out to the relevant authorities a number of individual cases where treatment has been inadequate.

The backdrop to the debate in 1993 was a local tragedy. In the summer of 1993, I attended the funeral of a constituent. There is nothing unusual about Members of Parliament doing that, but in that case I was attending the funeral of a 24-year-old constituent who had been receiving psychiatric treatment for some time. His mother had frequently written to me saying that the treatment was inadequate. I had written many letters to the psychiatrist and others trying to help him, saying that the care in the community that he was receiving was inadequate, that his mother knew her son much better than any psychiatrist did, and that the psychiatrists should listen to the mother.

They did not listen to the mother, and eventually, that 24-year-old boy dropped from the sixth floor of a building in my constituency and committed suicide. The death of a young man, which could have been avoided, is a galling experience which I shall always remember—the day life was tragically cut short because experts would not listen to a parent who knew much more about her child than they did.

During the eight years in which I have been a Member of this House, I have attended only three debates on the mentally ill, two of which, including this morning's, I have instigated. Since the debate in December 1993, a raft of reports has suggested that the care in the community policy is failing many of those whom it seeks to help.

In February 1994, we had a report into the murder of Jonathan Zito by Christopher Clunis. One must remember that Christopher Clunis had passed through the hands of 150 doctors, nurses, social workers and policemen, and had been into 14 hospitals, prisons and hostels, yet he was in the community and able to kill an innocent individual in London.

Another report in April 1994 said: Thousands of the mentally ill are relying on variable, patchy and under-funded services. In August 1994, it was pointed out that more than half of the 22 people who had killed an innocent individual after discharge into the community had refused to take the drugs that they had been prescribed, or to attend treatment.

In September 1994, the Department of Health's mental health task force referred to a serious problem of emergency access to appropriate care for severe mentally ill people. In September 1994, the Mental Health Foundation said: some services, particularly acute hospitals in inner cities are under such pressure that proper discharge planning of any sort is an unattainable dream. The Royal College of Psychiatrists produced a report in 1994, in which it said: It is common for there to be no admission beds at all, available in the South of England. In these circumstances patients … may have to be nursed for 24 or even 36 hours in a room in an accident and emergency department while doctors or nurses make numerous phone calls to locate a bed, often at a hospital many miles outside London. There have been instances where suicidal or dangerous patients have absconded while waiting and others where patients, who would have accepted voluntary admission to their local unit, have had to be compulsorily admitted because they did not wish to go to the distant hospital. The report concluded: It would be difficult to argue that to admit a London resident to a hospital on the south coast is any advance from the days when such patients would have been admitted to the large psychiatric hospitals that ringed London". More recently, in April 1995, the Royal College of Psychiatrists reported: 'True' bed occupancy was very similar to that in its previous survey—123 per cent. It said that that figure was accounted for by the fact that 189 people who should have been in London admission beds were inappropriately placed elsewhere. 102 of the 189 people … had to be admitted to distant hospitals because of bed shortages. That emphasises the fact that in London there is a shortage of beds in mental hospitals. Surely that should guide Government policy in future.

The Royal College of Psychiatrists also said: Violent incidents (mainly assaults on staff and other patients) are very common on psychiatric admission wards. 131 incidents were reported during the week of the census, 47 of which had resulted in some injury. The policy of closing large mental institutions by the year 2000 was instituted by Mr. Enoch Powell in 1961. It is ironic that that gentleman, who made his economic fame by attacking long-term or even short-term economic planning, should, as Minister of Health, have indulged in a policy of mega-long-term planning in deciding in 1961 what should be done by the year 2000. In the early 1960s, there were 140,000 beds in mental institutions; today there are 20,000.

The Powell thesis was fundamentally misguided. It was a reaction to the excessive incarceration, in the 1940s and 1950s, of people in mental hospitals who should never have been there. However, the fact that some people were wrongly admitted in the 1940s and 1950s was no reason to decide in 1961 that no one would need to be admitted into large mental hospitals in the year 2000, or indeed in the year 1996.

There is no doubt, to my mind, that the pendulum, which swung too far in the 1940s, has swung back too far in the opposite direction. Self-evidently, many of those who were in mental hospitals in 1961 should not have been there, because they have subsequently managed to cope by living in the community. However, it is equally true, and it is visible to anyone looking round London today, that some people cannot cope in the community and should be in an asylum.

That would be better for them. Their quality of life would be better. It would be far better for their families, who worry about what is happening to their sons and daughters, wives and husbands, and it would be better for society at large.

I recently sent several letters to my hon. Friend the Under-Secretary of State, the hon. Member for Battersea (Mr. Bowis), questioning the adequacy of the number of beds in London. There is a great deal of apocryphal evidence to suggest that I am right, and that some of the statisticians in the Department of Health are wrong. There are too many examples of patients being released prematurely, and of others having difficulties securing admission.

It is equally true that, just as there is a shortage of beds in the hospitals, there is a shortage of beds in the community. The shortage of beds in hospitals encourages the premature discharge of mental patients, and I am afraid that it is sometimes compounded by professional misjudgments.

I shall always remember one of my earliest surgeries. A large deputation came to visit me from one of the council estates in my constituency, and I wondered what the council had done. The people said, "It is Mr. Campbell," so I wanted to know whether he was the caretaker. They said, "Oh no, nothing like that. Mr. Campbell has just been admitted into the N block, and he has just come out of hospital." I asked what the problem was. They said, "He has been discharged from a mental hospital and he does only one thing—he plays music. The trouble is that he starts at 8 o'clock at night and finishes at 8 o'clock in the morning. We are all trying to sleep when he is playing his music, and when he is not playing his music we are trying to work." I wrote to the hospital. On that occasion they admitted that Mr. Campbell needed to go back into hospital, and he was taken back, but probably he should never have been released into the community.

The care in the community policy rests on the paradox that people are told that they are sufficiently fit to live in the community, but they are sufficiently unwell to need medication—and thoroughly nasty medication to boot. None of us like to take nasty medicine. I always remember that, as a child, when I had a severe illness during the war and I was given very nasty medicine, I once asked my mother, "Why don't you try the medicine?" She took it. I then said to her, "You have taken it today. I don't need to take it." She gave me a short shrift answer that that was not a logical response, and I agree with her in retrospect.

None of us likes to take nasty medicine, and most of those people who have been buoyed up by discharge into the community believe that they no longer need to take the nasty medicine. That is when they regress. That is when they become violent. That is when they sometimes lose their general practitioner. That is when they become aggressive to other people. That is when they end up in prison.

It is surely wrong that someone should be discharged into the community because it is thought that they are unsuitable for institutional care, and then end up in another institution—a prison.

Mr. Oliver Heald (Hertfordshire, North)

Does my hon. Friend agree that there are people living in the community perfectly satisfactorily and taking drug therapy regularly, and that they now have a freedom that they would never have had if they had remained in one of the large institutions? Surely the key is that those people should be adequately supervised.

Mr. Marshall

My hon. Friend has anticipated the next part of my speech, when I was going to discuss the Government proposals for supervised discharge.

One of the other ironies of care in the community is that many of the people who have been released into the community end up sleeping rough. I shall always remember one of my first constituency engagements, in, I think, September 1987, when I visited the National Schizophrenia Fellowship. I asked one of the members, "What is your problem?" and she explained that her daughter was schizophrenic. I asked where her daughter was, and she replied, "She is sleeping on a park bench somewhere in London tonight." If one talks to them, one discovers that a significant number of the people who will sleep rough in London tonight are people who have been released from mental hospitals throughout the capital.

Some people criticise the Government's power of supervised discharge in the Mental Health (Patients in the Community) Bill—which will shortly receive a Third Reading in another place, and will shortly thereafter come to this place—on civil liberty grounds, but those who do so are, I believe, making a completely flawed argument. That argument assumes that someone who is sufficiently troubled to need psychiatric help is sufficiently sane to decide rationally about his treatment. The protection of one person's civil liberties may well mean that they are denied to someone else.

Those who criticise supervised discharge ignore the fact that many of those who are released into the community commit suicide. There is no doubt that the official figures understate the number of suicides committed by released schizophrenics. The courts will take account of the religious susceptibilities of those who may or may not have committed suicide, or recognise that the validity of a life insurance policy will be determined by the verdict reached by the coroner. The NSF estimates that between 300 and 500 released schizophrenic patients commit suicide each year.

When we talk about civil liberties, we must also remember the civil liberties of those adversely affected by current arrangements. Jayne Zito had the civil liberty to expect that her husband would not be killed. Georgina Robinson, an occupational therapist, had the right to expect the civil liberty of being able to work in a mental care health centre without being killed by a patient. Ruth and John Gore's civil liberties should have meant that they were not hacked to death by their schizophrenic son. Jason Dalson's civil liberties should have meant that he was not killed by his mother at the age of 6.

Those are the civil liberties that we must remember. In each of those murder cases, the law recognised the concept of diminished responsibility when the individuals charged went to court and pleaded guilty to manslaughter rather than to murder. Is it not right to recognise the concept of diminished responsibility before a crime is committed rather than after?

One of the ironies behind the problem is that the strongest advocates of supervised discharge are the relatives of those affected. They do not believe that such discharges would affect their son's, daughter's, husband's or wife's civil liberties. They believe that it is essential that the discharge of their relatives should be better supervised than it is now, so that those relatives can enjoy a better quality of life.

One of my concerns about the treatment of the mentally ill is the attitude of GPs. I am sure that virtually every colleague in the House has received more than one letter from one of my constituents. That lady is convinced that her telephone is being tapped; that her mail is being intercepted; that foreigners are coming into her home whenever she is out of it; and that Mossad and the Japanese—a strange combination—are after her. It is rather odd that both of them should be after the same innocent lady living in Hendon.

I visited that constituent at her home. She saw me outside first and said that everything I said would be recorded by bugs. I went into the house to look for those bugs, but could not see any. She pointed to where the intruders had come in, and showed me where they had left their mark. In fact, she had metal windows, and the mark was rust. I asked that poor lady who her doctor was. Her initial reaction was to say that she did not need a psychiatrist, but I then discovered the identity of her GP. I have pestered the man to try to do something about that poor lady but he has done nothing.

I could spend the next hour recounting other similar examples, but I know that other colleagues, such as my hon. Friend the Member for Macclesfield (Mr. Winterton), want to take part in the debate. My hon. Friend the Minister should try to ensure that GPs are better educated about the problems of mental health, and show a greater willingness to do something about it.

As I have already said, I am a member of the advisory council of JAMI. It has encountered problems with two local authorities in London. The London borough of Barking and Dagenham has written to say: The value of JAMI is recognised". Mr. X is seen to benefit from his contact with you. However, I regret that my efforts to secure funding have not been successful". JAMI has been asked to carry on that beneficial treatment, but will be given no money for it by that London borough. The London borough of Ealing, with which I used to be associated, has refused to give any funds to the course of treatment and support that JAMI has been giving to one of its residents, because it feels that, although the treatment was helpful, the gentleman concerned would not need residential care if he did not get it. It has therefore decided to give nothing towards that treatment.

We need a change of emphasis in our treatment of the mentally ill. Mental health needs to cease to be the Cinderella of the health service. I should like the Minister to announce a moratorium on further hospital closures until adequate alternative services are in place. The bulldozer must stop: the destruction of existing hospitals must cease. We should construct new, smaller mental hospitals and provide better facilities in the community. Hospitals must not disgorge patients into the community when they are unable to provide them with adequate treatment.

The Royal College of Nursing has made it clear that there are grave concerns that the closures of psychiatric institutions have not been offset by sufficient alternative support and treatment in the community. There is an increasing body of evidence which exposes the inability of the current aftercare arrangements to meet the needs of people with serious mental health problems. I should like the Minister to make it clear that the Government recognise the need for more community psychiatric nurses. At present, about 4,000 psychiatric nurses treat 180,000 schizophrenics. Many of those schizophrenics may not be attached to a particular psychiatric nurse, but each nurse has a case load of about 55 clients. That means that she—or he: one must not be sexist—can see each client for about half an hour a week. I do not believe that that time necessarily provides the right amount of treatment. The Royal College of Nursing has certainly said that it believes that the number of psychiatric nurses should be more than doubled.

The professions concerned should recognise that they should pay more attention to the views of the parents and relatives of those suffering from mental illness. On 18 January 1995, The Independent stated: The time has come to jettison an Act which neither protects the public effectively nor provides the care which seriously mentally disordered people require to achieve a more fulfilled and happier life. That single sentence underlines the nub of what I have said, at greater length. Were that recommendation met, it would fulfil the needs of the country.

10.27 am

Mr. Richard Spring (Bury St. Edmunds)

I am grateful for the opportunity to take part in this debate. I congratulate my hon. Friend the Member for Hendon, South (Mr. Marshall) on securing the debate, and on putting his argument so coherently.

When "The Health of the Nation" was published in July 1992, handbooks on different key areas were also published. What struck me about the handbook on mental illness was the revelation that 18,000 people die from mental illness, directly or indirectly, but most notably from suicide.

It is true to say that this generation has stopped trying to sweep the issue of mental disability under the carpet. That happened before, greatly to our shame, but we now recognise that mental illness affects people across the nation. It is fair to say that there is not a family in the land that has not been struck, directly or indirectly, by some form of mental illness, temporary or permanent.

People have phobias, anxieties, compulsive eating disorders and more serious conditions, such as schizophrenia. All those conditions cause immense distress to the families and friends of sufferers. Almost 90 per cent. of those who commit suicide suffer from mental disorders. No fewer than 66 per cent. of suicides consulted general practitioners within the month leading up to their suicide, and 40 per cent. consulted their GPs in the previous week.

Just over a year ago, I initiated a debate in the House as a result of an experience in my constituency. My attention was drawn to a truly tragic case of a young lady with behavioural problems who fell between all of the stools of the mental health process. She was not defined as psychiatrically unwell, so she could not be treated. It was believed that she suffered from a behavioural problem, and a psychiatrist told me that the criminal justice system was the only route for her to follow.

That young lady suffered from an illness, whether behavioural or psychiatric, which prompted her to cause damage to herself, and which created fear within her family and in the community. As a result of that case, I have become particularly interested in the area of mental health, and I have been moved by the plight of those who are affected by such problems, and that of their families.

As my hon. Friend the Member for Hendon, South said, many mental health beds have been removed from the national health service. However, some 80,000 beds remain, both on a daily or permanent care basis, for those who suffer from mental afflictions. In the past decade, the number of clearly mentally distressed people who are living rough has increased throughout the industrialised world. It is significant that the Homeless Network's audit of rough sleepers found that 91 per cent. of those in that unhappy situation had one or more special needs, and that one in three suffered from mental health problems.

The homeless mentally ill initiative was introduced almost five years ago in order to provide specialist psychiatric accommodation for those with mental health needs in London. It has addressed, at least in part, that particularly worrying problem which affects not only the individual sufferers but all those who live in London. I certainly share my hon. Friend's view that communities feel threatened as a result of well-publicised cases of mentally ill people who have been released into the community prematurely.

Mr. Nigel Evans (Ribble Valley)

Three large institutions are located in my constituency, two of which have virtually closed, and the other will close in five years. Does my hon. Friend agree that the concept of care in the community is absolutely correct? The scheme costs twice as much money as the old Victorian system, but we must ensure that those who need help can receive it.

There have been a number of highly publicised cases of people who were released into the community, who are sleeping rough and who are suffering as a result of deficiencies in the current system. As a consequence, the whole care in the community system is suffering also. Does my hon. Friend believe that we should target more resources at the small number of people who are now falling between two stools in the health service, in order to ensure that the care in the community system receives the credit it deserves?

Mr. Spring

I am grateful to my hon. Friend for putting his point of view so eloquently. I will examine the effect of the proposed new legislation, and I shall also inform my hon. Friend how we are trying to address the problems in Suffolk. I believe that we must reassure the public about this matter. The situation is akin to the public's reaction to crime: statistics may be falling, but the fear of crime is extremely damaging to people's sense of well-being.

I hope that the Mental Health (Patients in the Community) Bill will address some of the legitimate concerns that have been raised by my hon. Friend the Member for Ribble Valley (Mr. Evans) and other colleagues. My hon. Friends the Member for Ribble Valley and for Hendon, South have asked what level of supervision is adequate to deal with the problems of individuals and to provide proper comfort to the communities and to the families which are blighted by mental illness.

A supervised discharge will be required for those who leave hospital after having been detained under the Mental Health Act 1983. The new legislation will also tighten up provisions for returning to hospital those patients who go absent without leave. The period wherein patients can be recalled will be extended from six to 12 months. My right hon. Friend the Secretary of State elaborated on the legislation in a press notice of 12 August 1993, in which she said: Under supervised discharge, patients would be subject to conditions, including a treatment plan negotiated with them and their carers, and a requirement to attend for treatment. A named key worker would be immediately responsible for that patient's care. He or she must ensure that the procedures agreed in advance are followed and that decisive action is taken if the patient does not co-operate". We know of well-publicised tragic cases that have horrified and touched the heart of the nation. Therefore, the safety of the public must be uppermost in our minds. The supervised discharge arrangements, which I accept are a valuable advance in this area, include a treatment plan and an obligation to receive treatment. Any failure to do so will lead to a recall to hospital.

I hope that the my hon. Friend the Under-Secretary of State for Health will assure the House that hospital discharge procedures will be improved. It is also critical that the supervision register is monitored properly and adequately upon its introduction. Every year £2 billion is spent on mental health. The number of community health nurses has increased substantially, despite the pressures that my hon. Friend the Member for Hendon, South referred to. More psychiatrists and psychologists are involved in the national health service than ever before.

My hon. Friend the Member for Ribble Valley said that it was incumbent upon the health authorities to draw up proper care programmes for mentally ill people who are discharged from hospital. I contacted the Suffolk health authority to seek assurances that my county is undertaking such programmes. The authority is appointing a programme manager for mental health services to oversee the formulation of a programme, and I am pleased that that appointment is in the pipeline. The health authority is also introducing a number of other initiatives, including the improvement of acute in-patient services, and the provision of a consultant psychiatrist in Suffolk to examine proper rehabilitation procedures.

Community psychiatric nurses are providing an important new assessment service to individuals with mental health problems who are in police or court custody. The link between the justice process and mental illness is inextricable, and the distinction is often unclear. The service began last month, and decisions will be made as to those who need treatment and those who should be punished. That distinction was blurred previously, and it was certainly not taken into account when I introduced my Adjournment debate.

The legislation in another place will advance the issue in a wholly constructive manner. However, my hon. Friend the Member for Hendon, South eloquently highlighted the remaining potential imbalance involving premature discharge and inadequate bed space for those who still require care. When the new procedures are introduced in the next year or two, we must monitor the situation carefully and compassionately. We have not struck the right balance over many decades. We are now moving in the right direction, but I believe that it is incumbent upon all hon. Members to watch the developments very carefully.

Of course we do not want monstrously large hospitals for the mentally ill. Specialists in the area have said that the best success can be obtained by developing smaller units, which are properly coordinated and humanely supervised. I hope very much that that will become increasingly the pattern in the next few years. We need a balance, and I hope that we are moving towards one. I am sure that we will need to monitor the situation carefully in the next few years.

10.39 am

Dr. Jeremy Bray (Motherwell, South)

I congratulate the hon. Member for Hendon, South (Mr. Marshall) on calling for this debate, and on the manner in which he and the hon. Member for Bury St. Edmunds (Mr. Spring) presented the problems.

Neither side of House has a monopoly of concern for mental illness. This sort of debate allows the concerns of hon. Members, based on our direct experience of the problems in our constituencies, to be properly drawn to the attention of the Minister, so that he can carry them into responsible action by his Department.

We can understand the pattern of care needed for the mentally ill if we distinguish between the different stages of a mental illness, and, indeed, the differences between individual cases, because such differences are enormous.

The stage at which a mental illness presents itself most dramatically can be at a patient's first appearance at an accident and emergency department, or, preferably, a specialised mental health clinic. It is the experience of many patients that an accident and emergency department is not a good environment for a mental patient first to contact the health service. There is enough trauma in an accident and emergency department in dealing with acute physical cases.

To introduce a distressed mental patient into such an environment causes chaos in the department, and is unfair on the medical staff and on other patients, who desperately need attention but cannot get it because the whole place is disrupted by the behaviour of a mental patient.

However, if a 24-hour specialised emergency clinic open 365 days a year is available—as there has been for some years at the Maudsley hospital in London—the staffing and the expert care that can be given to mental patients provide an entirely different environment. It is still hugely distressing for the patient—that is unavoidable—but nevertheless it is a quite different environment from that of the ordinary general district hospital accident and emergency department.

I understand that the clinic at the Maudsley is now available only to people living locally in the area covered by the hospital, rather than to the whole of London. If that is the case, it is a great pity, and I hope that the scope of its service can be changed. We need such clinics in every major urban centre and city throughout the country, so that they are available to people in those desperate circumstances.

The greater proportion of patients presenting themselves for first care do not require emergency admission. However, some do, and they face a desperate situation in terms of the availability of beds. Dr. Paul Lelliott, who is the head of the research unit of the Royal College of Psychiatrists, recently carried out a survey of the availability of beds in London. He will present his report at 6 o'clock this afternoon at a meeting of the all-party mental health group, of which I am privileged to be the chairman.

The report found that not only was there not a single bed available in the whole of London on some occasions in January, but that there was a 23 per cent. shortage of beds for those patients who needed admission. It was not just a flash in the pan of one patient not being offered a bed. A 23 per cent. increase in the number of beds was needed to deal with the number of patients who required emergency admission under newly identified diagnoses in January.

Mr. Nicholas Winterton (Macclesfield)

The hon. Member is making an extremely important point. Does he accept that the situation is compounded because of a number of cases in which people with mental illnesses have been brought before the courts? The courts would like to commit those people to mental hospitals for care and treatment, but cannot do so, because there are no beds. As a result, as my hon. Friend the Minister knows, those people are committed to prison, which is the last place where such people should be committed. We need extra beds—not in the future: we need them now.

Dr. Bray

Yes, indeed. The hon. Gentleman is absolutely right.

Beyond the shortage of beds, there is the question of what sort of beds. The hon. Member for Bury St. Edmunds pointed out the problem of beds becoming blocked up because hospitals do not have channels through which patients can be reasonably discharged, and because there is an inadequate support system in the community.

It has been proposed that hospitals should be allowed to run hostels, which can be a transitional stage for people returning to the community. Such hostels are run by several hospitals around the country for the physically ill, not the mentally ill. They work very well, and costs per bed in them are far lower than they are in the hospitals themselves. It would be possible considerably to ease the channels of discharge from mental hospitals if, under the control of the hospitals, there were hostel places where people could be accommodated as they got used to returning to the community.

People often do not have any circumstances in the community to which they can return. They do not have a house, or, if they have been allocated a council house, there is no furniture. If it is minimally furnished, there is no community support. To construct all that apparatus of support takes time and organisation. It needs all the different support services to get together to create such apparatus for cases where the person has no family. A hostel can greatly ease that problem of transition.

There is also the need for continuing care. The supervised discharge proposals are concerned with cases where people who are mentally ill have attacked members of community. However, the number of suicides and cases of self-inflicted harm is far greater—10 times or more—than the number of people who are attacked by the mentally ill. Consequently, the greatest physical suffering is that of people who are mentally ill.

The Minister could confirm that forensic psychiatrists are not making a case for the expansion of their particular services. They tell me that their service is the best staffed part of psychiatric care services. The extreme cases that are looked after by the forensic psychiatrists are already the best provided for. I am not saying that the system has no problems to consider or that need working through, but its problem does not seem primarily to be that of resources. We therefore need to get public pressure and public concern about such cases properly directed and channelled into the organisation of the services and the balance of support in the community as a whole.

After moving on from the more intensive period of community care, there are the various forms of therapy and counselling which are needed to tackle some of the behavioural problems faced by patients. There is no unique therapy or counselling, but there are many cases in which it has been helpful to try out various channels in order to find the most appropriate type of counselling or the most suitable person. Because that has proved successful in many cases, it needs resources. The resources that could be absorbed by counselling and therapy are unlimited, but there should be channels through which people can feel their way through the services.

As well as the responsibilities of the Department of Health, other Departments—specifically Social Security and Employment—are also involved in a patient's return to the community and to work. I accept that there is good will on the part of the Departments concerned, but there is sometimes a lack of an appreciation of the nature of mental illness. The Department of Health must ensure that the various schemes produced by the other Departments are realistic for the mentally ill.

For example, a clear vital statistic in the performance of the disability working allowance, apart from the sums involved and the conditions under which it is paid, is the consideration of how likely it is that a mentally ill person returning to work will be able to sustain 40 or even 20 hours a week of consistent attendance for the indefinite future, or even for six months. There needs to be tolerance when a patient knows that it is best to stay at home and not risk going into work and provoking a crisis.

That is well understood by everybody concerned with mental health, but it does not fit easily into the structure of social security or a job placement scheme, which is concerned with people who, quite properly, need other encouragements and disciplines. We shall be debating how all that is put together when we consider the legislation about supervised discharge. The health service and the Department of Health must make a major contribution to the basic planning stage and the perception of the problem.

Hon. Members undoubtedly see many different types of case. It is a healthy sign that there is legislation going through the House now and that there is increasing concern by individual Members arising from work in their constituencies. It reflects a greater public sensitivity to the needs and problems of the mentally ill. The younger generation have a much deeper understanding of the problems of mental illness than some of their forebears. It is that concern, together with the relationships they form and the support they give in the community, that offers the best hope of care for the mentally ill in the future.

10.53 am

Mr. Nigel Evans (Ribble Valley)

I congratulate my hon. Friend the Member for Hendon South (Mr. Marshall) on initiating this debate this morning.

I am extremely concerned about the good name of care in the community. We must do all we can to ensure that any deficiencies within the system are corrected as soon as possible. My hon. Friend the Member for Bury St. Edmunds (Mr. Spring) talked about the high-profile cases in which people have fallen between two stools and are not receiving the proper care or supervision in the community. Some are not taking their tablets, are found wandering the streets at all times of the day and night, and are sleeping rough.

Those are the cases that the public see. They are not aware of the 99 per cent. of cases in which patients are receiving proper care. They see only the small number of cases, including the suicides, that make the newspapers. Therefore, the whole concept of care in the community is tainted. I am extremely concerned that we should do everything possible to ensure that the targeting of resources and help is aimed at those who are in need so that they receive proper care in the community.

As I said in an intervention, I had three large mental institutions in my constituency, which must be quite unusual. Brockhall has now closed, and is being taken over. No doubt the site will soon be turned into a housing estate. Whittingham will also close shortly. That institution is what everybody thinks of when they think of an old Victorian asylum. It has superb gardens, where the mentally ill can wander within the confines of the institution. The people outside the community never see those people, because they do not go into the hospital grounds unless they need to do so. Again, planning permission is being sought to turn that site into a housing development.

In a number of years, Calderstones, another large mental institution, will be closing. There will be a small unit on the site looking after those with extreme and difficult problems. Having said that, there are currently 600 people living there, who will all be discharged into the community. If one considers how many people were living in those three large mental institutions and who have now, over a short time, been discharged into the community, one can grasp the task that was before the Government in implementing this policy.

Many people have reservations about the speed at which all this has been done. They think that it should have been carried out more slowly. Some people, myself included, think that it has been more cruel than kind to take people who have been institutionalised all their lives out of the large institutions and put them somewhere else. Do not get me wrong: I am not a defender of the large institutions; they were a mistake, and we have moved on. However, we must ensure that the resources are there, so that those who are discharged into the community receive the proper care.

Mr. Nicholas Winterton (Macclesfield)

I was horrified by what my hon. Friend said about the closure of a number of institutions in his constituency. He said that some of the sites will be developed for housing. He said that Whittingham had superb grounds. Will my hon. Friend accept from me, having taken a deep interest in mental health over almost 20 years, that one of the treatments for those suffering from schizophrenia in particular is found in the environment in which they live and are being treated?

Is it not sad that those wonderful hospital grounds, many of them quite close to cities and town centres, and therefore very much part of the community, are being disposed of merely for the capital gain of housing development? If a smaller and more modern unit could be constructed on those sites to care for the mentally ill, the environment, which is so important for the treatment of some people with mental illness, could be retained.

Mr. Evans

I accept everything that my hon. Friend says. The grounds at Whittingham are large, and it is appropriate in certain circumstances to have that sort of atmosphere and quietude. That institution is on the outskirts of Preston. Some of the high-profile cases involve people who have been in that environment but who are now wandering the streets of Preston. That must be wrong.

I know that, with the redevelopment of Whittingham, a new unit will be put on that site. I hope that sufficient grounds are kept aside within the development, so that people are able to enjoy the quietude and the asylum, away from the noise and the grind of everyday living.

Mr. Nicholas Winterton

Get a commitment from the Minister.

Mr. Evans

I know that my hon. Friend the Under-Secretary of State for Health, the hon. Member for Battersea (Mr. Bowis) has been to Calderstones in my company. I was there only a few weeks ago, taking a look at the good work that was being done, particularly with people with learning disabilities. My hon. Friend will know of the good work and commitment of the staff who work at such institutions. One of my concerns is that the spread of people going into the community will mean that there are insufficient numbers of adequately trained experts to deal with the problems.

Lady Olga Maitland (Sutton and Cheam)

I thank my hon. Friend for giving way—he has touched on some valuable points.

Does he agree that we should be carefully considering another category of patients? We need to consider not just those who have been sectioned and come out of hospital, but those who are vulnerable and who do not quite qualify for being sectioned, but who desperately need supervision so that they do not harm themselves and others.

Mr. Evans

I agree with my hon. Friend. That is exactly what we need. Those people do not necessarily need large institutions; they need smaller institutions, with sufficient grounds, so that they are not any danger to themselves or other people.

Whittingham has a tradition of looking after people with mental illness, to which a stigma is attached. Mental illness is something that one does not talk about. The people in Whittingham have grown up with the institution, and enjoy the fact that it exists in their area. The people with mental illness mix with the people in the village, and the position is a total reversal of the not-in-my-backyard syndrome—NIMBY. If one tried to set up such an institution in some districts, the residents would fight tooth and nail against it, but the people of Whittingham fought hard to retain the institution in their community, because they know and understand the problems that those people have.

The problem of people with mental illness being referred to prisons because there are insufficient beds available has already been mentioned, and it worries me. One of my constituents, whose son unfortunately has a mental illness, came to seem me a couple of weeks ago. He became involved in a crime; his parents say that he should not be on the streets, but receiving care, because of his problem. He is now in prison. He is not receiving the care that he needs.

At the end of his sentence, he will be released back into the community in no better shape—perhaps worse shape—than when he went in. We must ensure that sufficient beds are available for people who might become involved in crimes because of their illness, and we must ensure that those people receive the proper treatment they need.

Lady Olga Maitland

Does my hon. Friend agree that there is another problem: the shortage of longer-term beds? There is a danger that patients who return into the community enter the carousel system. They come out of hospital, after a period they are desectioned, they commit another offence and have to return to hospital. They never receive treatment in hospital for long enough—the required period could be six months, one year or even longer. The problem is that such people are released too soon.

Mr. Evans

I agree with my hon. Friend. Nothing can be more distressing to professionals than to see those with whom they have worked released into the community prematurely and being sent to prison because they have committed a crime, or falling into rough ways because they are not taking the tablets and are not being properly supervised. The process then has to start all over again.

I shall bring my remarks to a close, as I know that other hon. Members want to participate in what has been a useful debate. We need to target the resources at those who are not receiving the proper care in the community. Those who receive care in the community benefit from the small cluster homes, where they receive virtually one-to-one attention from the dedicated staff. We must ensure that they can benefit in future, and we must not throw the baby out with the bath water.

11.3 am

Mr. Oliver Heald (Hertfordshire, North)

I congratulate my hon. Friend the Member for Hendon, South (Mr. Marshall) on instituting the debate.

I very much agreed with the hon. Member for Motherwell, South (Dr. Bray) about the change in attitudes in our society in recent years. It is right to start by praising the policy of care in the community and the great strides that have been made in taking individuals who did not enjoy freedom out of asylums, so that they are now able to make their homes in the community. Such people have been de-institutionalised and are free to become part of the community and take up jobs—many of them responsible jobs—due to the new drugs and treatments that have become available. It is a tribute to the House and the Government that the change has been made, and has been largely successful.

When one makes such a change, one also has to manage it and deal with its effects. We must all accept that, in a tiny minority of cases, the failure to take drugs or to follow the care programme have led to disasters such as that involving Jonathan Zito, which has already been mentioned.

We must consider three issues. First, we must ensure that only those who are likely to co-operate with their care programme and with those trying to help them, and who take the drugs they need are discharged from hospital. The people who take the decision to discharge such patients should not be under pressure—be it financial pressure or the pressure to adhere to the convention or dogma that everyone can be treated in the community.

Secondly, we must ensure that everyone who is released from hospital is properly supervised, with proper accommodation and finance for that purpose. When the decision is being made as to whether to discharge a patient, proper account must be taken of the resources available. That may mean that somebody who could be released or discharged into the community purely on the basis of medical science if there were a huge input of resources and supervision, may not be discharged immediately because it is not possible to provide such support and supervision. The available resources must be taken into account when the decision is made as to whether to discharge a patient. There must be adequate supervision to protect the individual and the public.

My hon. Friend the Member for Hendon, South mentioned the Mental Health Task Force report. It stated: Patients with severe and chronic mental disabilities are being discharged without adequate supervision, or the provision necessary to meet their housing, social and health needs. This could incur risks not only to public safety but also to the safety of the individuals concerned".

Mr. Nicholas Winterton

My hon. Friend is making an important point. Does he accept that, if someone is discharged from a mental illness hospital into the community, the person who is nominated to be in charge of that case—in charge of that person—should be medically qualified, because mental illness is a disease, not something that a social worker can properly supervise? Does my hon. Friend agree that the person nominated should always be medically qualified?

Mr. Heald

I am grateful to my hon. Friend for making that point. A high level of expertise is needed. I am not an expert in social work and mental health—my hon. Friend knows far more about it than I do. There may be social workers who are so highly trained that they have more expert knowledge about care in the community than some of the doctors who deal with the specialty in hospital.

The important point is that hon. Members have responsibility for the public at large. We also have responsibility for those individuals. However, if there is a question of the safety of the public, the House should always err on the side of protecting the public, because the freedom of the public at large is always a high consideration for the House, and more important than an individual's freedom in such circumstances.

The hon. Member for Motherwell, South (Dr. Bray) said that the number of suicides was greater than the number of individuals who are attacked by former patients. That is not the right balance. It is vital that the public are protected.

Lady Olga Maitland

Will my hon. Friend give way?

Mr. Heald

No. I do not have time to give way.

The freedom of many individuals will be less if the public reach the point at which they are completely dissatisfied with the protection available to them.

If individuals are discharged into the community and they fail to co-operate, it is important that they are detained speedily and placed back in hospital. The Mental Health (Patients in the Community) Bill, with its provision for after-care supervision, taking to the House the power to effect a speedy readmission to hospital, is vital if the public are to be satisfied.

I hope that the Minister will tell us the current guidelines on the discharge of patients, and when the guide to co-operative working will be available.

11.10 am

Mr. David Hinchliffe (Wakefield)

I congratulate the hon. Member for Hendon, South (Mr. Marshall) on initiating the debate. Other hon. Members have contributed sincere thoughts and concerns about the current situation relating to the care of the mentally ill. In particular, my hon. Friend the Member for Motherwell, South (Dr. Bray) has a deep personal commitment to the issue, as chairman of the all-party mental health group.

As I listened to the debate, I had the feeling that one or two hon. Members were harking back to a golden age of the asylum that, frankly, never existed. Many years ago, as an authorised mental health officer, I had the misfortune, to some extent, to witness the system working. Some people who hark back to that system are thoroughly misguided, and do not appreciate exactly what it was all about. The process of moving from the 19th-century asylum system has rightly had all-party support over the past 30 years.

Public confidence in community care policy has been shaken in recent times. That has been due not only to some of the tragic cases that have been mentioned this morning, but to a much wider belief that the Government are more concerned with running down the existing system to save money than with developing an alternative system of community care.

In responding to public anxiety, the Government have been unable to answer two particularly important questions: first, in halving the number of psychiatric in-patients by 70,000 between 1982–83 and 1992–93, what has happened to the people leaving hospital? I have tabled questions but received no answers. Secondly, what has happened to the public resources that have been released by the huge closure programme? They have clearly not been invested in alternative provision within the community.

Immediately before moves towards community care in the late 1950s, 15 per cent. of national health service expenditure was on mental health. Now it is about 11 per cent. Although there have rightly been important developments in community re-provision since that time, it comes nowhere near matching the 4 per cent. drop in expenditure that has occurred. Key elements in community care are missing in many sectors.

The central emphasis of many hon. Members' contributions this morning is to urge the provision of acute beds—urging asylum. I urge them to look at examples of asylum within the community. People do not have to be in parks miles from the public, locked in institutional care. Asylum exists within the community. There are safe houses, supported accommodation and sheltered environments in which people can be enabled to live without being in the old bin system that many of us, unfortunately, knew intimately.

It concerns the Labour party that, within community care, mental health appears to be the poor relation. The Chartered Institute of Public Finance and Accountancy found that only 3 per cent. of the overall community care budget is spent on mental health. The Mental Health Foundation found that, of every pound spent on mental health services, 91p goes on NHS treatment, while the remaining 9p covers all community provision by local authorities and the private and voluntary sectors put together.

The public can see that the Government's mental health policy consists almost entirely of piecemeal initiatives, not a coherent thought-through strategy. That point was made not specifically but in general terms by hon. Members, including the hon. Member for Hendon, South. Each tragic incident, some of which have been referred to—I take them all very seriously—results in an ad hoc attempt to patch the holes in the care system, when it is clear that the system itself needs a thorough overhaul. I hope that the Government will respond to the points that were made by Conservative Members this morning.

The central issue that the Minister must address is the organisational framework of community care. When the National Health Service and Community Care Act 1990 was being debated in the House, I thought that it introduced a fundamental contradiction, especially in planning mental health services. Within the NHS, it introduced a competitive market in health, but alongside that was the requirement at local level to plan community care. The two elements were completely contradictory.

We have seen the result at local level, which has a bearing on some of the tragic cases that have been mentioned. The result has been the fragmentation of local provision, duplication in some instances, and gaps in provision, as has been mentioned by hon. Members. We must add to that the joker in the pack, which was not mentioned this morning—GP fundholding—which is undermining coherent planning in community care. If a fundholder purchases a community psychiatric nurse from outside the immediate area, in such circumstances local collaboration simply does not exist. The Government seem to be turning a blind eye to some of the inherent problems in the operation of the market as it applies to community care.

The divided structure between the national health service and local authorities adds to such organisational problems. Administrative difficulties undermine attempts at inter-professional and inter-agency working. No doubt the Minister will mention last year's Audit Commission report, which mentioned poor co-ordination, ineffective use of resources, and lack of communication and effective multi-disciplinary team working. Only 25 per cent. of health and social services authorities had actually established the criteria for operating the care programme, let alone actually got it working.

I have listened carefully to comments on the Mental Health (Patients in the Community) Bill that will shortly come before the House, but I am concerned that it addresses just one element, despite considerable pressure from a variety of sources for a much wider review of existing mental health provision and legislation. Indeed, the Mental Health Act Commission itself has called for the existing legislation to be updated and to reflect the shift towards care in the community.

There is concern that mental illness is regarded by that legislation primarily as a medical condition. That is where I disagree with the hon. Member for Macclesfield (Mr. Winterton),, for whom I have great respect. Mental illness is a much wider issue than a clinical problem to be dealt with by doctors. I shall deal with that point in a moment.

One matter that the Government must address—in a sense, it was ignored by the hon. Member for Macclesfield—is the clear connection between mental illness and social factors. There are social reasons why people become mentally ill, and they must be looked at in the context of reviewing the policy on the care of people who have mental health problems.

Although "The Health of the Nation" identifies mental illness as a key issue for prevention, there is tie acknowledgement of the need to shift towards social remedies to mental health problems. There is no acknowledgement that the deliberate widening of social inequalities has impacted significantly on mental health.

Mr. Spring

Will the hon. Gentleman give way?

Mr. Hinchliffe

I do not have time to give way. I apologise to the hon. Gentleman; I have two minutes left.

For example, a range of studies—I shall happily refer hon. Members to them—have now confirmed the connections between increased unemployment, mental illness and suicidal behaviour. Each year, more than 5,500 people commit suicide—more than those who die in road traffic accidents. We need to consider the social factors that result in such tragic figures.

It is crucial that the Government understand the clear connection between their own core policies and mental ill health. Housing policies result in record levels of homelessness, as people are dumped on the street because councils no longer have the ability to offer them proper accommodation. In areas such as mine, industrial policies that have wiped out entire industries, such as coal, and left people rotting on the dole, influence their mental health. The Government must address those problems.

Economic and social policies that lead to the redistribution of wealth away from poorer people towards those who have money have a bearing on the mental health of poorer people in our communities. Until the Government address those points, our debates will be on the periphery of the real issues we have to address.

The most important steps that any Government can take are preventive. Until the Government learn the central lesson that preventive measures are the key element, they will not come anywhere near dealing with the fundamental issues that need to be addressed in respect of the care of the mentally ill.

11.20 am

The Parliamentary Under-Secretary of State for Health (Mr. John Bowis)

I congratulate my hon. Friend the Member for Hendon, South (Mr. Marshall) on initiating the debate and raising this subject in the House for the second time. I know that he has provided long and effective support for a number of national and voluntary organisations, and I welcome his involvement and his thoughts.

I also welcome the thoughtful contributions from both sides of the House and all sides of the arguments. I should mention those from my hon. Friends the Members for Bury St. Edmunds (Mr. Spring), for Ribble Valley (Mr. Evans) and for Hertfordshire, North (Mr. Heald), and from the hon. Members for Motherwell, South (Dr. Bray) and for Wakefield (Mr. Hinchliffe), and the interventions from my hon. Friends the Members for Macclesfield (Mr. Winterton) and for Sutton and Cheam (Lady Olga Maitland), not forgetting the supervising presence of my hon. Friend the Member for Leeds, North-East (Mr. Kirkhope), who is a founder member of the Mental Health Act Commission.

Mr. Dennis Turner (Wolverhampton, South-East)

The Minister should not forget the Whips. He has mentioned everyone else.

Mr. Bowis

I mentioned supervising presences, and hon. Members can read into that what they will.

I congratulate my hon. Friend the Member for Hendon, South on his choice of title for the debate. The element of care, perhaps caritas, is crucial to all health care, but perhaps it is even more fundamental when we are helping people to cope with an illness which, after all, frightens them and other people. It can be invisible and unpredictable, it is widely misunderstood and it produces prejudices in others which exacerbate the problem for the sufferer.

If we start with the concept of care in both its strands—of mattering to us and looking after those who are ill—we begin to build the understanding that will help us do better for people with mental health problems.

We need to care enough to care for the mentally ill. We need to care enough to overcome ignorance, remove stigma and provide the range of services that we all need. It is not just the 10 per cent. of us who currently need those services; it is the one in four of us who will do so during our lives. Mental illness can affect any of us, and will affect many of us.

The hon. Member for Wakefield spoke about prevention. Of course prevention is crucial. That is why our policies put so much emphasis on initiatives such as the "Defeat Depression" campaign and our work with employers, helping people to cope with stress and to lead mentally and physically active and fit lives. Everyone can play a part. At work, a flexible employer with a counsellor on board can help people who may be under stress at home or at work and need that additional support.

As my hon. Friend the Member for Hendon, South said, it was Enoch Powell, some 30 years ago, who first advocated moving people from the old institutions back to the community, where many of them could live more fulfilling lives if given proper support. The development of new drugs for treating mental illness means that is possible for many more people. That does not mean that we can simply close down all the old hospitals and walk away. We need a range of facilities for care to work in the community.

It is our policy that hospitals should not close until and unless alternative provision is available. We need residential care—some of it sheltered—in or near communities. We need modern hospital facilities—long-term, medium-term and short-term. I have preached the case for medium-term hospital hostels to providers and purchasers in our health service, and I shall continue to do so. We need 24-hour crisis beds for those who cannot cope in the short term, and we need asylum in the best sense of the word—a place of safety in which to rest and improve one's mental health.

Some patients will need much longer spells in hospitals, and a few, sadly, will need to spend all their lives there. Some will need different levels of security, including medium-secure units, and a small number will need the high-security services in our special hospitals.

We have been concentrating on developing a range of facilities. Let me dwell for a moment on medium-secure provision, which is so important to so many issues that have been raised today. It fills a gap that was perceived and identified in 1974 by the Glancy committee. When the Government came to office in 1979, there was not a single medium-secure psychiatric bed in the country. We have invested £47 million in the programme, and by the end of next year we shall have provided 1,200 of those places. That makes so much more possible. In addition, further places are being developed by regions from mainstream NHS capital allocations, as well as in the private sector.

Reference has been made to enabling people to leave prison. In the past four years, we have enabled 2,500 patients to move from prison to hospital. I understand the impatience of my hon. Friends and the courts, but it is worth bearing in mind the fact that, a few years ago, that option was not available, as medium-secure beds were not being provided. The option has become available only recently, and it will increasingly be the route for the appropriate placement of people.

Reference has been made to the Mental Health (Patients in the Community) Bill, and I welcome what has been said about that. In answer to my hon. Friend the Member for Bury St. Edmunds, we have issued new guidance on hospital discharge. I commend to him the discharge handbook, which is helping people to make the right decision and to ensure that the decision to discharge somebody is made only if the care programme is available and ready in the community, with the key worker in charge, and there are provisions for that individual's needs.

We have introduced through the House the new code of practice to the Mental Health Act, stressing that a person's health, as well as the risk to himself or to others, is sufficient to take him for assessment and into hospital. We have introduced supervision registers, identifying those patients at significant risk of causing harm, committing suicide or harming other people if they are not given extra protection and care. Those are now in place in every health authority in the country.

We recognise the point, well made by hon. Members, about the need to have the right person in charge of someone in the community. It is not always a medical person. Sometimes the key need is social functioning. Sometimes—indeed more often—it is right that it should be a medical person, probably a community psychiatric nurse. We are making sure that those people are properly trained and know their role as key workers.

I am conscious of London's particular problems, which were referred to in the Royal College of Psychiatrists report, which drew attention to the fact that too many people were in the wrong beds. It was not just that there were insufficient beds, but that they were inappropriate beds. The medium-secure programme goes some way towards meeting that, as does the extra £10 million we put in and the mental health task force project, which identified good practice and listed where we needed to do better. It was followed up with a further report showing what had been achieved.

The £20 million homeless mentally ill initiative for London has funded 10 hostels, providing 150 bed spaces. Outreach teams are now taken on by the respective health authorities. In respect of accommodation, where the Housing Corperation agreed initially to 150 supported places, I am pleased to say that approval has now been given to some 162.

The mental illness specific grant is enabling local authorities to develop their community services. It has provided an extra £10 million this year, and £66 million in total. That has already supported 1,000 schemes throughout the country and helped 100,000 people.

The NHS has a role in ensuring that the care programme approach, registers and the priority that we give mental health are effective throughout the country. The beds are there, but we must ensure that they are the right ones. There are 20,000 acute beds and 80,000 long-term beds, as there have been over the past decade, but they are in different places. That is good news—provided that those beds are everywhere, to meet the range of need.

Nobody can be complacent about mental health. We must work together, because there is an inter-agency task ahead for us all. I re-emphasise, in this short response, our commitment to providing effective, appropriate and safe care for people with mental health problems.