§ 8.13 p.m.
§ Lord Molloy rose to ask Her Majesty's Government whether they will re-examine the decision of the South-West Thames Regional Health Authority to close six psychiatric and mental hospitals and homes in Epsom, Surrey.
§ The noble Lord said: My Lords, the Unstarred Question standing in my name involves a small group of hospitals, psychiatric and mental, in Epsom, Surrey. The story really starts in March 1982, when a DHSS inquiry was instituted into under-used and surplus property in the National Health Service as part of the Government's so-called efficiency drive. The inquiry team was chaired by the assistant director of works operations at the DHSS, and included the group property adviser to the Imperial Group PLC, a partner in a firm of chartered surveyors and four NHS professionals. Their report in January 1983 was designed to force health authorities to dispose, not just of surplus land and buildings but also those identified as under-used, as an essential part of their strategic planning process—I emphasise, "their" strategic planning process. Half a dozen people, it seems to me, were given massive power. I hope that the House will take note.
§ I regret to say that Mr. Norman Fowler welcomed the report and said that the Government were determined to see the disposal of property surplus to requirements. The stated intention of the South-West Thames Regional Health Authority to finance a new 1162 pattern of services for the mentally ill and the mentally handicapped from the sale of hospitals and hospital land within their region is the first substantial application of the Government's policy. I want to examine briefly the arguments that have been presented, in the main, by the RHA's working parties in their consultative documents, Future Pattern of Services for the Mentally Ill and Future Pattern of Services for Mentally Handicapped People. I wish to outline my major criticisms of these proposals. It is also incumbent on me to outline as fairly as I can the proposals submitted by the RHA.
§ The RHA's mental illness working party was set up in November 1980and charged with examining the psychiatric needs of the population of the South-West Thames region having regard to guidance issued by the Department of Health and new patterns of care, and to make recommendations on what changes and developments should take place in the service and their priority in the next 10 years and in the longer term, taking into account the known limitation on revenue and capital resources.
§ In drawing up a regional policy and strategy, the working party was asked to look at the needs of specialist groups such as children, drug addicts, alcoholics, the elderly and the severely ill, and to make recommendations on the future of the region's large hospitals. The working party was chaired by the district administrator of the East Surrey Health Authority. He was a member of the group which drew up the DHSS plan in the first place. It also included, I understand, a number of consultant psychiatrists. But there were no trade union representatives on the working party; there were no representatives of doctors, teachers, midwives, specialist nurses and so on.
§ The RHA's mental handicap working party was set up last year to produce a regional policy for services for the mentally handicapped, and to recommend a strategy for implementing this policy. The working party had before it the proposals of an earlier working party which it re-examined in the light of national policy and advice. Here, again, this working party had several people on it, but for some mysterious reason it lacked any representatives of the major trade unions within the NHS.
§ The mental illness working party identified four broad objectives for a new pattern of service to all groups: first, to develop an effective commitment to preventive measures and the education of the public in the understanding of mental health and available services; second, to enable the mentally ill person to maintain an independent life in his own home for as long as possible; third, to allow the mentally ill person who cannot be maintained appropriately in his own home to receive treatment or accommodation close to his home wherever possible; and, fourth, to integrate the general and mental health service and to provide a comprehensive service in each district.
§ The mental handicap working party set itself four similar objectives: first, to reduce the incidence of mental handicap by prevention; second, to investigate, diagnose, assess and treat disability as early as possible; third, to identify and implement the most appropriate forms of care in order to enable the individual to enjoy as complete a lifestyle as possible while also taking 1163 account of his or her own views; and, fourth, to provide a comprehensive locally based service in each district in conjunction with the local authority, social services, education services and voluntary services.
The mental illness document states clearly:
The development of community based services must be the first priority because it creates a service close to people's homes, reduces inappropriate admission to hospital and can be achieved without the need for expensive capital investment which, if available, has a long lead-in time".
I believe that this is a fair assessment of the working party's proposals and arguments.
§ The mental illness working party considers that the necessary funding for the new pattern of service could be obtained through proceeds from land sales, joint financing, minor capital allocation and even the use of revenue on a non-recurring basis as a result of under-spending or delayed implementation of agreed developments. In particular, the working party believes that sites will have to be identified which offer the greatest potential for releasing resources for re investment in the new type of district based service.
§ The mental handicap working party recommends that each of the region's 13 districts should have set up a district planning team by January next year to plan and co-ordinate services appropriate to their districts. That I believe is a fair assessment—indeed, some of it is a laudable assessment—of the moves to be made over the years to come.
§ The working party's proposals rest on four central arguments and opinions, which I believe can be summarised as follows. In line with the stated objectives of the Government, the DHSS and the health authorities, care must switch to the community. The Mental Illness Working Party view sees more locally-based psychiatric services as both necessary and inevitable, and they take the view that they must be maintained.
§ Central Government will not provide any extra finance for any of this new pattern of services. It is very important to take note of that point. All these wonderful proposals are being put forward, but just imagine the situation if we were considering the Navy, the Army or the Air Force and there was no money. People would go and shake a tin and get a couple of coppers from people passing by. They would say, "Help the RAF"; "Help the Royal Navy"; "Help the British Army"; "Help the police". That is what we used to do in 1936 and 1937 at all our carnivals and fetes to maintain our hospitals, because the death rate in the South Wales valleys was one of the highest in Western Europe. It is no good people saying that all that happened long, long ago. If you are going to put forward that argument it is no good celebrating Christmas in a couple of year's time because it happened 2,000 years ago. It is no good submitting that type of banal argument. This is a very serious problem although it affects only a small part of the country.
In those circumstances the central financial contribution can only be made by the sale of large hospitals. Retaining them would only increase the cost per patient as numbers further declined and would not represent the best use of the RHA's resources in land use terms. That is the argument of the RHA. I want to
state it as fairly as possible. The Mental Illness Working Party's proposals, more clearly developed in their financial strategy than those of the Mental Handicap Working Party, declare:
A major factor in implementing the policy is the release of resources, particularly capital, from the large hospitals.".
That, very roughly, is the position of the RHA.
I shall submit the criticisms of the working party's proposals as briefly as possible. These proposals represent a major step towards asset stripping the NHS. The sale of 570 acres envisaged by the working parties would dwarf previous known hospital land sales in England. There is nothing to compare with it. The property speculator mentality that has inspired these plans is clearly revealed in the language of the Mental Illness Working Party when they refer to the sale of the sites. Let me tell your Lordships how it reads. It says:
The development potential of such a site close to the new M25 with ultimate access to Heathrow, Gatwick and the Channel ports could be enormous. The demise of most of the large psychiatric hospitals in and around Epsom is bound to have an enhancing effect upon residential land values".
That is a particularly vulgar way in which to describe how to get rid of a number of hospitals and land. Suppose the Minister for Defence, Mr. He seltine, came along and said that he was willing to lend out a couple of regiments if anybody wanted to invade somewhere, or that the RAF was willing to lend out a few bombers to bomb somewhere. People would say that it was ludicrous. Why is it ludicrous to do that when we are doing it as regards the most poignant clients of the DHSS—the people who are mentally crippled and people who are mentally ill?
§ The Environment Secretary is going to be brought into it to work what I can only describe as a little fiddle—to cheat. That is fair and straight enough, is it not? There is nothing hinting about that. I have never hinted about anything in my life—even when I was in a concentration camp I was not prepared to give any hints of sycophancy, and I am certainly not going to start now at my age. The Environment Secretary has to decide whether under this Green Belt proposal he could re-zone all of this for development and meet the desires of the RHA. This is a Minister getting in on the act. I hope that we are not going to get a lot of talk about law and order from the party opposite in future.
I point out that the financial basis which the working parties propose for the new pattern of services apppears even weaker when consideration is given to what guarantees are on offer—that the money realised through the sales will be spent on services for the mentally ill and the mentally handicapped in the region. The introduction to the mental illness consultation document attempts to gloss over this problem. It says:
The principal on which the policy is based is that the total revenue expenditures on mental illness services is not reduced in real terms and any resources arising from the sale or development of land currently used for mental illness purposes should be devoted entirely to the service.
These and similar expressions by the Mental Handicap Working Party are no more than pious hopes. The reality is that the Government have already announced plans that will ensure that the increased expenditure on the NHS does not keep pace with demands of new medical technology and the
sharply rising number of elderly people, particularly those over 75.Those caring for the mentally ill and the mentally handicapped have ample experience of the lack of political will of Government to defend the vital services they provide and, given the flavour of the document to which I have just referred, they produce a reduction in the morale of staff. I believe that that is rather important.
§ Both working parties take the trouble to emphasise that they are not offering blueprints for the future patterns of service. I hope that that is noted by the Minister. This lack of direction and adequate strategic planning adversely affects the care of patients who will continue to require full-time residential provision. The Working Party on Mental Illness recognises that rehabilitation of many institutionalised patients is not a realistic possibility.
Staff as well as patients face disorientation during the open-ended transitional period. That could be really serious because it seems to me, on the figures with which I have been supplied, that to these difficulties must be added real worries about future employment for the 5,000-plus staff working in the six hospitals. In his foreword to the Mental Illness Working Party document, one of the members insists that:
management, the trade unions and staff must attack our problem together in order to make sure that the service takes on a new form and does not become a crumbling ruin with no hope for the patients and no future for the staff
There is a very serious warning there.
§ When the working parties refer to community-based services, they are very largely referring to services that do not exist at present in the region. In neither document is the extent to which the community care envisaged would be within the ambit of the NHS or be added to the demands placed on overstretched and under-funded local authority social services clear. There is also stress laid on the contribution of voluntary organisations. This raises the prospect of those bodies being asked to take on a burden that the National Council for Voluntary Organisations has acknowledged that they simply cannot in any way sustain.
As I draw to a close, I should like to refer to the Richmond Fellowship inquiry report, which I believe is a very valuable document to everyone who is interested in this rather poignant aspect of our National Health Service. The report says:
Many people do recover from severe mental illness and are pleased with the care they have received. However, it is clear to members of the inquiry that services generally fall woefully short of achieving the quality of life for the mentally ill and their families that was envisaged when the run-down of the large hospitals began with such a fanfare".
I submit to the Minister who is to reply that one really cannot just dismiss out of hand that comment from that particular source.
§ It is not a question of simply being mean or indeed—if I may say so at this time of year—of the apotheosis of the Scrooge attitude on the part of the Government. In many ways it is being downright cruel. The desperation, the pain and even the fear of mental illness, I believe demand humane responses. I also regret very deeply that organisations such as the BMA and its special sectors and the Confederation of 1166 Health Service Employees—the trade union that embraces so many of the mental hospital staff—were not in some way involved. They have always tried to be involved. It has been the desire of the confederation—and in very many ways its history will show how it became deeply involved in matters that have nothing to do with conditions of work and/or pay—to try only to improve the situation of a special group of hospitals, including the psychiatric hospitals, and it has made an outstanding contribution as a British trade union.
§ All we read in the newspapers is about trouble—strikes or threats of strikes—but the Confederation of Health Service Employees has been given credit by successive Secretaries of State, including the present one, for its realistic attitude towards contributing to a better health service for us all, particularly in this poignant field of mental illness. I greatly regret that it was not consulted, but it is not too late. I should be most grateful if the Minister or his right honourable friend in another place would be prepared to talk with Mr. David Williams, the recently elected General Secretary of COHSE, because I believe that the confederation has a real contribution to make and that it can help and assist the Government with its knowledge in many fields and this one in particular.
§ 8.31 p.m.
§ Baroness Macleod of Borve
My Lords, I am sure that we are all most grateful to the noble Lord, Lord Molloy, for asking Her Majesty's Government:Whether they will re-examine the decision of the South-West Thames Regional Health Authority to close six psychiatric and mental hospitals and homes in Epsom, Surrey".I believe that the noble Lord very briefly touched on that Question, but only very briefly. I do not propose to answer him in any detail, except to say that we are grateful for the opportunity to allay the fears which perhaps he has again created, and to counter the ignorant rumours in parts of the press.
I submit that, so far as I can make out, his premise is incorrect. I have carried out some research; I have done a great deal of telephoning today to try to find out which of any hospitals in that group are likely to be or will be closed. I can only say that there is a possibility that Banstead might be closed, but ample provisions have already been made for the transfer of patients to another nearby hospital.
We all worry about the care of psychiatric and mentally ill patients. Indeed, we all wish that there were no such patients in our society, but that is wishful thinking. We all agree that, both in and out of hospital, we must provide the best care that it is possible for human beings and financial giving to provide. Much is being done by the voluntary sector, but, more importantly, by those in the hospitals themselves. To my certain knowledge, a great many of the wards are being updated. The patients are being given more comfortable furniture; they are given better food; there is a better ratio of staff. But, of course, we are talking about six very old hospitals. They were specifically built there so that they would be out of other people's way, so that nobody should feel that he was obliged to go and see the patients within the hospitals. But that was in the Victorian era when nobody wanted to know and the less said about those patients the better.
1167 I come from the Hertfordshire area, where we also have four large psychiatric hosptials. In my capacity as chairman of a large voluntary organisation I happen to know something about most of these hospitals. I shall not take up too much time, but we must all realise, as I am sure we do, that modern medicine and technology have made it possible for a great number of these patients to be able to live in the community.
I should like to refer to Napsbury, because it is one of the largest psychiatric hospitals in Hertfordshire. I happen to the be president of the housing association, and I should like to tell your Lordships very briefly what happens there. It is a very large hospital. It was orginally for 1,100 patients but we now have 750. There are two flats into which are put men and women whom the nursing staff and the medical staff think will be able to get on together. By day, those patients all work outside in the community. They return to the flat at night. One of the patients looks after the other five; he or she cooks for them and looks after the flat generally. In the fullness of time, when it has been decided that they can live together, they are sent outside the hospital walls into the community in the full knowledge that if anything goes wrong they can return. They work outside the hospital and live in a house which takes no more than six mixed gender ex-patients. They all work; they all contribute; they all believe that, once more, they are part of society.
In many cases this has been made possible only by the new technologies and medicines. However, the Napsbury Hospital covers nine boroughs which have all made houses available to the housing associations and they have encouraged us to place ex-patients back in society. We now have eight houses, and I can assure your Lordships that all the patients are leading happy and secure lives. This scheme has been in being for about five years, and I think that in all that time only one patient has gone astray.
However, when patients are returned to the community, unless it is via a system of this sort, of which I personally cannot speak too highly, the local authorities have to help with funding and looking after some of these patients. Can the Minister say whether there is any funding in the pipeline for these patients when they are discharged? I should also like to know, although it may be too early days yet, whether the 1983 Act is being observed and whether the local authorities are aware of their obligations under that Act.
I hope that at the end of this debate my noble friend the Minster will be able to tell us that there is very little truth, if any, in the idea that this particular regional health authority is likely to close six hospitals which is mentioned in the Question. I conclude by paying my tribute to all staff, who, I know, are working in very difficult circumstances—the medical staff, the nursing staff and the ancillary staff, all of whom contribute towards the working of vast hospials. We can all pay our tribute to them for their patience and forbearance, and for their care of patients within their hospitals. But, as I said at the beginning, one can only hope that the day will come when far fewer patients have to be kept as in-patients in the hospitals. For that reason, and having got that off my chest, I am grateful to the 1168 noble Lord, Lord Molloy, for giving us this opportunity to air this subject this evening.
§ 8.40 p.m.
§ Baroness Robson of Kiddington
My Lords, I, too, should like to thank the noble Lord, Lord Molloy, for allowing us to have this debate about the plans considered by the South-West Thames Regional Health Authority. I had better announce my interest in the authority, as I was its chairman until January 1982. I was in fact chairman when the mental illness working party was set up. I am also grateful to the noble Baroness, Lady Macleod, for putting the question in its historical context, and for pointing out to us how these hospitals first came to be created, and why they were situated there. In addition, may I say in regard to the Question asked by the noble Lord, Lord Molloy, about the six psychiatric hospitals at Epsom, that only four of them are administered by the South-West Thames Authority and Horton and Banstead are administered by the North-West Thames Authority.
During the years that I was chairman of the South-West Thames Regional Health Authority mental illness patients living in the big institutions in that region—and it is one of the regions which has the greatest number of mental illness and mental handicap patients in the whole of England—numbered 12,675, and now, in 1983, there are 6,843. That is half the number. That is a great achievement, because it means that through enlightened policies we have been able to get people out of the institutions and move them back into the community.
I also should like to endorse the devotion shown by the staff who have been running the hospitals. Any noble Lord who has been down to Epsom and gone round some of the hospitals, will know how impossible it is to make them feel like a home, due to the way they have been built. It is only the devotion of the staff which has enabled them to go on running.
We are talking tonight about two reports by two working parties set up by the South-West Thames Authority. Both working parties have made recommendations to the RHA, and at its meeting in November the RHA accepted the recommendations as the long-term strategy for the region. No one would assume that this will happen overnight, but I should like to tell the noble Lord the Minister what he can do to help us make it happen more quickly. Nobody in their right mind believes that it can happen overnight, but no health authority can work without a strategic plan. You have to work towards something that makes sense.
The department, the medical profession, all of us agree that in modern times it is possible and right for the large majority of these patients to live in the community in which they belong, and not to be incarcerated miles away from anybody, all on their own. That is recognised policy for the future. There is nothing wrong with the South-West Thames Authority adopting that policy as its strategic plan. The whole emphasis in the working parties' reports is on better treatments for the patients.
I like many of the proposals in the working parties' reports. I like the idea of the core house, and the cluster of varying degrees of dependency in the community. I 1169 like the idea of creating for people who have been institutionalised for such a long time that they cannot go back into the community, much smaller units, which are more homelike and friendlier. I like all of those things.
I am worried about certain matters in the reports. First, I would hope that in the implementation of the solution patients from the hospitals will not be moved more than once, in particular the long-stay patients who cannot go into the community. To them the unit is home, however much we may think that it is a rather ghastly place. We could create better places for them, but I do not want them to be moved more than once.
Secondly, as the noble Lord, Lord Molloy, has said, an enormous amount of money will have to be spent in the community to create the right back-up services and conditions before the patients can live in the community. That will not be any cheaper. It will be more expensive, but it will be better for the patient, and, after all, that is what we are after. Therefore, we have a chicken and egg situation.
Enormous sums of money are tied up in the land values at Epsom, but the regional health authority will not realise that money until it has created alternative community services for the patients. If the Government are as dedicated as are all of us who have been involved in the health service to getting the patients out into the community, they should make available bridging loans for health authorities. The loans would enable the authorities to create the right conditions and move the patients into better surroundings. Then the loans could be paid back. That is the way to do it. Unless we move in that direction, we shall never get people out of unsatisfactory institutional buildings.
I know quite a lot about this matter because, apart from having been chairman of the South-West Thames Authority, I am a member of the Hammersmith and Fulham joint consultative committee. At the last few meetings between the local authority and the district health authority we have been scratching our heads as to how we can create the right conditions for receiving back the patients from Banstead when it closes. We have three years in which to create those conditions. But without financial help from the Government prior to the patients arriving, we shall not achieve what all of us want to achieve, and I should like to ask the Government to look into that particular problem.
§ 8.48 p.m.
§ Lord Auckland
My Lords, it is not a good reflection on parliamentary democracy that we are discussing an important Question of this kind with only 12 noble Lords and noble Baronesses in the Chamber. Although the Question—and I should like to add my gratitude to the noble Lord, Lord Molloy, for enabling us to discuss it—specifically mentions Epsom, the whole issue of mental health is implicit in it.
I intervene briefly in this debate because since 1954 I have lived in the Epsom area. For 18 years I was on the house committee of one of the hospitals to which the Question relates—St. Ebba's Hospital. Although with reorganisation of the health service I was, so to speak, out on a limb with many others on hospital management committees and house committees, both 1170 my wife and I still take a close interest in the hospital. Every Christmas we seek to visit as many wards as we can—and there are a great many of them—and join in the Christmas carol singing, which we hope to do again shortly.
An account has been given of the history of these hospitals and my noble friend, Lady Macleod, has rightly said both the St. Albans/Watford area and the Epsom area were designated in Victorian times when little or no treatment was given for mental illness and the unfortunate people, then classed as lunatics—which, thank God, we do not do now—were sent to these places so that they were out of sight and out of mind of the public.
I have studied the document produced by the South-West Thames Region, but I do not propose at this hour to go into technical details. I am not qualified to do so as I no longer officially serve on the region. At this stage I should like to pay a tribute to the good work which my late friend Lord Grenfell did when he was chairman of the hospital management committee of Queen Mary's, Carshalton. It is apposite to mention his name in this debate for the work which he did was quite outstanding.
These hospitals are now largely under-occupied. As I understand it, St. Ebba's Hospital is under-occupied compared with 20 years ago. There has been considerable upgrading of the wards and the general facilities there and also at other hospitals. Incidentally, I see from this document that at the Manor Hospital 96 more purpose-built six-bedded units are to be built.
I find it difficult to comprehend that six of these hospitals are to be closed. There may be a case for closing one or possibly more of these hospitals in due course; but as my noble friend Lady Macleod and the noble Baroness, Lady Robson of Kiddington, quite rightly said, with their vast experience of hospital work, it is absolutely vital that the needs of patients are considered. Although in some cases these patients still live under conditions that are far less than desirable, it is their home. Many have no families. Even more tragically there are patients—St. Ebba's is an example, where patients have been living there for a long time—who have families but their families never visit them.
As I see it, as a layman, we have this dilemma. We want to get more patients into community care outside the custodial care of the secure unit mental hospitals. But there are problems; first, of recruiting suitably sensitive people who can care for such people who have been virtually rejected by their families. That point must be considered. Secondly, on the other side of the fence, nobody wants to see these people living in conditions which, at best, are often highly depressing.
I should like to put one or two questions to my noble friend. Assuming that there is something substantial in the background of Lord Molloy's Question, what will be the position of the staff in these hospitals—the nurses, the doctors, the cooks, the speech therapists and all the other staff who are so essential in these establishments? Perhaps the Minister will confirm, too, that whereas there was a time not so long ago when the catchment area for St. Ebba's Hospital was the Paddington area, it is now local. They are no longer dependent on patients from Greater London, 1171 but many of the patients live locally and this is an important point. It means that there is bound to be more under-occupancy.
I have not mentioned this before in your Lordships' House, but if there is to be development and if there are 600 acres of land available there, there is a convincing case for some kind of development, but it should be development within the health service remit. It should perhaps be workshops. St. Ebba's is fortunate as it has an industrial unit, but I am not sure that is so of all the mental hospitals there. Perhaps there should be more recreational facilities. Matters of this kind are important when one is considering developing the land. The staffs of these hospitals come from many countries. We have just been discussing an important debate on ethnic minorities in this country. Many of these people work in our hospitals—and very good work they do too. Their position as well as that of the patients must be considered.
No praise can be too high for the staff of all grades who work in these hospitals in the Epsom area. Over the years I have had a chance of seeing them at work, both at in the daytime and at night. The lot of the patients is their first consideration. I am sure that my noble friend the Minister when he replies will take that on board. I believe it is very important that the Government come to an early decision on the remit of Lord Molloy's Question, whether it is entirely factually correct or not.
§ 9 p.m.
Lord Wallace of Coslany
My Lords, I should first like to thank my noble friend Lord Molloy for raising the Question on the Epsom hospitals. However, one must frankly admit that we have moved into a general debate on the mental health service and indeed we are really indulging now in a follow-up debate to last week's Unstarred Question of the noble Lord, Lord Beswick.
The proposals dealing with the Epsom mental hospitals appear as part of a national pattern, as the noble Lord, Lord Molloy, indicated. The purpose is to get rid of large and, in many cases, very old mental hospitals and to replace them with smaller units, allied to community care, of which the noble Baroness, Lady Macleod, has spoken so movingly. I entirely agree with her about the system of house or homecare, and care in the community, being carried on. I have quoted in two previous debates my own experiences of such a scheme in Norwich, where voluntary organisations, local authorities and the health service, have all worked together to provide what to me was a revelation of care for these people, bringing them back into the normal world which many of them have not known for some time.
That policy, on the surface, appears to be forward-looking and progressive; but a considerable number of difficulties arise, including of course, as the noble Baroness, Lady Robson, has pointed out, the provision of adequate finance. Naturally the first problem that arises is the disturbance to staff and patients—and patients not released will take some time to settle down in new surroundings. But, as the noble Baroness, Lady Robson, also pointed out, this situation is capable of being eased by the skilled 1172 nursing care of staff who are known to their patients. We have to face the fact that if you close a mental hospital and open new units of accommodation built to the best standards—smaller units—it will take a long time for those patients to get accustomed to their new surroundings. The hospital wards and areas they are familiar with have become part of their lives, and many of them have known nothing else. It will take a long, long time before they settle down. Therefore change in itself is unsettling and it is a problem that we have to face up to.
Staff, on the other hand, face in one sense greater problems because, as the noble Lord, Lord Auckland, hinted—and we may get a more satisfactory answer later—there may be some redundancy among all grades; and not only redundancy but disturbance of family life because of an enforced move to a new area, together with the uncertainty caused by rumours due to lack of communication.
In other words, I am saying that at all stages of any change there should be full consultation procedures taking place between management and staff. My noble friend Lord Molloy indicated that this has not taken place. That is very much to be regretted because hospitals are the most fertile source of rumours, as I and many of your Lordships know full well.
There is the problem of land disposal. I think the Minister will be telling us where the money goes after the sale is completed. I believe it goes to the health service but no doubt he will confirm this when he comes to reply. However, it appears that a theory exists that the sale of surplus land would meet the cost of the new units. There are a lot of snags to be overcome before that can be achieved. In the first place, the new units have to be provided—and this has already been stressed by the noble Baroness, Lady Robson—before the old hospitals can be demolished and the land disposed of. Most buildings that are being disposed of would be unsuitable for other use, and thus public expenditure would have to be incurred before any compensating money from land sales has been received.
Planning permission would be necessary before private development could take place. In passing—although we are dealing generally with a national situation—I understand in Epsom there is an additional problem because the town is very favour ably placed in a Green Beltarea. Although the hospitals may be pretty tatty these days, if they are demolished there will certainly be great problems afterwards over what is to be done with the land. I like the suggestion that was made by the noble Lord, Lord Auckland, that the land would be ideal for recreation areas, and so on. But if that were the case, you are not going to get much money from private property speculators; so you have to face up to that. So far as Epsom is concerned, that is certainly a restricting factor. Even if planning permission is received for property development, it must be borne in mind that although this exercise might be designed as a form of saving, in fact such development means more public expenditure on schools, roads, health service facilities, transport, sewers, shops and many other services not always thought of by planners until afterwards, as many of us know only too well in any newly developed area.
1173 Reverting to the planned new units, it does not follow that administrative costs will be reduced, and in any case if a large number of patients are released adequate measures of community care cannot be provided cheaply. In many cases they are not adequate at the present time to meet existing needs. I think it was the noble Baroness, Lady Robson, who pointed out that a great deal of spending is needed, and a restriction on local authority spending will very severely interfere with the ideal of providing community care. I have no objection to the abolition of outdated mental hospital facilities and their replacement by units of accommodation suited to modern needs, together with an increased system of community care. There is a very old mental hospital at Darenth Park, which is close to where I live and with which I am very familiar—as a visitor, not as a patient. It is partly demolished. I saw a nurse on television who said that the patients will be very disturbed when they are moved and that it will take time to put them right.
So to assume that this can be provided by land and property sales is too optimistic. In any case, as the House has already been told, it will take a long time to achieve. The fact must be faced that community care facilities provided on an adequate scale will considerably increase expenditure, particularly by the local health authorities. I was reading about an area—I think it was Wandsworth—where they were going to demolish a hospital to provide land for new units. But because the health authority does not have the money, they are having to sell the land for property development instead, and there will be no new units. I do not know whether that report is accurate, but it is in today's Guardian.
Finally, I come back to what is to me a very important aspect: that is, staff involvement. The avoidance of rumours, misunderstandings and resultant unrest can only come from full consultation with staff at all levels. Surely it is possible for the Government to arrange for staff representatives to be involved in the planning of any changes. These people at least have experience of working in the system, and therefore they have knowledge and experience to provide. This is a lesson not only for the mental hospital field. It is a lesson for the whole of the National Health Service, which is going through some troubles at the present time, mainly due to lack of communication, with resultant rumours and unrest among the staff.
Changes may be on the way in the mental health service, but before drastic action is taken I advise the House and the Government not to put on one side the advice and experience of those very dedicated people who serve and care for patients every day and in every way—often far beyond the normal scope of their duties. They deserve the highest praise. As I indicated, many of them are not even British subjects. Many of them have come from overseas. I have seen many Spanish nurses and coloured nurses who are devoted to their patients.
I do not know how they have the patience to cope, and sometimes they even face physical danger. Some years ago, I had to deal with the case of a male nurse who had been hit over the head with a chair by a patient and that finished the nurse's working life. So we have to face up to all those facts, and they are not 1174 pleasant to think about. I appeal to the Government to take into account those people who are involved in the service, and that can only be to the advantage of the Government and the whole service. I hope that changes take place. I should like to see these new community units and community care extended. It is a great ideal, but it will not be done on the sale of land or achieved in five minutes.
§ 9.11 p.m.
§ The Parliamentary Under-Secretary of State, Department of Health and Social Security (Lord Glenarthur)
My Lords, I think we shall all be very grateful to the noble Lord, Lord Molloy, for raising, with his usual eloquence, a subject which I know concerns him a great deal, and many others of your Lordships as well. I hope that in replying I can reassure him and others about the South-West Thames Regional Health Authority's plans for providing psychiatric and mental handicap services in that part of the country.
Perhaps it would be helpful if, by way of back ground, I were to start by reminding your Lordships of the reasons for the location of mental illness and mental handicap hospitals in areas such as Epsom. This matter was touched on by my noble friend Lady Macleod. Around the turn of the century, when these hospitals were being built, there were two main aims in caring for the mentally ill and mentally handicapped—whose differing needs were not always distinguished at that time. These were partly to protect society by providing custodial care behind locked doors and high walls and away from centres of population, and partly to protect the patient by providing him or her with a secure shelter. A large hospital in the country met both these objectives.
As I am sure your Lordships will agree, mercifully and thankfully attitudes towards the mentally ill and mentally handicapped have changed a great deal since then. The emphasis now is on avoiding segregation and institutionalisation, and on enabling as many people as possible to live as normal a life as possible within the community. As the House will know, and as has been stressed this evening, the main thrust of mental health policies of successive Governments from the 1960s onwards has been to move from psychiatric and mental handicap services based in these large isolated hospitals to a locally based service in the community, in which health and local authorities collaborate to provide a wide range of services to meet varying individual needs.
But we fully recognise the continuing need for in-patient treatment for some patients, both on a short to medium basis during an acute phase of illness and for long term care in the case of a minority of patients whose needs can be met only in this way. The noble Lord, Lord Wallace of Coslany, the noble Baroness, Lady Robson of Kiddington, and my noble friend Lord Auckland referred to this need. They spoke of patients feeling that these places are home. That, to me, is quite clear. I have seen them, and fully agree. But the vast majority of people with mental health problems only rarely, if ever, need the degree of treatment and support which can be provided only on an in-patient basis. For them, what is important is a wide range of services which would enable them to live 1175 as normally and as independently as possible in the community.
One of the problems we now face is the concentration of these large, old, isolated hospitals, particularly in the home counties, with a steadily reducing number of long-stay patients and a pressing need to provide more appropriate types of care within each health district. It is precisely this problem which the South-West Thames Regional Health Authority is now looking at. The regional health authority set up two regional working parties to advise them on the future pattern of services for the mentally ill and mentally handicapped. The reports of these working parties were published earlier this year. The noble Lord, Lord Molloy, referred to them. They attracted considerable press interest, but they also attracted a certain amount of misleading speculation, I am afraid. Following extensive consultation, their main recommendations have now been adopted as regional policy.
This does not mean that a number of large hospitals will be closed overnight and patients discharged into the community without adequate care. What the South-West Thames Regional Health Authority will now be doing—along with other health authorities up and down the country, and in conjunction with the social service departments concerned—is to look at ways of providing alternative and more appropriate forms of care. These will range from hospital in patient care at one end of the spectrum to, at the other, a range of support services enabling more people to live independently in their own homes.
§ Lord Molloy
My Lords, if this kind of thing has to go on, would the Minister ask regional health authorities not to put advertisements in newspapers saying how much nicer it will be to live down there when all these mentally ill patients are moved? This is what the South-West Thames Regional Health Authority did. It is highly distasteful to put something like that into advertisements for the sale of land. They can say that it is desirable land, but not that it will be much better in the future because when mentally ill people are no longer there the price of property will increase, which will be to everybody's benefit.
§ Lord Glenarthur
My Lords, I am not quite sure to which advertisement the noble Lord is referring. If he will show me any particular advertisement which he thinks is distasteful, I shall certainly take up the matter with those concerned.
§ Lord Glenarthur
My Lords, I am convinced that the region will agree with the noble Baroness, Lady Robson of Kiddington, who suggested that patients should not be moved more than once when it comes to their turn and it is suitable for them to move into community care. This is a very important point which I am quite certain will be strictly adhered to wherever possible.
Now might be an appropriate moment to talk about funding, a point which has been raised by various Members of your Lordships' House. The noble 1176 Baroness in particular asked about bridging finance. The "care in the community" initiative which was announced some time ago will make joint finance arrangements between health and local authorities more flexible, and will provide £15 million over the next five years for new projects. I hope that authorities will take full advantage of this additional source of funds to help to develop local, community-based mental illness and mental handicap services.
In the short term, the South-West Thames Regional Health Authority has set aside special capital and revenue reserves to develop mental health services. In the long term, income from land sales is expected to finance the new pattern of services—and not only land sales but the closure of hospitals and all the revenue that is trapped in those hospitals. I do not like quoting my own speeches, but when I spoke last week on the Richmond Fellowship report I was able to give the example of Banstead Hospital, where it was costing over £500 per patient per year for heating alone. That is a fairly staggering figure.
So far as local authority obligation is concerned—and my noble friend Lady Macleod of Borve raised this point—yes, there has been a duty placed on local authorities to provide after-care for mentally ill people since 1959. The Mental Health Act 1983, which my noble friend specifically asked about, also repeated that point in respect of some formally detained patients.
As the working party on mental illness services highlighted, there is a particular problem around Epsom because of the presence of those six large mental illness and mental handicap hospitals; five of which are clustered within about one and a quarter miles of each other. Those hospitals provide mental illness and mental handicap services to nine districts. As we have heard, all but two of them are managed extra-territorially and provide services to districts many miles away.
Given the steadily reducing population of those hospitals and the urgent need to release the vast resources which are locked up in them so as to provide locally-based services and alternative forms of care, it is only sensible—in fact, it is vital—to look at the role of those six hospitals to see whether, by sensible planning, there might be a better way to provide services and at the same time provide better and more appropriate care for the patients.
Clearly, that is likely to mean that some of the existing hospitals in and around Epsom will not be required in the longer term. South-West Thames has no definite plans yet for closing any individual hospital and disposing of the property and land. The only firm proposal so far concerns the closure of Banstead Hospital, to which my noble friend Lady Macleod of Borve referred. That hospital is managed by the Victoria Health Authority in North-West Thames and, following the closure of Banstead, the proposal is to transfer patients to Horton Hospital. The short answer to the question of the noble Lord, Lord Molloy, is that there are no plans for the wholesale closure in the way that his Question describes.
The noble Lords, Lord Molloy and Lord Wallace of Coslany, and the noble Baroness, Lady Robson of Kiddington, referred to the role of staff. I should like to 1177 associate myself entirely with all they said about the caring and sympathetic way in which the staff at those hospitals look after their patients. It is, to someone who comes to it for the first time, particularly striking to see their dedication and the enthusiasm they show for their work.
Although the South-West Thames Regional Health Authority has no specific proposals to close any particular hospital, as I said, it fully recognises that the skill and experience of existing staff will be needed for the new pattern of services which will emerge. Decisions about the future of employees in particular hospitals will have to be considered carefully when proposals are being drawn up to close a particular hospital, to transfer services to another hospital, or to provide alternative forms of care in smaller units or within the community. I can assure your Lordships that the health authorities concerned will consult staff interest fully when drawing up proposals. I believe that point was one to which my noble friend Lord Auckland also referred.
The noble Lord, Lord Molloy, described the selling off and the disposal of the hospitals in due course as "asset stripping". That is a very wild assertion, if I may say so. There is absolutely no question of "asset stripping". There are no proposals to close any of the hospitals in Epsom which are managed by South-West Thames. But, as I said, the population of those hospitals is steadily declining and it is the regional health authorities' intention to review the future of those hospitals, to ensure that available resources will be used in the most effective way.
The National Health Service's estate is large by any standard. I do not have a figure for the total amount of money that it is worth, but it must be into hundreds of millions of pounds. It is important that its size is regularly reviewed to take account of changing needs. That means, as it always has done, that the NHS will need to buy and sell land. It is not sensible for the NHS to hold on to land that is no longer needed. It is of course far better to sell it and use the proceeds to finance other priority needs of the health service. Like it or not, we are in the property business and we must treat that property with care; we must treat it in the way that others would treat it if they were hanging on to the sort of values we are talking about.
Regarding the unions, the noble Lord, Lord Molloy, asked particularly about COHSE; and he also mentioned consultations with doctors and others. The noble Lord will be aware that COHSE, under the chairmanship of Mr. Mallinson, who contributed so much with his statesmanlike approach, produced a report which supported the development of community psychiatric services in the interests of patients. There were a number of medical representatives on the mental health and mental illness working parties. The regional health authority has consulted all interested parties on the reports, and the full consultation procedures will be followed before any specific proposal is implemented. The recent report of the inquiry into underused and surplus property in the NHS and South-West Thames's own working party report on psychiatric services referred to the concentration of the large hospitals around Epsom and to the problems of disposing of surplus land in the Green Belt area. The green belt area was a point raised by the 1178 noble Lord, Lord Wallace, when he also spoke about the question of planning permission. I shall return to both those points shortly. These two reports recognised that the development potential of the Epsom estate could be considerable and recommended therefore that there should be co-ordinated action on the part of the several health authorities concerned to review the future of hospitals on this site.
My honourable friend the Minister for Health recently met the chairmen of the South-West and North-West Thames Regional Health Authorities to discuss how best to tackle these issues. They agreed that the two chairman should oversee a review of the Epsom estate which would take account of the long term service planning issues, the interests of the patients now in these hospitals and the property considerations which are aimed at maximising the benefits to be released for the NHS from a carefully considered and phased disposal of parts of the estate. This work will now need to be set in hand as a matter of urgency, but it will probably be some time before firm plans for rationalising the Epsom estate as a whole are put forward. Proposals for changes in services will of course be subject to the usual consultation procedure.
I should stress to your Lordships that if a redundant hospital is closed and the land sold it should not be viewed as a lost resource; indeed quite the reverse is true. Revenue savings, such as I described earlier, will be used to support and develop other services and the same applies to the proceeds from sales of surplus land. Perhaps I could take this opportunity of setting the record straight on this particular matter. My noble friend Lord Skelmersdale inadvertently and quite uncharacteristically I think made a slightly wrong assumption when he answered a question yesterday in your Lordships' House. So far as the proceeds are concerned the correct position is that when surplus NHS land is sold the proceeds are retained for National Health Service use, and we follow the principle that, wherever possible, the services of the district health authority which has disposed of the land should be those which benefit from the sale of the land. I know that my noble friend has written to all those concerned with this particular matter.
To turn to green belt land, to which the noble Lord, Lord Wallace, referred, where a hospital located in the green belt or other rural area is no longer required, health authorities should, in full consultation with local planning authorities, explore all the possibilities for acceptable alternative uses. If such a use is found, they should prepare plans for redevelopment and seek planning approval from the local planning authority, at present using the non-statutory procedure, but the noble Lord will be aware of the change to which my noble friend Lord Skelmersdale referred yesterday during the Question concerned.
Generally speaking, planning approval is not given for the construction of new buildings inside a Green Belt area except in very special circumstances. However, the opportunity to remove a large hospital complex from a Green Belt area and its replacement with a building more in keeping with the surrounding area which can actually improve the local environment without putting additional demands on the local infrastructure as well as providing an additional 1179 opportunity to relocate psychiatric patients in the community may—I say may—be regarded as very special circumstances. But this is very much a matter for the local planning authority in the first instance and ultimately for my right honourable friend the Secretary of State for the Environment.
I hope that in answering the noble Lord's Question I have been able to reassure him about the South-West Thames RHA's plans for developing mental illness and mental handicap services in this part of the country. There are still significant numbers of mentally handicapped and mentally ill patients inappropriately placed in hospital and we should fully support proposals by the South-West Thames RHA to remove such patients into a more suitable environment in the community. There do not seem to be many of your Lordships who have spoken this evening who would dissent from that ideal. At the same time both we and the region recognise fully that, for a minority of patients, hospital in-patient care will remain the most appropriate and necessary form of care. It is therefore vital that the need to develop community services is balanced with the need to maintain high standards of care for those who need care in hospital.
§ Lord Skelmersdale
My Lords, if the noble Lord is addressing a question to my noble friend before he sits down, then he is in order to do so. Apart from that, he is not in order to respond to an Unstarred Question.