§ Motion made, and Question proposed, That this House do now adjourn.—[Mr. Wells.]
9.34 am§ Mr. John Marshall (Hendon, South)Today marks the anniversary of the introduction of Wednesday morning Adjournment debates. Everyone who has taken part in them agrees that they have been an outstanding success, enabling Members to articulate a number of topics of concern to their constituents and the wider public in a non-partisan way.
Despite what my hon. Friend the Member for Hertford and Stortford (Mr. Wells), the Government Whip, may say, Wednesday morning debates have tended to be non-partisan. That may be helped by the fact that members of the press do not arrive in the House of Commons until 2.30 pm; they leave at 4 pm and then write about the short working day of Members. My right hon. Friend the Leader of the House is to be congratulated on this innovation and I make no apology to the House for introducing yet again the subject of the treatment of the mentally ill, about which I have spoken in a previous Wednesday morning debate.
Yesterday's papers reported widespread concern about the operation of care in the community. It is obviously difficult to talk about the subject because we hear only about the cases that fail. There are a large number of successful cases of care in the community, but my concern and that of the House and the country is that there are too many unsuccessful cases. Certainly, the views of the relatives of those affected is that sometimes the psychiatrists do not listen to the parents and relatives of those afflicted with schizophrenia as often as they might.
§ Mr. David Martin (Portsmouth, South)In addition to the concerns of parents and relatives are those of our constituents who live next to, opposite or in the same block of flats as people who have been released into the community. They sometimes feel that they are given insufficient back-up when there are major problems with a neighbour who perhaps ought to go back into secure care, and that their concerns are not sufficiently taken into account when they ask for action along those lines.
§ Mr. MarshallI thoroughly agree with my hon. Friend. About a dozen or 15 people from a council-owned block of flats came to one of my earliest surgeries, and I wondered what on earth had gone wrong. They explained that the problem was all to do with a Mr. Campbell. I asked whether he was the caretaker and they replied, "No. He is a patient who has been released into the 656 community." Having been released into the community, Mr. Campbell lived in a flat where he had an armchair and a stereo system. His way of life was to operate his stereo system from 8 pm to 8 am and rest for the entire day. That was fine for him, but not for those of his neighbours who had to get up at 8 am to go to work.
My hon. Friend is quite right to say that the neighbours frequently suffer. It was with great difficulty that I was able to get a psychiatrist to look again at Mr. Campbell. In far too many cases, neighbours and individuals who are divorced from the problem become victims of it.
Yesterday's papers were full of the murder of the south London schoolteacher Suzanne Steckel by her son Gilbert, who then committed suicide. Gilbert had discharged himself from the Maudsley hospital, which is a mental hospital. Two lives were lost unnecessarily because of the ease with which he was able to discharge himself.
Secondly, there was a report that 61 murders had been committed by schizophrenics, who were involved in more than 200 suicides. That represents five unnecessary deaths every week. It is not sufficient to say that the trend is downwards from 109 murders in 1979. There are still too many unnecessary killings and deaths as a result of people being released prematurely from hospital.
Yesterday, a report in The Times stated that the Royal College of Psychiatrists attributed suicides and homicides to three factors—a failure of communication, lack of face-to-face contact between patients and doctors, and patients not taking their medication. An article in The Independent yesterday by Nicholas Timmins, a widely respected journalist writing on social issues, described the lack of psychiatric hospital beds. The Royal College of Psychiatrists estimates that London has a bed occupancy rate of 120 per cent. and that Londoners can be sent into secure accommodation as far afield as in Yorkshire or Wales, 200 miles away. The article pointed out that the bed manager of Gordon hospital in London has the telephone numbers of 37 secure units, so that when he receives a request for a secure bed, he has 37 units to call, on the off-chance that he will be able to locate such a bed.
All that is bad enough, but The Independent this morning contained another article by Nicholas Timmins, with further worrying comments:
At one end of the system, approaching a quarter of Broadmoor's 450 patients could be discharged to a less secure environment if space was available… At the other end, ordinary acute wards are having to handle growing numbers of seriously disturbed patients because they cannot be moved up to more secure accommodation. More medium secure accommodation beds are being provided—numbers are due to rise from 700 to…1,200 by December".The Mental Health Act Commission believes that the figure should be 2,000 rather than 1,200, and says that there was an underestimate of how many beds were needed to allow for occasional relapses. The commission reported the discovery of previously undetected cases by new community teams, said that there were too few 24-hour nursed beds outside hospitals and noted the premature discharge of patients from mental hospital to free beds for even more drastic cases.Premature discharge is one of the real issues that we must examine. Individuals are released so that others in a worse situation can take their beds. They are released before the suitable time, then are taken back into hospital. It would be much better if their treatment could run its natural course in hospital, so that patients might be released into the community with a chance of real success.
657 As a Member of Parliament representing a London constituency, one tends to talk about the capital—hut the situation that I have described is not unique to London. The Mental Health Act Commission states:
Occupancy levels of 100 per cent. and above have been reported from areas as far apart as Devon, East Anglia and Cheshire".I am glad that my hon. Friend the Member for Macclesfield (Mr. Winterton) is in his place to represent that distinguished county. All those issues were raised in yesterday's newspapers, but earlier this year homicides were committed by Wayne Hutchinson, who was guilty of killing two individuals and wounding another three. It was commented that he had been "released by mistake". Earlier this year, Martin Murcell was gaoled for life for the murder of his stepfather and the attempted murder of his mother. In January, doctors reporting on an experimental scheme run by the Institute of Psychiatry in south London noted that 92 patients had been released, resulting in the suicides of three patients, while another killed a young baby.Last December, Dr. Imweldo in Hampstead was attacked in his surgery when he attempted to defend another doctor, who happens to be a constituent of mine. We read about such cases in the newspapers and all have personal experience of individuals not receiving the treatment which they need and which we and their relatives can see that they need.
There is a tradition in the House to declare one's interests. My interest is as vice-president of the Jewish Association for the Mentally III—although I assure hon. Members that it advises me rather than relies on my advice. I pay tribute to the work of JAMI's volunteers and those of the National Schizophrenia Fellowship. Most are relatives of victims of schizophrenia. Some have lost their loved sons and daughters through suicide, but they have not become introspective and miserable. Instead, those parents and relatives decided to use their experience to help other victims of schizophrenia.
The treatment of mentally ill people in this country and every other has undergone a revolution. In the middle ages, the mentally ill were burnt as witches or kept chained in unpleasant and unsavoury surroundings, and that does not happen today. The Victorian asylums that Mr. Enoch Powell was so anxious to close were a remarkable improvement on the dismal surroundings of the past. When people sought to close asylums, they forgot that asylums were a place of refuge—that the mentally ill did much better in them than they would have done at home or in the community. Of course, the rules of the 1940s were far too restrictive—it was much too easy to have someone committed to a mental hospital. The Mental Health Acts of 1959 and 1983 went from one extreme to another. Admission to a mental hospital is now seen as the last resort. The power to section remains, but it is used far too reluctantly.
There has been a failure by psychiatrists to acknowledge the problems of care in the community, under which it has been assumed that persons so mentally ill as to require treatment were sufficiently mentally acute to acknowledge the need for that treatment. Drugs are a powerful weapon in dealing with schizophrenia, but a most unpleasant weapon. We all remember being given a nasty dose of medicine as children and being told by 658 our mothers, "The nasty medicine is the most effective." I once persuaded my mother to try the medicine, and with the sort of logic that would not befit a politician I said, "You've taken the medicine, so I do not need to take it." She replied, "Yes, you do. The nasty medicine will make you better."
One may say to a schizophrenic, "You arc sufficiently cured to enter the community, but not to avoid the need to take nasty medicine." Some patients may willingly accept the first piece of advice, but be reluctant to accept the second. The result is that such patients become a danger to themselves and to other people. A policy horn of compassion was misguided in part because it failed to recognise that asylums were a haven for troubled souls and that some individuals needed treatment in institutions rather than in the community. Others will need periods of treatment in hospital, to enable them to return to the community.
Three areas require development. There should be a moratorium on patients, or at least we should reverse the policy of reducing the number of beds for the mentally ill. The dramatic decline from 145,000 beds in 1961 to fewer than 45,000 today has been too drastic.
The remarks of Dr. Searle were quoted in The Independent on 26 September. He said that he had left Hackney
because it was so appallingly bad".He continued:You had to throw out people who were very mad in order to admit people who were very, very mad. They are still doing that, having to discharge people who down here"—Dr. Searle now lives in Bournemouth—I would be admitting.There was an article in The Independent on 15 June last year, which stated:Hackney operates at 140 per cent. capacity instead of the 80 per cent. recommended to allow for emergency admissions. Admissions are restricted to psychotic patients threatening suicide, violence or facing imminent breakdown. Often, to make room for them, others are discharged before they are ready. Many seriously mentally ill patients are shunted in and out as their condition slightly improves with hospital care and then deteriorates without it.The reduction in the number of beds has been far too drastic. I am concerned about what will happen to patients at Napsbury when the closure takes place. I would prefer Napsbury not to close. It is an issue of great concern in north London. I ask my hon. Friend the Minister to explain how many beds will be provided elsewhere if and when Napsbury closes.We need a change in the philosophy of psychiatrists. I accept that psychiatry is not an exact science. If someone is suffering from pneumonia, the doctors know what to do. Psychiatrists, however, do not always know what to do when dealing with psychiatric problems. It is too easy to leave mental hospitals and it is too difficult for some people to enter them.
Mrs. X, as I shall call her, is one of my constituents. She has written to many Members claiming that she is being pursued by Mossad, by the Japanese, by MI5 and by various other organisations. The lady's quality of life is quite impossible. I once went to see her. She met me outside the block of flats in which she lives. She said. "We must speak very softly because we are going to he overheard." When I went inside I asked her, "Have you got a doctor?" Her immediate reaction was, "I don't need 659 a psychiatrist." I had referred to a doctor, not a psychiatrist. It was clear that the lady's quality of life was appalling.
I went to a meeting in honour of former Prime Minister Rabin. Mrs. X was standing outside with a poster that went from her head down past her knees. Her quality of life is such that she feels persecuted. She is a victim living in the community who would be much better treated somewhere else.
I have another constituent who became convinced that my right hon. Friend the Member for Brent, North (Sir R. Boyson) was about to kill her. We had 19 telephone calls on our answering machine one weekend. She kept on saying, "It is Roddy Boyson. He is coming to get me." I could not think of anyone less likely than my right hon. Friend to attack a lady living in west Hendon. I could not believe that my right hon. Friend was going to live on the west Hendon council estate so as to attack this poor lady. Her quality of life was very poor. I cannot believe that she benefited from being in the community. She would have been very much better if she had been cared for elsewhere.
There is talk about civil rights, and I believe that everyone has civil rights. The parents of patients have rights. They would much prefer to see those patients in hospital rather than in the community. Potential victims have civil rights. The right to life is the greatest right of all. We must weigh the rights of neighbours, patients and individuals when considering whether people should be in hospital or in the community.
When we adopted the policy of care in the community, I believe that the Treasury was seduced by the capital that it could see flowing into its coffers. It did not realise that proper care in the community would be very expensive, involving purpose-built homes, adequate supervision and the training of many staff. The Royal College of Nursing believes that we need to double the number of community psychiatric nurses if care in the community is to work.
For far too many, care in the community has been a poor-quality service. I shall always remember my first meeting with members of the NSF. I turned to one lady and asked, "What is your problem?" She replied, "It is my daughter." I asked, "Where is your daughter?" She said, "I don't know. My daughter will be sleeping on a park bench somewhere in London tonight." That girl and her family were cheated by care in the community. The Economist was surely right when it commented that care in the community
has turned out to mean neglect on a street corner.That has been the outcome for some. The irony is that some of those who are released into the community for care in the community end up committing crimes and find themselves in a different institution, a prison rather than a hospital.I welcome the suggestion in The Daily Telegraph of 28 December that the Government will produce a charter for the mentally ill that will provide for easier access to hospital treatment and for consultation with carers and relatives before patients are released into the community. One of the great failings of the care in the community policy is that we have not listened to parents, relatives and carers. All too often, their wishes and knowledge have been ignored. They know the patients best. They should be able to tell psychiatrists more than perhaps psychiatrists sometimes want to hear.
660 It is not sufficient to produce a charter. It is necessary to produce more beds for the mentally ill. The current supply of beds is an incentive for premature discharge into the community. It underlines the reluctance of some members of the psychiatric profession to keep patients in hospital.
However, my right hon. Friend the Secretary of State has great experience because he was the Minister with responsibility for the mentally ill. I believe that he recognises the problems. My right hon. Friend the Chief Secretary should as well because he is a former Secretary of State for Health. But if we fail to recognise the need for improving the quality of care in the community and the need for more beds for the mentally ill, we shall be failing not only the mentally ill but their relatives, their friends, their neighbours and society at large.
§ Mr. David Hinchliffe (Wakefield)I commend the hon. Member for Hendon, South (Mr. Marshall) for introducing the debate and once again obtaining time to discuss a serious issue. He has previously been successful in doing exactly that. I genuinely respect his strength of feeling about the problems that have arisen in many respects although I differ to some extent with the solutions that he has put forward. On his own admission, he has concentrated primarily on failures rather than successes. He accepted at the beginning of the speech that there have been successes. It is important to recognise that the successes do not hit the headlines. They are not reported widely in news bulletins and accordingly do not come to the attention of Members. That should be borne in mind. Indeed, it should underpin our thoughts this morning.
I have probably been involved in most, if not all, of the debates on community care since the introduction of the National Health Service and Community Care Act 1990, and on the White Paper that preceded it. I have listened with interest to the opinions of Conservative Members. There is the irony that there is probably more support for the principle behind the Government's policy on the Opposition Benches than on the Conservative Benches. There is a scarcely concealed romantic vision—it underpinned the speech of the hon. Member for Hendon, South—of the past in psychiatry, where there were no problems on the streets and the lunatic asylums were full. I do not share that romantic notion because, as the hon. Gentleman is aware, I spent much of my working life before becoming a Member of Parliament discharging from psychiatric institutions—the former lunatic asylums—people who had been wrongly incarcerated, in many instances before I was born.
I feel strongly that although it is nice to go back to that romantic, idealistic past, we should not forget what happened to vast numbers of people in our society who were incarcerated in a way that nobody should defend. Nobody should want to go back to that. I do not suggest that the hon. Gentleman wants to go back to that, but I remind him that I was involved in discharging people from hospital who were incarcerated as moral defectives. They were not in any way mad or ill. They were simply people who had a different way of life from the majority of people at that time. All were women. I had never met a male moral defective until I came to this place. "Back to basics" exposed one or two, but I shall not go into detail on that.
661 I respect the fact that the Minister believes in the policy. I have worked closely with him over a number of years, so I exempt him from my accusation. The difficulty that the Government have is that they believe in institutional incarceration, whether in psychiatry or the penal system, but they are not prepared to pay for it. That difficulty has caused many of the problems that we now have in community care. Community care is nothing new. In a sense, what is new is institutional provision. If one goes back in history, one will see that community care was the norm. People lived in the community. There was the village idiot. Such people were accepted more than they are nowadays.
The institution was, for a variety of reasons, invented. Enoch Powell, who was the Minister responsible for the hospital plan in 1962, was advised that there had been changes in the drug regimes and that we could treat people in the community. There was vast evidence—from Goffman and others—of the effects of institutionalisation, but the key issue that persuaded Enoch Powell, who was a monetarist before Lady Thatcher, was that it was far cheaper to keep people in the community. What concerns me, and in a sense the hon. Gentleman referred to this, was that the Treasury attraction to the policy in the 1980s, and the rapid—perhaps too rapid—move towards closing and disposing of establishments and moving patients into the community, was driven primarily by monetarist policies aimed at realising the assets of the institutions rather than looking at the principles behind community care and the human rights that we would all agree should be accorded to people with mental health problems.
I was a member of a health authority when the process was going ahead and I recall the pressures that the authority in Wakefield was placed under to get rid of its psychiatric beds. I remember vividly one meeting at which we had a letter from the Yorkshire regional health authority, expressing concern that the people in Stanley Royd hospital in Wakefield were not dying as quickly as expected and that the number of beds was therefore not being reduced. Concern was expressed to the health authority about the impact of the policy.
We should look at what happened in the 1980s, because that is the key to unravelling some of the problems that we now have. One of the most insidious elements of what was happening with the care in the community programme in the 1980s was the introduction of performance-related pay for senior health officials on the basis of achieving bed reductions, ward closures and the closure of hospitals. They were personally paid bonuses—not to ensure that people were properly rehabilitated in the community, but to achieve the disposal of psychiatric facilities. That'is why we have the problems now. There was a rapid, ill-thought-out move to care in the community—care which, frankly, did not and in many respects still does not exist.
Perhaps the hon. Gentleman agrees with many of the points that I am making. We are now picking up the pieces as a result of that ill-thought-out, Treasury-driven policy in many of the tragedies that we face. I in no way underestimate the difficulties facing many people as a result of some of the tragedies. Like the Minister, I have met people who have been directly affected. Jane Zito is an extremely courageous woman for whom I have the greatest respect. After suffering the most appalling 662 personal tragedy, she has gone out and fought. As she knows, I do not always agree with what she says, but I admire her courage, and the courage of others who came recently to the House of Commons when the supervised discharge order was being debated, to lobby Members of Parliament about their concerns. I appreciate their concerns and their courage in attempting to say to Members of Parliament, "Do something so that others do not have to face similar tragedies."
The real weakness of Government policy is that community care seems to he in a narrow policy box, divorced from a range of wider issues that impact on the lives of people in the community who face various mental health problems. We had an example of that this week. I understand that the Government are to slash 3,000 prison officers from the Prison Service. In my constituency, I have two prisons, one of which is a top security prison, and I know for a fact that a significant number of people in both those prisons suffer from mental illness. In slashing the number of prison officers and addressing the prison budgets, there has been no evaluation of the impact that that will have on the mentally ill. There has been no consideration of the knock-on effects that that will have or of the way in which the prison system is dealing—in my view, completely wrongly—with many people who should be helped by other means within society. The Government's housing policies have a clear impact on the ability of people from psychiatric hospitals to obtain and respond to care in the community.
What about employment prospects? The mass unemployment policy impacts on the most vulnerable. Clearly, people who want to be rehabilitated need employment opportunities, which are often denied them due to the policy of mass unemployment.
The key area that I wish to emphasise is the wider organisational aspects of community care. We have never really addressed the way in which, in terms of its framework, the current organisation of community care is a shambles. What we have as an organisational framework to assist people in the community is simply not working. I felt that that was so when the National Health Service and Community Care Act 1990 went through Parliament. I am on record as saying that I felt that we were not offering a way forward, although I did not differ with the Government on moving to assessments by the local authority and on community care planning. Everybody knows that the central motive for the community care changes was Treasury driven—the desire to reduce the social security budget. That was the real reason why we moved to the current system.
I found it amazing that on the one hand the Government introduced community planning within local authorities, and on the other introduced an internal market in health. The two simply do not square up. When there has been an inquiry into what has gone wrong when a person has come out of hospital and caused problems, and when sometimes there have been fatalities, the finger often points at the organisational structure of what is on offer to such people when they are being rehabilitated into the community. I appeal to the Minister to look at the division between local authorities and the NHS, because so long as there is a split responsibility on issues such as community care and continuing care there will he problems. There will be disputes and people will blame one another. That is at the heart of our present organisational difficulties.
663 Government policy has become reactive. It changes from day to day in response to various tragedies. As the Minister knows, I understood his dilemma in relation to supervised discharge orders, but the Government have ignored representations from virtually everyone who will have to administer the new arrangements. It has been pointed out that those arrangements are unworkable, and do not deal with the real problems of care in the community.
No alternatives to hospital provision have been devised, although hospital provision has been run down. I agree with the hon. Member for Hendon, South that we need to consider the lack of beds—I hope that he was referring to acute rather than long-stay beds when he spoke of a moratorium—but we should not return to an agenda that involves putting more and more people in asylums. We should, for instance, consider asylum in the community. We do not have to put people in Victorian buildings, away from society. The real challenge of community care is rehabilitation. I have seen good examples of asylum in the community—drop-in and day centres where people feel safe—but, sadly, they are few and far between.
Today's debate is about care in the community. We have reduced the opportunity of vast numbers of people to receive care in hospitals: rightly or wrongly—rightly, in my view—we have tried to move away from the old system. For many people, however, care in the community is not available. The Government should look forward, rather than back to a "golden age" of asylums that, in fact, never existed.
§ Mr. Nicholas Winterton (Macclesfield)I congratulate my hon. Friend the Member for Hendon, South (Mr. Marshall) on obtaining yet another Adjournment debate. I am pleased to be able to speak on this important subject.
We have heard two well-informed speeches, both of which have contributed to a better understanding of the problems relating to mental health. I agreed with every word uttered by my hon. Friend the Member for Hendon, South, and with the overwhelming majority of what was said by the hon. Member for Wakefield (Mr. Hinchliffe). He and I served for some years on the Social Services and, subsequently, the Health Select Committee, and this subject was frequently discussed in both Committees. The Social Services Select Committee produced excellent reports on mental illness and mental handicap.
No one doubts my hon. Friend the Minister's commitment to care in the community. Hon. Members on both sides of the House consider him humane, sensitive and caring, and his reputation justifies that. But—here I agree entirely with the hon. Member for Wakefield—there has been a change in policy which dates back to the actions of Enoch Powell in the 1960s. As the Select Committee pointed out many times in its reports, the policy of decanting people from long-stay institutions to care in the community was initially Treasury driven: it was thought that care in the community was a cheaper option.
In fact, as anyone who has anything to do with mental illness or handicap will know, care in the community is not cheaper but more expensive, although I agree that it is more humane. I share the view of hon. Members on both sides of the House that long-stay institutions should become a thing of the past, but—and here I disagree with 664 the hon. Member for Wakefield—I believe that a number of long-stay beds in asylums are still needed. Hospitals can provide the necessary care for the acutely mentally ill, who may suffer from drug or alcohol problems.
I support the principle of care in the community, but I believe that we have moved too fast. The closure of institutions is often driven by a desire to realise capital gains from the sites involved. Many long-stay hospitals are located in areas where land values are very high, and those managing the health service for the Government are often motivated by performance-related pay. I think it unfortunate that we introduced performance-related pay in a caring service. Hospitals were closed before adequate facilities were available in the community, including staff. In seeking to proceed with a desirable policy, we have thrown the baby out with the bath water.
My hon. Friend the Minister is well aware of my involvement in these issues, and my support for Parkside, a long-stay mental hospital in Macclesfield. He knows of the battle that I have fought, along with many local people whose relations have suffered from mental illness. We have campaigned to save the hospital; sadly, we have failed—which may demonstrate the lack of power possessed by Members of Parliament. Although for some years I have been a member of the party that is in government, propositions that I consider wise—fully supported by those most closely involved—have been ignored by those who manage the health service on behalf of the Department of Health and, indeed, on behalf of the people.
At Question Time yesterday, I raised two constituency cases. I make no apology for raising them again today. Two people died. One was a young girl called Emma Larkins, who burnt herself to death in her flat in Victoria Park in Macclesfield. She came from a family that was sadly split: her parents divorced when she was three years old. I do not think that I am being disrespectful or unfair to Emma or her family when I say that her behaviour had caused the authorities serious problems for many years. Much of that behaviour was generated by drugs and, perhaps, alcohol.
Emma's father has been in touch with the east Cheshire coroner, sending him his account of his daughter's life and the events leading to her death in November. He points his finger at social services. I agree with the hon. Member for Wakefield, who speaks with considerable knowledge on these matters, that there is a divide between the health service and social services. In the main, that is the gap that has to be closed. More thought has to be given by the professionals and by the Department to how to close that gap which allows tragedies such as that of Emma Larkins to take place.
Mr. Larkins says that social services are responsible and that he is concerned not just for his daughter who is now dead but for all young people like Emma. The social services have said that they do not want to comment on Emma's death until after the official inquest. Emma's mother is more specific. She feels that the health service, and Parkside hospital in particular, is responsible because her daughter went to Parkside hospital on the day of her death seeking help and, basically, seeking support—recognition of her problems. Sadly, the help that she required was not forthcoming. As a result, she returned to her flat and burned herself to death. Moreover, she could have caused the deaths of many other people if the fire had not been caught early before it spread to other apartments in the Victoria Park flats complex.
665 As I have said, there is a gap. Why is it that social services, which had been involved with Emma for many years, and the health service, which is responsible for dealing with people who have mental and behavioural problems and who engage in alcohol and drug abuse, were not able more closely to monitor this young person and give her the support and back-up that she needed to prevent her from taking this tragic action? I want to see that gap filled.
Yesterday I also referred to another case in my constituency, that of Lynn Fox who was not such a young woman as Emma Larkins but had created considerable problems for the community for a long time. She had been before the courts and had been taken in by the police, and had received treatment from East Cheshire NHS trust for her condition. She caused her neighbours immense aggravation, to such an extent that one of them, because of the pressure under which he was living, the aggravation that she had caused and the tension that had built up, stabbed her to death. The young man in question, Jason, is now in Walton gaol serving a sentence of just over three years. Why was this allowed to happen?
In recent weeks I have corresponded with Jason Lucas's wife, Deborah, who has provided me with some interesting material. In her latest letter she states:
I am in possession of all the evidence collated for Jason's trial. This includes a copy of a statement by a Consultant Psychiatrist at Parkside hospital. In his statement he says that Lynn was frequently admitted to hospital, via A and E, after claiming to have taken an overdose. Later she would sometimes admit this was a lie, and declare that she had only said it to get help. The statement also contains the following comments:—'In my opinion Fox was a chronic alcoholic who could not give up alcohol, she was also addicted to tranquillisers and she used to mix both and overdose on them.When she was drinking she became abusive and violent and tended to become psychotic.'I accept that this is a borderline case. It might be the responsibility of social services or the health service because of that psychotic condition which, I believe, is a mental illness. As a result of Lynn's activities over a protracted period of time, one of her neighbours—the young man whom I have mentioned, who perhaps suffered a bit too much from an aggressive personality—took the action that I have described. I understand that he had received some treatment. None the less, he and his neighbours were driven to hate this woman and in the end he was driven to kill her.In justification of what I have said about what that man did—that he was driven to do it—I shall relate some comments by the neighbours who shared his problems. One of them said:
I am not surprised that someone has been driven to do something about the problem.Another said:I'm honestly surprised that she has not been assaulted by someone before. I have certainly felt like hitting her myself, as she has really wound me up on occasions.Another neighbour said:I felt relieved when the police told me she was dead. I feel no sorrow for her at all.A fourth neighbour said:Fox upset and depressed us so much that I thought of doing her harm myself. I am not surprised at all that someone has done her harm. I've been expecting it for some time now.666 I was in touch with the authorities about the behaviour of Lynn Fox over a period of time and nothing was done. I am sure that the House shares my concern about the fact that a young man now finds himself in prison because he was driven to take action, although the responsibility for dealing with this case lay with the health service and the social services.What can be done to fill the gap and prevent further tragic cases such as the two that I have mentioned? I repeat that I have total confidence in the Minister's commitment and humanity. I say to my hon. Friend the Member for Hendon, South that care in the community is a humane and civilised way of dealing with those who suffer from mental illness. However, we must not go over the top. Long-stay beds are still needed and we need to be able to bring into hospital for treatment those who are clearly suffering from mental illnesses but who, because of their condition, are not prepared to take the decision to go for treatment. My hon. Friend highlighted that point in a number of the cases that he drew to the attention of the House.
I seek to be constructive in these matters. Certainly in respect of the Lynn Fox case I am in touch not only with social services in Cheshire but with East Cheshire NHS trust. I have had 100 per cent. co-operation from the chairman of that trust, Mr. Peter Hayes, who is held in high regard, is committed to the health service and is deeply concerned about matters relating to mental illness. He has given me 100 per cent. support in this case. I am also in touch with Councillor Simon Cussons, chairman of South Cheshire health authority, with the probation service, social services and the police. I am in touch with the Home Office. When I have received replies to all the representations, particularly my latter ones to the probation service and the Home Office, Peter Hayes and I propose to convene a meeting in Macclesfield of all the authorities that I have named to see whether we can prevent such a case recurring. I am seeking to be constructive and, like the hon. Member for Wakefield, to bring the health service and social services closer together so that we do not have this divided responsibility, whereby a gap can result in tragic deaths, with all the problems that go with that.
By securing this debate, my hon. Friend the Member for Hendon, South has done a great service in relation to mental illness. I agree with every word that he said. His concern is genuine, as is mine. The hon. Member for Wakefield is very informed on these matters. Although I disagree with him on a number of issues, overall I have complete confidence in what he is seeking to achieve. We are not far apart—we both want care in the community to work, but problems still exist and I hope that my hon. Friend the Minister will assure us that the gaps and problems will be dealt with.
§ Dr. Lynne Jones (Birmingham, Selly Oak)Time is short and, if the Minister is to be allowed sufficient time to reply—I certainly want that—I must confine myself to one or two short remarks.
It is a coincidence that this debate is taking place in the same week as the confidential inquiry report into homicides and suicides was published, and that the junior Health Minister who set up that inquiry in 1991 is now Secretary of State for Health. In a press release issued at that time, he said: 667
we must insist that if a discharged patient is involved in homicide or similar incidents, every detail of the history of that patient's management is fully examined and the lessons learnt. One such incident is too many. But if a repeat incident occurs because the lessons of the first have not been learnt, we are all culpable.It is sad that, since that time, a number of well-publicised incidents have taken place. Usually, the ones that have received the most publicity have involved the killing of people who were unrelated to a mentally ill person. We have had reports on the Christopher Clunis case and several others, some of which have been mentioned this morning. Can the Minister say, hand on heart, that all the lessons of those reports have been learnt?The Ritchie report into the Christopher Clunis case said that care in the community for that person was a
catalogue of failure and missed opportunity".Other reports have highlighted the lack of co-ordination, which has been mentioned this morning, between the various agencies, the health service and social services.Those are the cases that have received publicity. The confidential inquiry report has shown that, although there have been 39 homicides, most of them have involved members of the mentally ill person's family and that a far higher number of mentally ill people have committed suicide. It is estimated that one in 10 schizophrenics commit suicide.
I congratulate the previous Secretary of State for Health on her intention to give mental health a higher priority and on "The Health of the Nation" target to reduce suicides among mentally ill people by 33 per cent. Sadly, that target has not been met, and we must ask ourselves why. No doubt the Minister will tell us about the increased resources for mental health services. Figures show that more has been spent, but, as a proportion of the total amount spent on health, the mental health service budget has been declining in importance.
I am sure that no hon. Member present, knowing the experiences that they have had, can say that this country has ever had a first-class mental health service. My father suffered from schizophrenia. In the 1950s and 1960s, I had personal experience of the failures of mental health care. He attempted to take his life and, on one occasion, threatened to murder me. I do not think that that was a serious threat—most mentally ill people are not a danger to the community—but, traditionally, this country has failed mentally ill people. We must give mental health a higher priority.
That is not happening in my constituency in south Birmingham. The figures show a dramatic reduction in the number of psychiatric beds—about 150 since 1985—and only about 85 community psychiatric nurses are in post. I have seen people working in the one mental health centre in the community that we have and have witnessed the stress that they are under. All too often, the service shuts at night and at the weekend. We need 24-hour community services and mental health centres.
The promises that we in south Birmingham were given have not materialised. Mental health centres were promised, but have not been opened, and staff have not been appointed. As a result, all too often, flagrantly mentally ill people receive treatment, but people who, in Marjorie Wallace's words, are silently suffering, are ignored and people, relatives and neighbours who silently, and not so silently, suffer with them are ignored as well.
668 We must do much more. The concept of community care is supported, but we must have increased resources—it is not enough to say that the resources are sufficient. Last year, in south Birmingham, the mental health service budget was cut by £500,000. This year, it faces a 3 per cent. cut because of so-called efficiency savings. There is no increase in the budget and no possibility that the community services that were promised when Rubery hospital was closed will be provided.
I ask the Minister urgently to consider the position. It is not just a matter of resources, but I note that the confidential inquiry recommends that higher resources should be provided for people who are seriously mentally ill. That is true, but not if there is a shift from other services for people who, as I have said, suffer in silence.
§ Mr. Alan Milburn (Darlington)I congratulate the hon. Member for Hendon, South (Mr. Marshall) on securing the debate and pay tribute to all the speeches that hon. Members on both sides of House have made. We have had an informed debate about an extremely important topic.
As my hon. Friend the Member for Birmingham, Selly Oak (Dr. Jones) said, this is a timely debate, coming hard on the heels of the confidential inquiry report, which highlighted the tragic toll of homicides and suicides involving people with severe mental illness. The hon. Member for Macclesfield (Mr. Winterton) showed how that death toll is tragically continuing. It is unusual for a month to go by without a further newspaper report highlighting some of the fault lines in the mental health services provision system.
As my hon. Friend the Member for Wakefield (Mr. Hinchliffe) said, however, all the tragedies tend to obscure many of the successes. It is right to have a sense of perspective. In responding to the confidential inquiry, the Minister has been quick to point out, for example, that the overwhelming majority of people who suffer from mental illness are not a threat, either to themselves or to others. Even people with schizophrenia are more likely to be withdrawn and quiet. If they do harm at all, they are more likely to harm themselves than anyone else.
It is right to strike a balance in these debates and to emphasise that mental illness is not a single problem: it covers a multitude of problems and a multitude of people, but the switch over recent years to care in the community has brought public attention to the plight of mentally ill people. I welcome the care in the community approach because it recognises that most mentally ill people prefer life outside hospital and prosper as a consequence. No one wants a return to the old, large, remote, anonymous asylums. where sometimes brutal care was hidden from public gaze. Care in the community is both more humane and more effective, but the tragedy is that recent failures have dented public faith in the policy to such an extent that I now believe that there is almost a crisis of confidence.
As my hon. Friend the Member for Selly Oak said, yesterday's publication of the confidential inquiry is but the latest in a long catalogue of reports that have highlighted the inadequacies in current health care provision and, indeed, policy. Christopher Clunis and Jonathan Zito may well have become household names, but many others have fallen victim to the failures in the current approach to 669 mental health policy. Let us not forget that yesterday's report analysed 240 suicides and 39 homicides. The battle to overcome the fear of, and ignorance about, mental illness has been badly compromised by those incidents. Whether the number of homicides and suicides is rising is not the question—what is worrying is the extent of public concern about those incidents. Too often, in too many parts of the country, that concern has slipped into fear.
There is now a danger that the care in the community approach, which the Opposition support, will cease to command public support unless urgent action—the need for which was highlighted in yesterday's report—is taken. The hon. Member for Hendon, South referred to a failure to ensure that patients complied with treatment. There have been pleas this morning for more powers to be made available over those who suffer from mental illness. However, by and large, my view is that there are sufficient powers on the statute book. The problem is a lack of implementation.
Hon. Members have highlighted three main problems. The first is a failure of co-ordination between the relevant agencies involved. The second—it was dramatically highlighted in yesterday's report—is that the staff who work with the mentally ill are often overworked and overstressed. The third is that, all too often, appropriate accommodation, whether in the community or in hospital, is not available. The confidential inquiry loudly and clearly referred to the number of overcrowded wards and the lack of appropriate hospital and community facilities. That lack of support is compromising the implementation of care in the community.
The Government have been warned time after time that there is a serious problem. This latest report comes hard on the heels of many others. The mental health policy, as implemented over recent years, has given us the worst of all possible worlds—too few beds in hospitals, inadequate facilities in the community and a shortage of specialist staff in both.
The hon. Member for Hendon, South referred to the dramatic decline in acute provision in our hospitals. The closure rate over recent years has not been accompanied by a similar dampening in demand for acute services. When the Mental Health Act Commission reported last November, it highlighted average occupancy rates of 130 per cent. in some inner-city hospitals—and not just in London. There is a temptation to think of it as a purely London problem, but it is not. The report also referred to occupancy rates in excess of 100 per cent. in Devon, Cheshire and East Anglia. It is a nationwide problem.
It is all too common for psychiatrists to have to spend hours on the telephone desperately trying to find an acute bed for someone who is severely mentally ill. Quite simply, there are not enough appropriate beds available for patients when they need them. There are not enough facilities in the community. The Audit Commission, in its recent report "Finding a Place", argued that comprehensive mental health care facilities in the community had been slow to develop. As a consequence, in too many parts of the country the cart has been put before the horse. There was a rundown in acute provision before the introduction of appropriate community facilities. There must be a balance in provision to deal with the serious concerns that have been highlighted both in today's debate and in yesterday's report.
670 There is need for emergency action to deal with the shortfall in provision and the issues of public confidence that have been raised. I have four brief suggestions. First, there should he a moratorium on further acute bed closures pending the development of an appropriate community infrastructure. Secondly, there should he immediate implementation of the care programme approach in all parts of the country. There has been yet another delay in implementation—with the latest deadline now being the end of March—yet the programme was duc to be implemented in April 1991. Thirdly, there must he urgent action to deal with the problem of staff shortages, which is compromising patient care. Fourthly, over time, there should be changes to the mental health funding allocation formula so that cash ends up going where it is most needed. We all know that the inner cities experience a particular problem. Without urgent action, I fear that, before too long, the House will again be debating the same issues, but also a new round of tragedies involving mentally ill people.
§ The Parliamentary Under-Secretary of State for Health (Mr. John Bowis)I echo what the hon. Member for Darlington (Mr. Milburn) said about the quality of speeches from both sides of the House, including those from the hon. Members for Wakefield (Mr. Hinchliffe) and for Birmingham, Selly Oak (Dr. Jones) and from my hon. Friend the Member for Macclesfield (Mr. Winterton). In particular, I commend the speech of my hon. Friend the Member for Hendon, South (Mr. Marshall), who initiated this debate. As usual, he made a robust but thoughtful contribution. I always welcome his views on these matters.
I echo the points made about the need for a balance. We have a great national health service, which has made giant strides in mental health care. I pay tribute to all those working in health and social services, who have achieved so much for mentally ill people. They have transformed the approach to mental health.
Hon. Members were right to point to shortcomings and to the tragedies that occasionally occur. I agree that we need to continue looking for improvements while implementing the right policies. As my hon. Friend the Member for Macclesfield said, we need to close the gap.
My hon. Friend the Member for Hendon, South referred to the closure of Napsbury hospital. The decision was made some time ago and we are currently considering the consequences. As he knows, our policy is that no psychiatric hospital should close unless there are adequate replacement services. I understand that the chairman of Barnet health authority has given an undertaking that Napsbury will not close until replacement services based in Barnet are ready. Following the debate, I shall write to the chairman of that authority asking for evidence to satisfy me that that is indeed the case.
My hon. Friend the Member for Macclesfield made balanced and constructive points about the Lynn Fox case. I welcome what he is doing in bringing the agencies together. If, having done that, he would like to come to see me and tell me about what he has discovered, perhaps bringing the trust chairman with him, I would certainly welcome his visit.
My hon. Friend the Member for Hendon, South mentioned people who do not seem to have homes, which has been a problem in London. That is why we launched 671 our initiative for homeless and mentally ill people. Indeed, immediately following the debate, I shall be going straight to Tower Hamlets to open another stage of that initiative: some move-on accommodation run by the Look Ahead housing association.
Five outreach teams are in place. They cover different parts of London, especially inner London. All 10 hostels that we promised are open. The last one opened in October. They provide 148 bed spaces. We are making progress with the move-on accommodation, to which I have just referred. We have an agreement with the Housing Corporation not only for the 150 supported places that it initially promised us, but for 181 places. Five schemes offering a total of 36 places were open by the end of last year and all the places should be available by the end of the financial year 1996–97. A valuation of that scheme has been generally favourable and I shall be looking to build on that scheme in future.
Reports often refer to the issue of beds. We know that there is a fairly constant provision of 80,000 beds and about 20,000 acute beds. However, important factors are the mix of available beds, where they are, whether they are effectively and efficiently managed and whether the right people are in the right beds. All those factors have come up in this debate and we shall continue to consider them.
We asked the mental health task force to consider the provision of beds, especially in London. I certainly noted the points made in the report by the Royal College of Psychiatrists. It drew up plans with all the inner-London authorities, which have in turn drawn up their own action plans. I hope that they will prove effective. I am not complacent about London. I am very conscious of the need for community work to be supported by the provision of beds.
Indeed, on one occasion, while meeting representatives of an authority, I heard talk of the ability to close beds once the community facilities were up and running. I said that that was not the case and that the authority would need beds to ensure the success, efficient running and well-being of patients in community service. That is very much the message that I bring to the House and to our mental health service.
Mention has been made of the high-security service. The range of Reed reports on that area of care has exercised our minds. From April, a new structure of three new special health authorities to run three special hospitals supported by new commissioning structures and boards will he introduced. Our purpose is to integrate more closely those hospitals with mainstream mental health services, which—I hope—will prove effective.
The hon. Member for Wakefield mentioned people who are in prison but perhaps should not be, and the need for mental health support. That support is sometimes provided in 'prisons and sometimes provided by transferring prisoners to mental health hospitals—often secure hospitals, for obvious reasons. That support has been a tremendous success. We are not often given credit for the way in which, since 1990, we have enabled more than 2,500 patients to move from prison to hospital. In 1994 alone, 784 people were transferred and found places in the health service under the provisions of the Mental Health Act 1983. That was more than double the number of transfers in 1990.
The facts that we have been discussing illustrate the scale of the issue before us. We know that one in four of us is estimated to suffer from mental illness at some point 672 in our lives. We know that mental illness is three times more common than cancer and as common as heart disease, and that few of us will pass through life without being touched by it—whether personally or, as the hon. Member for Selly Oak rather movingly told us, through the suffering of a friend or family member.
The cost of mental illness to society is heavy—not only in terms of human misery but economically. In 1991, for example, some 91 million working days were lost to mental illness even without taking into account days lost by carers who were looking after somebody who was mentally ill. A degree of stigma is still attached to the topic. That is damaging because it makes life more difficult and distressing for mentally ill people and prevents others from seeking help when they need it. Removing stigma is part of our policy and must be part of the onus placed on all of us.
In Health questions yesterday, I referred to Professor Norman Sartorius, the president of the World Psychiatric Association and the former head of the mental health division of the World Health Organisation. Overnight, we have received a further message from him stating:
England has taken the lead in work to prevent mental illness and to tackle stigma.Although that is good news—I welcome the tribute—we must strive ever more. We sponsor surveys of public attitudes, we have produced leaflets which discuss in jargon-free terms the policies in different areas, and of course we support World Mental Health Day, which focuses especially on young people.The debate has concentrated on the sort of support needed to avoid problems. That is why one of the keys to successful policy is the care programme approach, which aims to ensure that care is provided on the basis of properly assessed individual need, with a coherent care plan and a facility for regular review. The vast majority of health authorities have already implemented it. Perhaps, as the hon. Member for Darlington said, some progress is still to be made. On the whole, that relates to those who are not severely mentally ill, in ensuring that such care is available for everybody.
It is our firmly expressed policy that hospitals should not close unless and until alternative provision is available. Indeed, many are not closing but being converted to more modern and appropriate facilities We must have a range of facilities, including residential care, varying degrees of support, hospital facilities, crisis beds and medium-term hospital beds. The whole concept of asylum is essential as part of the package of measures to help people who are mentally ill. Some people will have to spend long periods of time in 24-hour nursed beds—in some cases the whole of their lives—and we should not duck that responsibility.
We also attach great importance to the development of primary care in mental health. We are continuing to part-fund a senior GP fellow who takes national leads in the education of GPs in that area. A senior primary care nurse facilitator does likewise. Our work on defeating depression is also part of that development.
I make no apologies for reminding the House of our programme to increase the number of medium-secure psychiatric beds. They are essential. Despite the fact that a gap in provision was identified by the Glancy committee in 1974, there was not one such bed by 1979. The Government have responded to that, and by the end 673 of this year, there will be more than 1,200 such beds through our £47 million investment. With an additional 300 regional beds, and the provision of about 500 beds in the independent sector, the figure just about totals the 2,000 beds to which my hon. Friend the Member for Macclesfield referred.
Mental health services are at the top of our agenda. I am grateful that hon. Members of all parties recognise the priority and emphasis given to that area of our health service by my right hon. Friend the Secretary of State. That is why, last August, we wrote to health authorities requiring them to let us have details of their plans for service development. The results of that exercise are now being analysed and we hope to make an announcement on the conclusions shortly. I shall be surprised if those conclusions do not show that there are widespread plans for increased investment in mental health services. That underlines our commitment to the mental health service. It is one of the five key areas in "The Health of the Nation" strategy and one of the six medium-term priorities for the 1996–97 priorities and planning guidance for the NHS.
Mentally ill people, like everyone else who receives care, have a right to expect standards of care, and that is why we shall launch for consultation our draft booklet in the patients charter series specifically for users of mental health services. We can improve the system and we can improve the service. We shall do so if we all work together for the benefit of patients.