§ 8.36 p.m.
§ Lord Rowallan
My Lords, I beg to move that this Bill be now read a second time.
The subject of mental health is a comparatively new one for me. Last year I was watching a programme on television, which I very seldom have time to do. It was "Panorama". People were talking about the way the mentally ill were treated. To put it bluntly, I was horrified by what I saw. As the programme continued it became obvious to me that three things were not happening that should be happening. First, the mental patient was not receiving enough attention either because there were no beds available for him to be an in-patient or because care in the community was not working properly. Secondly, the psychiatrist was under intolerable strain working with a lack of proper facilities at hand. Thirdly, the general public were in danger as a direct result of the mentally ill being in the community before they were ready.
Since that programme every one of the patients interviewed has subsequently been involved in some crime—mostly minor, I am glad to say, but nevertheless worrisome—or is back in hospital as an in-patient having been released into the community. In the case of one patient he has committed murder, and a particularly brutal one at that. It received a lot of media attention at the time as a young policewoman was sadly killed entering a house without her bulletproof jacket on.
In Victorian times we put the mentally ill into large asylums and forgot about them. Out of sight, out of mind. Now we do the reverse. We throw them into the community and forget about them, leaving them to fend for themselves where they can stop taking their medication and lose all the progress that they have made in hospital. The medicines that we offer them are old and have side-effects, like feeling as if one has Parkinson's Disease, where one loses control and feeling in one's legs and arms. But they can be long-acting, for up to six weeks, if taken by injection.
1226 Modern drugs are more expensive, do not have side effects but, most importantly, are only found in pill form and so are not long lasting. So the mentally ill have to use an old drug in the form of an injection every five or six weeks, with side-effects or a new one in the form of a pill daily, which they have to go to a chemist for on a regular basis and also to their GP to get a repeat prescription, whereas they can get the injection from the hospital they have attended quietly and without fuss and without their neighbours knowing that they are ill.
The Mental Health Act 1983 is the current Act dealing with mental health. It still deals with Victorian thinking and desperately needs updating. This amending Bill that we have before us today deals only with in-patient care. I would like to introduce further legislation at a later date to deal with out-patient care. In an ideal world we should have a new mental health Act. Sadly, we do not live in an ideal world. There are more important issues for a government. Please note that I say "a government" and not "this Government", because mental health should not be a political issue. What surely is required is the provision of an environment for this group of unfortunate people whereby they can relax and get better; where the psychiatrist and the nursing staff have the facilities and the wherewithal to look after them; and where the country as a whole has the belief that the best is being done for them.
At the moment all too often that is not the case. Psychiatrists do not want to put their patients, especially female patients, into some units as it is not a therapeutic environment for them to recover in. There are insufficient beds and thus some patients are put out on to the streets to allow someone who, on that particular night and at the moment the decision is taken, is judged to be in an even worse state. When it turns out that those patients should not have been released because they later have a relapse, as happens all too often, the media get hysterical and we endure lurid headlines.
Aftercare is difficult as there is so little supervision as the ill move from carer to carer, from health authority to health authority and get lost in the social welfare system. Would it not be better to have sheltered units with a nurse and doctor on hand in the same way as we provide sheltered accommodation for the elderly? In that way, all such patients could be in one area where their needs medically, financially, and environmentally could be watched over with simplicity. They could regain a sense of independence, find peace and tranquillity and yet have all the help that they could want on hand, in a sort of halfway house between in-patient care and care in the community.
In 1989 a White Paper Caring for People was published. It proposed agreements with developers to build new places for the mentally ill to live in exchange for their developing the old asylums. Insufficient bridge funding meant too little has happened and 40 per cent. of the old asylums remain vacant at an annual maintenance cost of somewhere between £10,000 and £330,000 each. What a waste of resources! In 1994 the then government wanted to ring-fence that money. It was not done.
1227 That, in simplistic terms, is the background to the problems facing the mental health services today. Add to that governments of all shades who do not view the mentally ill as a high profile group and it is easy to see why so little is happening except for debate, debate and debate. It is not debate we need; it is action. We know the mentally ill exist, but we do not want to admit that they exist by doing something concrete to help them. They are the forgotten society.
Then there is the problem of the non-integration of the charities involved. All do a wonderful job dealing with their own speciality in a vast subject that ranges from bulimia and anorexia at one end through schizophrenia to manic depression and total madness at the other. Each charity is determined to provide for the betterment of the mentally ill, but often they are conflicting in their advice and thinking on how to achieve that panacea. I was delighted, therefore, to receive the backing of all of them for Clause 2 of my Bill which states that there should be single-sex wards in all psychiatric units and security for the patients themselves. It is a sad fact that the mentally ill become sexually oriented. At a time of emotional crisis when a woman needs to feel secure in order to recover, the last thing that she needs is to be harassed, abused or raped by a man in the very place that is supposed to be safe and therapeutic.
In 1996 the mental health commissioners visited hospitals and psychiatric units all over the country. They found to their horror that in over 50 per cent. of the units that they visited evidence of harassment to women existed. Only 35 per cent. of women have access to women-only sleeping areas with separate toilet facilities; 27 per cent. have to pass through male areas and wards to get to their bathrooms; 32 per cent. have access only to mixed bathing areas; and 3 per cent. have to sleep with men in the same ward. What a disgraceful state of affairs—and hardly conducive to a healthy environment for recovery.
In January 1997 the National Health Service chief executive, Alan Langlands, set health authorities the task of providing safe facilities for patients in hospital. By August of that year, only 43 per cent. could report that they had met the standards. Paul Boateng, the Parliamentary Under-Secretary of State in the Department of Health and with special responsibility for mental health, has indicated to me that the remainder must provide those standards by 1999, but admits that most have indicated their inability to give a guarantee that they can do it in time.
The performance targets are not enormous. They are, first, to ensure that appropriate organisational arrangements are in place to secure good standards of privacy and dignity for hospital patients; secondly, to achieve fully the Patient's Charter for segregating washing and toilet facilities; and, thirdly, to provide safe facilities for patients in in-care hospitals to safeguard their privacy and dignity.
Surely all that this Bill does is to give the Parliamentary Under-Secretary the extra clout that he needs to force health authorities to provide those things as part of law—all, I should have thought, easily 1228 achievable in the suggested timetable, and essential for the betterment of the mental health service. The resources are there, if the recommendations in the Caring for People White Paper are taken up.
I have dealt with Clause 2, so perhaps I should turn to Clause 1. Some of the charities have indicated to me that they are not so happy with Clause 1 as they think it is restrictive. MIND would like Clause I to read, "To prepare a strategy for the provision of care for persons who require treatment for acute episodes of mental illness". I can go along with that. It is the nub of the problem, as all too often there is simply nowhere for the patients to go.
The Mental After Care Association, MACA, says that bed-blocking and bed shortages are not best resolved by increasing the number of in-patient beds. It wants to see a greater provision of a range of community-based mental health services, so do I—so do we all, I presume, but we cannot run until we are walking, and the provision of adequate in-patient care is a jolly good starter for 10. When we have that, we can turn our attention to out-patient care.
The National Schizophrenia Fellowship and SANE both like the Bill. Both deal with the biggest mental illness, schizophrenia. There is a 1 per cent. chance of having that dreadful disease at birth. Three or four people in every 1,000 experience some form of schizophrenia at any one time. It is the same the world over—black or white, rich or poor, civilised or pygmy—the statistic remains exactly the same. Fifty per cent. of all admissions to psychiatric hospitals are schizophrenics. Their mortality rate is two-and-a-half times higher than that of the rest of the population; 15 per cent. will commit suicide; 25 per cent. will commit grievous bodily harm to themselves; between 10 and 20 will commit murder, of which one-third will be of total strangers and two-thirds of parents, nurses, carers or someone they know. One in five of the prison population are schizophrenics—perhaps we should think about taking them out of the prison system—and so are one-third of those living rough.
With those figures in mind, can any of your Lordships be content with the current situation? I think not. Something must be done and that something must be done sooner rather than later—and preferably now. The Parliamentary Under-Secretary of State wrote to Julian Lewis M.P., stating:While I agree it is important to ensure an individualised programme of care for each person who requires admission—and these principles are embodied in the Care Programme approach—I do not believe that physically separate in-patient facilities is the appropriate way to provide in-patient care".I say that this Bill—and I am supported by eminent and respected psychiatrists, such as Dr. Martin Deahl of Homerton Hospital in Hackney, Dr. Mark Salter of Bart's and Dr. Mike Harris of St. Andrew's Hospital, Northampton—is in line with the departmental policy of separating out different types of patient. It cannot be right that mothers with young children should be in the same ward as people with acute psychotic conditions or that people with psychogeriatric problems, who are especially vulnerable, should be in the same area as people with acute problems.
1229 In 1998 Peter Tyrer, professor of community psychiatry at Imperial College, London, published an article in the British Medical Journal. He is recognised as being the country's leading expert in community psychiatry. The gist of the paper was that based on a cost/benefit analysis rather than on clinical care quality, the cost of providing a service in Brent, which just happens to be Mr. Boateng's constituency, where beds have been reduced too far, was double that of providing an identical service in a neighbouring health authority which has a heavy community presence and a much larger number of available beds.
The principle is therefore transparent: although community psychiatry is good, it needs to be backed up with appropriate numbers of acute beds within each catchment area so that community services can have the beds as part of the total service. This Bill does just that in Clause 1. SANE says,This Bill recognises in patient care should be tailored to the individual's needs, giving real choice to those currently denied help in hospital. Because of this crisis in inpatient care people with mental illness are being ignored and neglected and lives are being lost. These proposals may well prevent many unnecessary tragedies".SANE has campaigned on the issue of beds—or rather the lack of them—for 15 years and feels strongly that patients must have the choice of where they want to be treated.
I remind your Lordships that through various Written Answers I have been told that no data are kept by the Government on how many mentally ill people commit crimes, nor how many commit them as a result of early release from hospital into the community. The Government should keep such records, as those involved in mental health care need them for future planning.
We have fewer psychiatrists per 100,000 people in London than in any other city in the world except Teheran and Bangalore, and because of exasperation with the system we have only 5,130 psychiatrists working full time with the mentally ill in Britain. There are 5,130 psychiatrists to deal with up to 6 million people, if it is accepted that one in 10 of the population are liable to have a mental problem during their lifetime. In practice most psychiatrists have 400 patients on their books at any one time, but 14 per cent. of all psychiatric posts-450 posts—are today unfilled. London has fewer hospital beds and a lower amount of available cash to look after the mentally ill than any other industrialised city in the world. What a sadness.
Most mentally ill people are not violent; most can walk unnoticed in the community; and most homicides and suicides are preventable. But these objectives can be achieved only with better care, better communication between the service providers and better risk assessments provided by better facilities in which psychiatrists can work. Then and only then can we ensure that there are fewer unnecessary deaths and at the same time the public will have their fears allayed and the ever-hysterical media can be silenced. We cannot wait for government-led primary legislation to upgrade the Mental Health Acts. However undesirable it may be to this Government, we must work piecemeal 1230 through the 1983 Act to provide what a modern society requires for its mentally ill minority. We must act now. This is the first step. It will help the patient, the doctor, the carer and the community at large.
§ Moved, That the Bill be now read a second time.— (Lord Rowallan.)
§ 8.51 p.m.
§ Lord Hunt of Kings Heath
My Lords, I should like to begin by declaring an interest as a policy adviser to the Sainsbury Centre for Mental Health. I also thank the noble Lord, Lord Rowallan, for this opportunity to have a serious debate on mental health services in this country. This is a timely debate, although I regret that I have reservations about certain aspects of the Bill.
I have no objection to the provisions relating to single sex wards. I recognise that there have been considerable problems in this area in a number of psychiatric hospitals and that they have created considerable pressure and strain on both patients and staff. I am doubtful, however, whether legislation is the answer. The noble Lord believed that the Minister required the extra clout to put this into practice. The reality is that ministerial priority backed up by ministerial action is sufficient. But one should not underestimate the practical issues involved in moving very speedily to a solution in this area.
I have considerable concern about Clause 1 of the Bill. I recognise that there are problems in some areas in relation to the sufficiency of in-patient facilities. It is important that appropriate access is available to those who require it. But it is wrong to focus narrowly on the issue of beds in mental health hospitals. The danger is that by focusing solely on the issue of beds we will send the policy on care in the community into certain retreat. It is vital that on this issue we debate the whole context in which mental health services should be provided in this country. Mental health services are a very important part of the NHS. One-eighth of all NHS expenditure is spent on mental health. It has been estimated that mental health problems underlie up to one-third of GP consultations.
Despite the rather gloomy assessment made by the noble Lord, I believe that in the past two to three decades great strides have been made in the way that the health service has handled mental health issues. When I began my career in the health service 25 years ago I visited a considerable number of mental health hospitals. The conditions in those hospitals were pretty deplorable. They were overcrowded, had few staff, provided institutionalised care and lacked support. As we well know, the result was a series of inquiries in those hospitals in which staff had been abused in one way or another.
In the past 20 years we have seen a huge improvement. As we have developed community care thousands and thousands of people have had better support and care and have been able to live their lives in the community. Problems have arisen from the early discharge of patients without proper support. There have also been resource problems. We have been unable to provide investment to maintain some of the old hospitals 1231 while we have developed new services in the community. There have also been problems related to inter-agency working as between health and local authorities. Despite those problems we should not forget the dramatic improvements that have taken place in our mental health services.
Nothing that has happened in the past few years can justify the hysteria that has been created in relation to a number of homicide cases in which the mental health services have become everyone's whipping boy. Instead of looking just at bed numbers we must look at the much broader picture. I suggest that our approach to mental health services should be governed by three broad principles. First, we need to base it upon a recognition that people who experience mental illness are citizens who retain equality of access according to need to health services, social services, housing and other services. The second principle is that those who experience mental illness should have the opportunity, where possible, to manage their own lives and make their own distinctive contribution to society. The third principle is that good outcomes will flow from the integration of people who experience mental illness within society generally wherever possible.
I believe that the key elements in trying to ensure that those principles are put into practice effectively are the following. First, it is absolutely essential that we have integrated service plans which are agreed jointly by health and local authorities. Secondly, those should be underpinned by the pooling of budgets between those agencies. I very much welcome the Government's approach in this area. Thirdly, at operational level we need to go beyond simply talking about joint working. Health and social care staff must begin to work together and be integrated within the same teams. Fourthly, with the emergence of the new primary care groups under the Government's NHS White Paper we must ensure that they work very closely with community mental health teams so that there is a completely co-ordinated approach to primary and community care.
Further, we must tackle some very difficult staff issues. I do not believe that any of us can pretend that the morale of all staff working in the field of mental health is always at a high level. We must invest more money in the training and development of staff. We require a package of measures to support staff recruitment and retention. We must also concentrate on leadership in our mental health services. I am concerned that the people who manage those services can be isolated from the mainstream managerial cadre in the health service. I should like to see concerted action taken to implement programmes to develop and support that leadership.
The noble Lord referred to the public perceptions of the risks involved in community care. Certainly, they appear to have become negative and distorted in the past few years. I believe that that poses major problems for the morale of people involved in mental health services and those who have to develop and plan services for the future. I question the impact of compulsory inquiries into homicide incidents. I believe that often they have attracted maximum publicity with little new being learnt 1232 from them. They have undermined public confidence and placed an enormous amount of pressure on the people involved.
All of us recognise that public interest demands a mechanism to carry out reviews of all serious incidents. I wonder whether there can be developed a constructive alternative to public inquiry after public inquiry. I favour the suggestion that we might appoint an ombudsman who, on the basis of the available information, might advise as to whether a public inquiry were warranted in every case. Tackling public perception may be the greatest challenge that we face. It is an enormous task, but it is one to which we must devote attention.
Next, I shall reflect on the impact of the Government's White Paper on the NHS. The overall theme of the integration of services is consistent with what we need to achieve in the mental health field. There are a number of key issues which we must face. The first is our capacity to manage change. That is a large agenda. It is not for just a year or two, it is for a decade. We must look carefully at the support that needs to be given to the people who will have to lead that change in the mental health field.
Secondly, we must be careful about the potential marginalisation of stand-alone mental health NHS trusts. I well recognise why the Government have decided that that should take place. We need to have available a package of measures to ensure that those people working in those stand-alone trusts do not become isolated from the rest of the health service or social care.
We must look carefully at the commissioning skills available in health authorities and primary care groups. I have been worried about the scarcity of talented people available to health authorities to help commission mental health services. As primary care groups take on that role, there is a similar problem in trying to ensure that at that local level they have people who understand mental health services, and who can commission effectively.
We shall have to devise new ways so that scarce skills can be shared between primary care groups and between health authorities. Finally, in relation to the White Paper and its impact on mental health services, it is important that, as between trusts, health authorities and primary care groups it is clear who is accountable. We cannot afford for people to slip through the net. It must be clear as to which agency is accountable for which client of the health service at the end of the day. The White Paper offers overall a strong, positive way forward in relation to the NHS generally and specifically to our mental health services. It offers a much more positive way forward than the narrow concern about the number of beds available within mental health hospitals.
§ 9.03 p.m.
My Lords, one of the themes running through last week's memorable debate in your Lordships' House on the golden jubilee of the NHS was the progress which has been made over the past 50 years in making the NHS more responsive to patients' needs. That continuing aim, which the previous government 1233 endorsed, perhaps most tangibly in the Patient's Charter, and which the present Government have also recognised expressly in their White Paper on the future of the NHS, is not merely ethically right, it is also, almost self-evidently, a part of that necessary process which ensures that resources are utilised efficiently.
Responsiveness to patient need is a principle which runs right through the health service. It is a theme which resonates with particular clarity in the area of patient care to which my noble friend has so graphically drawn our attention—that of mental health.
Improving mental health is one of the four key targets in the Government's recent public health Green Paper, Our Healthier Nation. The prevalence of mental illness and its profound consequences on so many aspects of our national life are starkly delineated in that document. I shall quote a brief section from page 76:mental health problems are a major cause of ill health: the 1995 Health Survey for England showed that 20 per cent. of women and 14 per cent. of men may have had a mental illness; mental disorders accounted for an estimated 17 per cent. (more than £5 billion) of total expenditure on health and social services in 1992/93 (the largest single cause); they also accounted for 15 per cent. and 26 per cent. of days of certified incapacity in the early 1990s in men and women respectively".Those statistics, shocking as they are, reflect a multitude of different conditions and disabilities whose causes are varied and complex. Ever since the Mental Health Act 1959, which did so much to destigmatise mental illness, it has been the policy of successive governments to shift the emphasis of caring for mentally ill patients from the institutions to the community. That process gained added momentum, of course, with the National Health Service and Community Care Act 1990.
However, in implementing that broad policy, which has attracted cross-party agreement, both this Government and the previous one have recognised the importance of in-patient care, and the need to ensure an adequate number of psychiatric beds in hospitals. A great deal of discussion has taken place recently on whether there is a need to create more such beds, both acute and long-stay, and whether, in particular, the apparent pressure on acute beds could be alleviated by better management of admissions and discharges. But those are not issues which need to concern us this evening. What matters in the consideration of this Bill, or more precisely Clause 1 of the Bill, is that there is a clinically acknowledged need for in-patient care which NHS trusts and health authorities have a duty to meet.
My noble friend set out the background to the Bill with skill and persuasiveness. I shall not go over the ground which he covered so ably. But if we accept that there is a clinical need for in-patient care and that provision of that care is not always—for whatever reason—readily available, then two conclusions must follow. The first is that the minds of health authorities should be focused on the task of ensuring that the needs of mentally ill patients are properly met; and the second is that the conditions in which such patients are looked after must meet basic standards of safety and privacy. Those standards are ones which we expect to find, and usually do find, in community psychiatric homes. They 1234 are also standards which are of fundamental importance for the care and rehabilitation of disturbed, and sometimes highly vulnerable, men and women.
Worryingly, a recent report by the Sainsbury Centre for Mental Health, looking specifically at London, highlighted major differences in standards between NHS hospital wards and community homes. It suggested that, compared to the consistently high standards to be found in community homes, hospital wards were often in a poor state of repair, with residents more likely to be isolated and less likely to enjoy any measure of privacy.
A report published in 1996 by the Royal College of Psychiatrists makes similar points about the standards of care in NHS psychiatric units, laying particular emphasis on the need to improve on standards of hygiene, safety and privacy. But it is perhaps the vulnerability of women patients that has given rise to the greatest concern. My noble friend has already rehearsed the sobering facts revealed by the recent report of the Mental Health Act Commission. It is perhaps impossible for anyone who has not experienced life on a mental ward to imagine the fear and trauma experienced by women who find themselves harassed, molested and sometimes horribly injured by fellow patients whose close proximity in the hospital ward has allowed all too easy a level of access to those unfortunate individuals.
The best efforts of nursing staff are bound to be insufficient in such circumstances. The commission report revealed that more than half the wards it examined had experienced incidents of sexual harassment, some serious. On that issue, a report last year by the King's Fund, London's Mental Health, described the number of assaults and cases of sexual harassment on in-patient wards as "unacceptably high". Over a period of a fortnight in January 1995, 131 assaults were committed by patients in London's psychiatric units, of which four resulted in major physical injuries. The survey was repeated a few months later and the findings were, if anything, even more alarming. The point here is that violence is not only to be condemned in itself, but, as my noble friend emphasised, its prevalence calls into question the ability of psychiatric units to provide a safe and therapeutic environment for patients.
The Government's acceptance of the principle of single-sex wards is on the record. No one doubts their commitment to making that a reality across the NHS over a period of time. The Minister may say that for some health authorities time is needed and that, in any case, legislation is unnecessary because appropriate guidance is already in place. No doubt there is a case for accepting such a response for the generality of NHS hospital patients. But there is a real difference between a general surgical ward and the ward of a psychiatric hospital.
In a psychiatric unit, the issue is not simply one of preserving the dignity of the patient; it is that without the kinds of measure specified in Clause 2 the patient's physical safety is in constant jeopardy. For that reason, and with respect to the noble Lord, Lord Hunt of Kings Heath, I believe that primary legislation is an entirely 1235 proper way for the issues to be addressed and that it is proper, too, for the necessary resources to be allocated to fulfil the legal requirements which ensue.
The aims of the Bill have attracted support from the major voluntary organisations representing mentally ill people; MIND, the National Schizophrenia Fellowship and SANE. Of those, only MIND has expressed reservations, and then only on the effectiveness of Clause 1 as drafted. I do not believe that this is an all-or-nothing Bill; nor is the wording of the Bill wording to which we necessarily need to feel wedded. Indeed, my noble friend indicated his readiness to look at amendments which might serve to improve the Bill.I hope that the Government will take note of that and respond constructively. In other words, I hope that they will look for ways to accept the key elements of this Bill, even if the precise approach adopted by my noble friend is not one which they can endorse entirely. At the very least, I would like to hear the Minister say tonight that she will go away and reflect on what she has heard and, if necessary, offer to meet my noble friend prior to the Committee stage.
I take serious note of the authoritative and thoughtful speech of the noble Lord, Lord Hunt of Kings Heath. However, the objective of the Bill is to ensure that the requirement on the Government to provide adequate standards of psychiatric care is strengthened by a specific duty to address some of the grave shortcomings which impact directly on the care and well-being of some of the most vulnerable members of our society. I cannot for one moment quarrel with that aim. The Bill deserves the support of your Lordships.
§ 9.14 p.m.
§ Lord Sainsbury of Turville
My Lords, I congratulate the noble Lord, Lord Rowallan, on bringing forward this Bill. It raises the vitally important issue of in-patient care for mentally ill people. Your Lordships will be aware, I am sure, of the intense pressure on acute psychiatric beds, especially in inner cities. The Bill attempts to address that pressing issue. It is surely right that health authorities should have costed and timetabled strategies for developing local psychiatric care.
However, the Bill, I believe, is less helpful than it could be because it seeks to address in-patient provision as if it existed in a vacuum. Most people who suffer from mental illness live in the community and have done so for decades. For 95 per cent. of people who suffer from severe mental illness this is also the best place for them to be. It is essential therefore that reform and improvement to our system of mental healthcare addresses support for people in the community as well as the adequate provision of in-patient care. These are not separate options which can be pursued independently. We have to make progress on both fronts simultaneously.
Studies of pressures on acute beds have shown that patients often remain in hospital because they have no accommodation to go to, and there is little or no skilled support available in the community. Equally, we know that community mental health teams often find it hard to cope because they do not have ready access to beds 1236 when the condition of a patient is deteriorating. Simply investing in beds will not solve the problem, as these beds will then be rapidly occupied by people who cannot be discharged due to lack of appropriate housing or support. More beds may be needed in many places but they must form part of balanced and comprehensive services. If investment in beds did take place at the expense of community services as a consequence of this Bill, that could make the crisis in mental healthcare worse rather than better.
A poorly balanced strategy also makes little financial sense. Maintaining someone in a hospital bed or similar environment costs around £50,000 a year whereas providing someone with a severe mental illness with suitable residential accommodation and a high level of support outside hospital costs £10,000 to £20,000 a year. The maths speaks for itself.
I would argue that developing targeted systems of care for severely mentally ill people is the single highest priority within mental health. We are relying far too much on a limited range of services. Little account has been taken of the international evidence that shows how to run mental healthcare successfully. Severely mentally ill people require the same range of services and support as do other disabled or vulnerable people. Crucially, this includes adequate supported accommodation, and something useful or interesting to do during the day.
Successful services will particularly require skilled and dedicated workers to be in touch with patients frequently—sometimes daily or twice daily. They must be able to offer a range of health and social support services. These workers should be organised into what is known as assertive outreach teams that have a specific responsibility for delivering services to the most mentally ill people. On 9th March, the Sainsbury Centre for Mental Health will be launching Keys to Engagement, a report which will set out clearly and forcefully the arguments for assertive outreach.
Finally, I would like to say a word about mental health legislation generally—the third part of a mental health strategy besides community support and places of safety. I believe there is now a need to review mental health legislation to see what more can be done to support and enable staff to work with the most ill people. We need to examine what can be done to help ensure patients can be taken into hospital rapidly when they begin to show signs of illness in the community instead of waiting until they become very ill. As always, we need to be balanced in our approach, and I would like to make it clear that I am not supporting the draconian style of community treatment orders, which I do not feel would be widely acceptable in our country. But the time has come to see what can be done to make mental health legislation fit more effectively with modern mental health services.
Like other noble Lords before me, I very much welcome the opportunity to have a debate on this vital subject. But I cannot emphasise too strongly the need to develop mental health policies and mental health law that address the whole spectrum of mental health services including hospital, residential care and intensive support outside hospital. A piecemeal approach to this issue simply will not work.
§ 9.18 p.m.
§ Lord Mottistone
My Lords, I congratulate my noble friend Lord Rowallan not only on introducing the Bill but also on the great interest he is taking in the very important problems of mental illness, for the reasons that he told us.
The principles of the Bill are strongly supported by both SANE, which helped Dr. Julian Lewis prepare the Bill in its earlier stages, and by the National Schizophrenia Fellowship. Your Lordships will be aware, although perhaps not those who are present now, because there have certainly been some changes on the Benches opposite compared with a year ago, that I am chairman of SANE and that I have been supporting the National Schizophrenia Fellowship in this House for over 15 years.
My noble friend Lord Rowallan explained the purpose of the clauses of the Bill, with which I agree. I wish to underline particular points. With regard to Clause 1, there is no doubt that the over hasty shutting down of mental health wards and the removal of beds by all health authorities throughout the kingdom during the past 20 years has had two very adverse effects.
Before I go on to tell noble Lords about those effects, I have to say that when I listened to the noble Lord, Lord Hunt of Kings Heath, and the noble Lord, Lord Sainsbury of Turville, I agreed with practically everything they said, if not everything. However, particularly in the case of the noble Lord, Lord Hunt, I felt that his speech was devoted to the White Paper which he mentioned and not to the Bill. Much the same really applied to the speech of the noble Lord, Lord Sainsbury, which was concerned with what the debate ought to have been about rather than the Bill. The Bill is important but its contents are not the only things that matter. I ask the noble Lord, Lord Sainsbury, whether you must wait until you can have a monster revision of the 1983 Act, which is what he was roughly suggesting, and not tackle immediate problems because there are some immediate problems. I shall mention two of them which relate to Clause 1.
First, the shutting of beds too quickly over a long period has meant that, in too many cases, there is now not enough suitable accommodation for all the mentally ill people who are at times beyond the capabilities of any form of care in the community, whether with their families or in some sort of public care. Secondly, there is now not enough suitable accommodation for all the mentally ill people who seek temporary protection from the stresses of any community as voluntary patients.
Clause 1 invites health authorities to assess how, in their area, the balance of beds needed to rectify the current shortage for the two types of patient I have mentioned can best be provided. It does not require immediate extra expenditure but points to the best direction for that to be provided when the moneys are available.
Clauses 2 and 3 deal with the more immediate need to provide safety and reassurance for people who are in the care of mental hospitals either as patients in instances where care in the community cannot cope or as voluntary patients of the type I have described. 1238 Action to provide such safety factors should be taken soon in those hospitals which need them. It seems to me that at this stage they are not getting the encouragement that they need. It has become obvious to me over many years of studying the problem that, by the way in which the National Health Service is run, the Government have been able to escape criticism for far too long on shutting down beds because they could say, "Oh well, it is all being done by the local health authorities; it is not our business at all." In fact for a long time they would not even say they had the figures. They said they were being collected locally. Therefore one could not obtain the relevant statistics. If one has not come across such a response in a parliamentary framework, one might not quite appreciate this point. Governments can escape and not do things when they want. They can blame someone else; they can say that someone else is responsible. That is a matter which needs to be tackled. As Back Benchers in this House we need to keep a sharp eye on that. I am not being in any way critical of the present Government. I am really being critical of my own noble friends, one of whom is sitting on the Front Bench but did not have to deal with this subject.
It seems to me that what my noble friend Lord Rowallan is trying to do, and what Dr. Julian Lewis was trying to do in another place, is to help the Government reverse the swing of the pendulum of care for the mentally ill. It has swung too far towards the community and away from care in proper buildings. I spent much of 10 years before the election trying to persuade my noble friends in the previous government that they were allowing local health authorities to push the pendulum too far and too quickly towards community care. At the time I felt that many noble Lords who now support the Government, and who are not present tonight, agreed with me. They are perhaps not here because they seem to have forgotten their earlier concern.
Before I realised that there was such an early change of heart on the part of Back Benchers opposite, I was most surprised that the Government used the blunt instrument of talking out a Commons Private Member's Bill showing what seemed to me to be their contempt for the efforts of those who really care for the sad fate of mentally ill people when there are not enough of the caring facilities they really need. I hope that we shall see, as a result of this Second Reading debate, more understanding shown in this House and by the Government, and that they will make an effort to see how they can help the Bill achieve an acceptable wording which can be made to work and so help the legislation through both Houses of Parliament.
§ 9.27 p.m.
§ Lord Acton
My Lords, it is a great pleasure to follow the noble Lord, Lord Mottistone, even when he criticises my noble friends Lord Hunt of Kings Heath and Lord Sainsbury. At least he was even-handed; as I understood it, he also criticised the noble Earl, Lord Howe, and the rest of his Front Bench.
At the outset I should say that I am a vice-patron of MIND. Between 1992 and 1994 that leading mental health charity's "Stress on Women Campaign" heard from women all over the country that they did not feel 1239 safe in psychiatric hospitals. Accordingly, I welcome the principle in Clause 2 of the Bill introduced by the noble Lord, Lord Rowallan, which places a duty on health authorities to provide single sex ward areas in all existing psychiatric units. So much for Clause 2.
I am firmly opposed to Clause 1 of the Bill. It is solely concerned with treatment for in-patients and will therefore increase the proportion of mental health spending allotted to hospital beds. This scheme immediately brings to mind the 1994 report of the Audit Commission, Finding a Place: A Review of Mental Health Services for Adults. At paragraph 27 the Audit Commission stated,Where most of the resources are tied up in providing hospital beds it is difficult to break out of the vicious circle and to relieve the pressure on them".Exhibit 9 graphically depicts the vicious circle: most resources are tied up in providing hospital beds; thus there is no spare capacity to develop community services; thus people are unsupported in the community and so are admitted to hospital; thus hospital beds are full, so most resources are tied up in providing hospital beds, and round and round and round the circle goes.
The Audit Commission called on all authorities to plan how to break the vicious circle and work out what mixture of services users and carers required. Applying that thinking to Clause 1 of the Bill, health authorities, as my noble friend Lord Hunt of Kings Heath said, preferably together with local authorities, should not only prepare a strategy for hospital provision but also for community services such as 24 hour crisis care, non-medical crisis houses and houses with flexible care and support for up to 24 hours a day. Other services users, requirements include home care to help them plan their day or week, employment advice, drop-in centres, support for self-help groups, counselling, befriending and various forms of therapy.
Alas, on all such community services Clause 1 is silent. Far from breaking the vicious circle, Clause 1 merely perpetuates it. I emphasise to the noble Earl, Lord Howe, that MIND opposes the clause and explains,By creating a duty focusing only on in-patient facilities for acute patients it will distort the allocation of resources and in particular divert resources from community based provision".On 12th December last year, a debate was held in another place on an equivalent Bill. The noble Lord, Lord Mottistone, mentioned it. Mr. Patrick Nicholls, the honourable friend of the noble Lord, Lord Rowallan, gave the impression from the Opposition Front Bench that Clause 1 could always be deleted in Committee. That is the course of action that I would advocate now. By all means proceed with the provision of single sex ward areas. But take heed of the Audit Commission and of MIND. Do not make the circle even more vicious. And, with a single clean stroke, sever Clause 1 from the Bill.
§ 9.32 p.m.
§ Lord Lucas of Chilworth
My Lords, I am grateful to my noble friend Lord Rowallan for his limited Bill and the way he described it. I cannot agree with the noble Lord, Lord Acton, who wishes to delete Clause 1 from the Bill. My noble friend describes the Bill as one 1240 step on. Let us not delete too much, nor at a later stage add too much to it because that will confuse the issue. Let us treat the Bill as one step along a long and tortuous path.
Other noble Lords who have spoken have taken the advantage—it is an advantage that I shall take, perhaps to the ire of my noble friend Lord Mottistone—of not discussing the Bill any further but of discussing the somewhat narrow but immediate issue concerning mental illness. In that regard I beg the indulgence of your Lordships' House today.
Some noble Lords may ask why I am involved in matters of health. I am not well known in your Lordships' House for discussing these matters. It is simply because I have been approached over the past three or four months by a large number of people, some of whom are engaged in the health service and in the area of mental health and by patients who are frightened and concerned and who do not know what is happening.
I have a number of examples. However, it is late and perhaps I should give just two. One is from the professional side. A clinical services manager in a mental health resource unit tells of a patient who is very well-trained, about 40 years of age and has been in and out of employment over a number of years. The type of work that the patient does is stressful, and when the stress reaches certain levels he becomes disoriented and unstable and then has to fall back on the medical services available. Each time, his benefits are scrutinised; sometimes they are removed and sometimes they are replaced. I am given to understand that in circumstances such as that suicidal tendencies emerge. As noble Lords will know, there are very many cases of attempted suicide, probably more as a result of the stress associated with the illness—in trying to combat it and so on—than of the illness itself.
A "Panorama" programme on Monday night discussed these matters in relation to Merthyr Tydfil. An instance was given where both the GP and the wife were quite convinced that it was the stresses associated with the illness—the stresses of getting adequate support, including benefit—that drove the husband to suicide. It was a sad example. I fear that other, similar evidence may come to light unless we are extremely careful.
On the patient's side, the patient in my second example has been reassessed. I shall return to that point. Without being given a particular reason, that patient has had her benefit cut. She now has some six or eight weeks' rental arrears. There is nowhere to go and nobody to help. Perhaps that is why she came to me, believing that ignorance is bliss and that I could perhaps take up the point.
The point of course is, just at this moment in time, that the plight of the people to whom I have referred—and as I said earlier, there are many of them—rubs off onto others. So before very long, a whole number of people are infected with that fear.
The publicity currently given by both the Government and the media to the Benefit Integrity Project and the use of "adjudicating officers"—I do not know what an adjudicating officer is in relation to health matters, and 1241 particularly mental health matters—has given further cause for concern. What is happening? What is going on?
In a Written Answer in another place on 9th February, the Minister responding said that,This Project is operating under the normal assessment and adjudication rules that are applied to all DLA cases"—[Official Report, Commons, 9/2/98: col. WA 76.1She states that the matter can go to an appeal tribunal and so on.
But, surprise, surprise, on the very day that that entry appeared in Hansard, in Middlesbrough at a party meeting, as reported on Tuesday 10th February in the Daily Telegraph, Ms. Harman insisted that information about the care and mobility needs of DLA beneficiaries was essential, but acknowledged that she was,unhappy with the quality of the decisions made so far".Apparently Ms Harman has now banned officials from automatically withdrawing or reducing benefits. Against the background of a White Paper on welfare reform, it seems rather odd to me that a new or enhanced project should be set in place. The Minister said that she was unhappy at some of the decisions that had been made. What about the feelings of those disabled by mental illness who have been affected? What about the case that I quoted? Will there be compensation for that person with the rent arrears? Will someone have a further look at some of the recent decisions and, where they have borne harshly on people, will some immediate remedial action take place?
I do not believe that those of us who enjoy full health can understand what an unending struggle it is to be disabled through any cause and what a great desire there is among disabled people to make a contribution—limited though it may be—to the society in which they live. They should he helped to do that rather than being harassed by officials, many of whom I am given to understand have no medical experience whatever.
§ 9.41 p.m.
§ Baroness Young of Old Scone
My Lords, I shall keep the noble Lord, Lord Mottistone, happy because I shall discuss the Bill. I also hope to make him slightly happier about the people he faces across the Chamber by talking about my credentials as a newcomer to the debate.
I was responsible for the management of mental health services in North London for about 10 years, working in some of the most deprived inner-city districts such as Lambeth, Haringey, Brent, north Kensington and parts of north Westminster. That included arrangements for the appropriate care of people with mental illness in connection with the run-down and closure of some large mental hospitals.
This is a serious and important subject that we are addressing tonight because mental illness is a personal catastrophe for individuals and families. It is a drain on society's resources and, alas, it is an increasing phenomenon. We are seeing mental health problems connected with a range of subjects arising through unemployment, racial tensions, homelessness and 1242 refugee status. There is a whole variety of reasons why mental health is becoming a more and more pressing issue for society these days. It is most pressing in terms of its personal load on individuals when they are unable to take a normal role in society.
I shall be brief tonight. It is in the interests of the mental health of us all that we get home and get some sleep. I do not think anyone could argue with Clause 2 of the Bill in terms of content. Quality of care is vitally concerned with issues of single sex areas and appropriate security devices. But there is already guidance available in the provision of those facilities. It is inappropriate for them to be the subject of legislation.
Clause 1 is more difficult. It asks for a strategy for in-patient facilities. One could say that drawing up a strategy is a fairly harmless activity, but there are three reasons why it is inappropriate to legislate for that strategy. First, as we heard from other Members of the House, in-patient facilities and services are only part of a wider picture. What we need is not strategies for in-patient resources but a strategy for comprehensive and integrated mental health services and a balanced service system. The ability to give support to the damaged people who suffer with problems of mental health depends on a range of services. We have heard some of them outlined tonight. Crisis in-patient services are only one part: community crisis services are vital as well. Also, there is 24-hour staffed nursing homes, the kind of outreach services to which my noble friend Lord Sainsbury referred in terms of the ability to prevent mental health breakdown, issues of employment, long-term care, intensive home support. A whole range of services needs to be provided. In-patient care is only one of them and to plan piecemeal is inappropriate.
A second reason why the Bill is inappropriate is that services cannot be planned by health authorities alone. Many aspects of care that are required are not delivered by health authorities: they are delivered in conjunction with social services and housing authorities. Strategies therefore need to be planned with all three of those authorities working in conjunction. We want to see the same professionals providing care across the divides of different authorities. We need a care programme approach which focuses on individuals, and it would therefore be inappropriate for a Bill to require health authorities alone to prepare the strategies.
The third issue has already been touched on; that is, the question of distortion of priorities if in-patient care is given inappropriate high priority as a result of being the subject of legislation. I believe that the provision of in-patient beds in many settings, particularly in inner cities, is one of the most inappropriate forms of care. I do not know whether any other noble Lords have spent a night in an acute psychiatric ward anywhere in this country but particularly in some of the inner city units. As we see the rising tide of mental illness and fewer and fewer resources available for mental health care, we see in some of the in-patient wards the most inappropriate people, who are in a severe mental health crisis. I may be accused of being flippant, but nobody in their right mind would want to go into one of those facilities on occasions. They are quite often full of extremely disturbed people, often in an inner-city area. 1243 They arrive there as a result of being collected by the police, possibly under section, and often with extreme racial tension on some of the wards. It is highly inappropriate for many people to be admitted to such facilities. We need a range of appropriate facilities as part of an integrated care service.
My last point is that there is already a requirement laid on health authorities by the NHS Executive for strategies for a comprehensive range of mental health services. We do not need more strategies or more legislation. We need more sharing of good practice, more evaluation and monitoring and perhaps particularly we need sufficient resources in the highly deprived inner-city areas to provide an adequate standard of mental health care for everyone.
I congratulate the noble Lord, Lord Rowallan, on bringing these issues to our attention, but I urge your Lordships not even to consider these issues as being appropriate for legislation.
§ 9.47 p.m.
§ Lord Swinfen
My Lords, it is an honour to follow the noble Baroness, Lady Young of Old Scone, with her detailed knowledge of this subject. I must admit that my knowledge of the issues surrounding mental health is minimal. As the House knows, I normally speak on issues to do with physical disability. However, the Bill should be welcomed from all quarters of the House as an honest attempt to raise this issue and to produce a possible solution.
I have a strong feeling that when the Minister responds to the debate, the answer is likely to be a lemon—not necessarily because she believes it but because the Treasury has got its sticky hands around her throat. And that is enough to drive anyone mad.
The noble Lord, Lord Sainsbury, pointed out that 95 per cent. of people with a severe mental illness are cared for in the community. I agree that in most cases that is probably the best place for them; as near normality as possible. I have a feeling that madness breeds on madness. Like other diseases of an infectious nature, I am sure that people who have a severe mental illness are not helped by being cooped up at the same time with others with slightly different mental illnesses.
Mental health patients, even those in the community, go through crises from time to time and need more intensive care. I may be wrong, but I do not see in Clause 1 of the Bill provision for respite care. I may have misread it. In that case, I apologise to my noble friend. However, I feel that the Bill could be improved by making specific provision for respite care. That is where immediate short-term help can be given to those from the community who are going through a crisis. The help is not just for them; it is for their family and their carers at the same time.
If those who care for the mentally ill in the community are not given proper support, they themselves will become ill—possibly mentally, but more likely physically. That in itself will cost the community more than giving them and the person with the mental illness the appropriate support when required. Not only will there be additional costs in trying 1244 to restore that individual to health but there will be loss of service to the community because often they will not be able to continue in work and there will be a loss of tax to the nation because they will stop earning and not pay tax. There could also well be the additional burden of social security payments.
Clause 2 of the Bill deals with the question of single-sex accommodation, which, as the House will know, is part of the Patient's Charter and is therefore recognised by the present Government, as it was by the previous government. I know that it will take time to bring in single sex accommodation everywhere, but it is of course desirable because a mental illness may possibly have started—I am not a skilled psychiatrist and I may be talking through my hat—by the individual having been sexually abused or raped at an earlier time. That goes for men as well as for women.
There is also the fact of religious concerns. In some communities women have to make certain that they are not seen by any male other than members of their own family. Being in a mixed ward, going to and from the bathroom under these circumstances, could have a deleterious effect on their health. In one extremely strict Moslem sect a woman may not even shake hands with a male who is not her father, her husband or her son. Every other male is off limits even for the purpose of shaking hands. That makes it extremely difficult for her. In looking after people with mental illness, we must also ensure not only that they do not suffer any form of sexual harassment when in hospital but that they do not suffer racial abuse or abuse on grounds of their sexual orientation.
We should support the Bill but I feel that we may need to improve it as it makes its way through the House.
§ 9.54 p.m.
§ Lord Alderdice
My Lords, I would first like to thank the noble Lord, Lord Rowallan, for bringing this Bill before your Lordships' House and also to declare an interest. I am a consultant psychiatrist and psychotherapist working in Northern Ireland. I say that not only to declare an interest, but also to say something about the background that I come from. It is one of commitment to working with people in the community. When establishing a service in psychotherapy, I chose to move out of an acute hospital trust to work in a community trust. I work in Northern Ireland, where health and social services have been integrated since the early 1970s and where so many of the problems that were so eloquently spoken about by other noble Lords in that sense at least do not apply. I am a psychotherapist and have spent a good deal of my interest and time working with people, not using medications particularly, sometimes working with patients with severe psychosis, but with very limited use of medication. I say that because it is important that noble Lords understand that background, since some of the things I shall say will be at odds with some of what other noble Lords have said.
Let us go back a little in history. It is perhaps rather striking that we are speaking about these issues of community care—and, particularly in relation to this 1245 Bill, about in-patient care—so shortly after the death of Enoch Powell. He was a man with whom I disagreed on almost every issue. Yet in 1961 it was he, as Minister of Health, who spoke about the big mental hospitals being places that we should move towards closing down, moving people into the community, which was much the best place. On that issue, if on almost nothing else, including Northern Ireland, I very much agreed with him.
That possibility arose for a number of reasons. In the 1950s there had been developments in psychological terms and also in the production of pharmaceutical preparations which made the discharge of patients into the community a more realistic possibility. There was also a change of philosophy which helped people to accept into the community those whom they had wanted to banish away. For a number of years, slowly, much too slowly, there was a gradual move towards community care.
Then two things happened which combined to speed up the development of such care and, more importantly, the closure of the mental hospitals. One was the more radical attempt to develop community care which said, "Let us close down as many of these hospitals as possible". There was also concern about public expenditure by a Conservative Government which realised that when people are put into the community it is much more difficult to measure whether one is producing adequate services for them. There was also the excuse of closing beds and wards to enable people to go out into the community. The result was that many people, particularly on this side of the water, went out into the community with a lack of preparation.
For various historical and other reasons the case of Northern Ireland was much less a problem of that kind. Very considerable preparations were made and a whole range of services of the kind referred to by noble Lords have been provided. Yet I believe that within all this what sometimes was forgotten was that there are patients who need in-patient care for a period of time. There are also others who need a variety of other kinds of care, such as 24-hour nursed beds, out in group homes, and all kinds of other things.
But it would be very wrong of us indeed to pretend to ourselves, as people often have in the past, that there is not a need for people to be looked after for sometimes prolonged periods of time and, in other cases, shorter periods, in acute in-patient psychiatric facilities.
I know that the move towards community care was very important. I will never forget being called at three o'clock one morning to see an elderly lady with a medical problem in a psychiatric hospital where I was working as a junior psychiatrist. She was in her 80s. She had been in the hospital for over 50 years. She had been admitted with moral imbecility: she had had a child out of wedlock. That was sufficient for her to be admitted. That experience on its own, never mind the many others, convinced me that many people had been incarcerated in mental hospitals who did not need to be there. On the other hand, more recently, I have become increasingly convinced that there are many people who are being denied adequate in-patient psychiatric care. Many go 1246 into hospital and find places without adequate staff, who themselves are feeling inadequately supported in their work.
One only needs to look at the statistics, which can lie in all sorts of ways. There are bed-occupancy rates well in excess of 100 per cent. Psychiatric staff are leaving hand over fist and 14 per cent. of consultant posts are vacant, with hundreds of psychiatrists leaving the service as soon as they can, because they find themselves working in an environment which is stressful, unpleasant and, frankly, untherapeutic and indeed, sometimes, anti-therapeutic. The percentage of patients admitted on orders has increased by 300 per cent. since 1980. That has created an environment of fear, tension and enormous difficulty for patients and staff alike.
It is self-delusion to suggest that the resolution of that problem will come with the integration of health and social services and the provision of many more community facilities. It will not. Of course, things could be done to help and, yes, some of those in in-patient care could be provided for in 24-hour nurse-staffed units, if those units were adequately staffed. However, we should not pretend to ourselves that there are not those who need such care and who at present are not receiving it.
If I could make two amendments to the Bill, the first would be to expand Clause 1 and to ensure that it related not only to in-patient but also to other residential facilities. I do not think that that would detract from the Bill; I think that it would strengthen it.
Secondly, while considerable care is taken in Clause 2 to speak about the separation of the sexes, there is absolutely nothing about young people who find themselves entering in-patient psychiatric care with adults. Adolescents or those in their early 20s frequently enter in-patient care having been sexually abused, but they find themselves on wards with those who are, or have been, abusers. We are not necessarily talking about massive numbers of people. That is one of the reasons why separate facilities have not been provided, but that should not lead us to the very attitude that we deprecate in our predecessors who turned their eyes away and who put out of sight the most disturbed. If we say to ourselves that the solution to the problem is merely to provide community care and to provide it at its best, we are averting our eyes from some of the most disturbed people with the most difficult of problems. We should not put such people into places where we would not. and could not, work. Increasingly, staff are finding that they cannot work in such places and are leaving the service.
A serious input of resources is inevitably required. However, community care is not necessarily a cheaper option, because many of those who can be cared for in that way require intensive domiciliary arrangements. That is not necessarily the cheapest option. We have done that in my trust, particularly with patients with dementia. It has been markedly successful, but there is then the problem of resources and of being able to fulfil one's financial requirements.
1247 It is sometimes suggested that we do not need more strategies. It is only a few days since we had the Turnberg Report, which referred to mental health services in London. It recommended that we address the situation of mental health services because that is the service that is under the most pressure in London. It was said that we need a mental health strategy for London, but what did the Secretary of State for Health say? He said that he accepted the whole of the Turnberg Report and its recommendations.
We have to face the fact that some of the perfectly legitimate arguments that have been put forward tonight by noble Lords are based on two difficulties. First, they have argued a case that has already been made. The case for moving to better community services is made. I fear that we sometimes forget that there is also a case to be made for in-patient care. The other problem is providing the resources for all that care. Those on the Benches opposite have a fundamental problem there because, having accepted the spending limits of the previous administration, they find themselves not easily in a position to provide the necessary resources either for community care or for in-patient care.
The suggestion that the way to improve community services is to rob even more resources from hard-pressed in-patient care will lead to a shortage of trained staff. An extraordinarily high level of expertise and commitment is needed to work in such facilities, particularly if you take a psychological approach rather than one dependent on medications alone. I fear that those who do have to be in-patients—the young, the middle-aged, the elderly, men, women, whoever—will increasingly find themselves in a kind of custodial care that is a shame to us and the community at this time.
I support the Bill, not because I want to see less community care or because I want to see more people receiving in-patient care, but because I want those who require care to be properly catered for. I want staff to work in situations in which they can survive during their professional lives rather than simply opt out and leave it to juniors and agency nurses. I want better community care, but I am honest enough to say that it will require resources. Robbing Peter to pay Paul will not better the community health of our nation one whit. I ask noble Lords to support the Bill not only at this stage but at the next stages. If one or two minor amendments are made, as I believe they must be, the Bill can be improved and can proceed. But let us not commit the most dreadful mistake of all and make the ideal for which we all strive the enemy of the good which we can achieve by the passage of a Bill of this kind.
§ 10.6 p.m.
§ Baroness Ramsay of Cartvale
My Lords, I believe that some considerable time has elapsed since your Lordships have debated the issue of mental health. I very much welcome the debate this evening and the valuable contributions that have been made. We have benefited from an impressive breadth of experience and expertise from all sides of the House, and we are all grateful for that. In declarations of interest and experience by noble Lords throughout the House we have heard the names of organisations with proud 1248 records in the field of mental health: SANE, MIND and the Sainsbury Centre for Mental Health. At the same time, noble Lords have an impressive record of present and past health service management experience. Last but not least, we have heard from a noble Lord who is a practising consultant psychiatrist. In this debate there has been an impressive degree of caring, experience and knowledge.
I agree with the noble Lord, Lord Rowallan, that mental health is not a political issue. The Government accord mental health a very high priority. We have identified mental health as one of the six medium-term priorities for the NHS in 1998–99. We agree with the desire expressed by the noble Lord, Lord Rowallan, and other noble Lords who have spoken tonight, to develop strong mental health services which are responsive to different levels of need and in particular the varying needs of different groups of service users and their carers.
While I agree that this is not a political issue, I cannot completely disregard the legacy that the Government have inherited of inadequate action on mental health services over the past 18 years. Some progress has been made in developing local services. Many dedicated people have worked very hard to make the policies work. But, as my right honourable friend the Secretary of State for Health said recently, for many the move from institutional care to care in the community has failed to deliver the necessary levels of support. The noble Lord, Lord Alderdice, spoke of that in his very impressive contribution.
We are determined through our policies to build public confidence and trust in the mental health services. Although I agree with the noble Lord, Lord Rowallan, that improvements to the infrastructure are necessary, I am afraid that I cannot agree that the proposals set out in the Bill are the right way forward. It is not just a question of resources, although I am sorry to spoil the dramatic imagery of the noble Lord, Lord Swinfen, of Treasury hands around my throat. It is true, as the noble Lord, Lord Alderdice said, that we have accepted the overall spending limits, but the spending will be to our priorities.
The intention in Clause 1 of this Bill is to extend the provisions of the Mental Health Act 1983 to establish an entitlement to separate and therapeutic environments for patients who need care and treatment. To go down this road would, in our view, severely restrict the capacity of health authorities to plan services flexibly while taking account of national priorities.
Any statutory provision for a right of access to such services would cut across fundamental principles of the National Health Service Act 1977 which place a duty on the Secretary of State to continue to promote a comprehensive service and to provide services as he considers necessary to meet all reasonable requirements. Current gaps in mental health services result to a large part from chronic under-investment in the past 18 years. But as the noble Lord, Lord Rowallan, is well aware, new resources to redress the situation are not available as if one could turn on a tap. In this context it is vital 1249 that health authorities retain the flexibility to commission and develop services, within government priorities, according to local need.
Health authorities are, in any case, already required to have a strategy for the provision of an appropriate range of facilities for the care and treatment of people with a mental illness; for example, in-patient facilities, 24-hour nursed beds and crisis care, form part of this range of provision.
We agree that it is important to ensure an individualised programme of care for each person who requires admission. Those principles are embodied in the care programme approach, introduced by the previous government to ensure continuity of care, and which we are keen to see remains in place as the cornerstone of policy.
We do not believe, however, that physically separate in-patient facilities for different conditions are the way forward.
The reservations in that connection expressed by my noble friends Lady Young and Lord Sainsbury, and other noble Lords, are well-founded. First, the benefits for patients of a supportive and therapeutic milieu are well documented. The low prevalence and incidence of certain conditions could result in some patients being kept in almost total isolation and that would not be to their benefit.
Secondly, there is sufficient common ground between different conditions to mean that it is of positive benefit, and not merely an expedient, to continue to provide for their needs for a generally supportive and therapeutic environment in one place.
Thirdly, operationally and in terms of the diagnostic framework, it is not clear where we would stop creating separate environments. The principles outlined in the care programme approach reinforce the fact that what matters is what care is provided rather than where. Asylum can be provided effectively in the community. Points in connection with that aspect were excellently made by my noble friend Lord Sainsbury. I agree with his point that in-patient care does not take place in a vacuum.
The noble Lord's Bill would also place health authorities under a duty to monitor progress in implementation of the suggested strategy and place an obligation on health authorities to provide the Secretary of State with an annual report on progress. Monitoring progress on the implementation of comprehensive mental health services already forms a part of the NHS Executive's performance management framework. A review of mental health services was carried out this year and similar exercises were undertaken in the previous two years. There is no reason why Ministers should not continue to request an annual review to be undertaken and for the findings to be reported to them. There is nothing to be gained from enshrining these requirements in primary legislation.
I turn to Clause 2. I wish to reassure the noble Lord, Lord Rowallan, and other noble Lords, who have expressed concern about single-sex wards. I acknowledge in particular the concerns raised by my 1250 noble friend Lord Acton, the noble Lord, Lord Rowallan, the noble Earl, Lord Howe, the noble Lord, Lord Swinfen, and others. We abhor, as does everyone, attacks upon vulnerable women within in-patient units and we want to create a framework which minimises such risks and ensures the privacy and dignity of individuals. I repeat what has been said at this Dispatch Box on many occasions; that we are totally committed to working towards the elimination of mixed sex accommodation. I am grateful to the noble Earl, Lord Howe, for accepting that our commitment on that point is real and sincere.
It might further reassure your Lordships to know that health authorities have been required to set local performance targets for trusts within their boundary in order to deliver the following objectives. First, to ensure that appropriate organisational arrangements are in place to secure good standards of privacy and dignity for hospital patients. Secondly, to achieve fully the Patient's Charter standard for segregated washing and toilet facilities across the NHS. Thirdly, to provide safe facilities for patients in hospital who are mentally ill which safeguard their privacy and their dignity.
The noble Lord, Lord Rowallan, confirmed that he discussed the matter with my honourable friend Paul Boateng. Therefore, he knows that many health authorities have already achieved or made considerable progress towards these objectives. However, a substantial number of health authorities have told the NHS Executive that they will not be able to deliver these objectives until after April 1999. That is not acceptable. The NHS Executive is reviewing with health authorities any target which has been set for after April 1999 and is considering what scope there is to bring that forward. A cental monitoring system is being developed which will provide further, regular information on authorities' performance against those objectives. It has been piloted and will be issued as soon as possible.
I turn now to the noble Lord's suggested amendments in relation to the security and design of psychiatric units. Guidance prepared in 1996 by the NHS Executive Estates Agency already contains advice on both issues.
The guidance makes clear that, where possible, patients should be able to lock their bedroom door for safety and security and to safeguard their property when they are not in their room. But also it recognises that staff need to be able to open the door rapidly in the event of an emergency. The guidance also explains that it is desirable to have en suite toilet facilities whenever possible to avoid situations where female patients have to move about the ward in night attire.
Wards should be capable of flexible use and sub-division to separate sexes, where appropriate, to safeguard the needs of in-patients. But staff observation of the patients is a fundamental requirement for safety both of the patients and staff.
Staff are expected to supervise ward entrances to prevent access by people who have no valid reason for attendance. At night closed-circuit television surveillance of the entrance at a staffed base should maintain the necessary level of security. Security may 1251 be achieved by temporarily locking doors but care must be taken to ensure that such arrangements do not contravene safety measures, including fire regulations.
The guidance also explains that staff at the reception desk need to be able to see clearly through the entrance area in order to greet people arriving and also as a security measure. They should be able to raise an alarm in case of danger from violent behaviour or other emergency situation. We require project directors to ensure that design teams are familiar with the standards issued by the NHS Estates Agency as the basis for any new health buildings.
The noble Lord, Lord Rowallan, raised the problem of the mentally ill who are homeless. The noble Lord will wish to know that through the Department of Health's homeless mentally ill initiative—and I should say that that initiative was announced in July 1990 in response to concerns about the visible concentration of homeless and mentally ill people on the streets of central London—the Government are making available £4.2 million to local authorities in areas where rough sleeping causes a significant problem to assist with the care costs of homeless people with mental health problems. The initiative has recently been independently evaluated to determine its effectiveness. My honourable friend Paul Boateng is currently considering the report of that review.
In that connection, the work of the Social Exclusion Unit is also relevant. That has been established by the Prime Minister to help co-ordinate action across government policies; to move towards preventing social exclusion; and to find more integrated ways of tackling the worst problems. The unit's early priorities include considering ways to reduce further the extent of rough sleeping. The role of the Department of Health's homeless and mentally ill initiative will be encompassed within that programme.
I hope that your Lordships will begin to understand why we are not convinced of the need to legislate along the line of the noble Lord's Bill. Our views are shared by others, as has been mentioned by other noble Lords who have spoken this evening. MIND has said that it does not support Clause 1. The Mental Health Aftercare Association, while expressing its support for improvements regarding single-sex accommodation and security devices, does not believe that primary legislation is necessary, and similar views have been expressed this evening by my noble friends Lord Hunt and Lady Young.
Generally we do not favour piecemeal changes to a complex piece of legislation such as the Mental Health Act. Significant changes to the legislative framework should, in our view, be taken as part of a full review of the Mental Health Act. I can confirm that we will be considering the need for a review of the Act and will take into account the views of all interested parties.
As I have already said, mental health is and remains very high on our agenda. My honourable friend, Paul Boateng, has established an independent reference group to advise him on mental health issues. This group of experts in the mental health field includes service users and carers. Ministers will be looking to them 1252 particularly for help in identifying what needs to be done to strengthen existing arrangements to ensure that we have a range of mental health services throughout the country. We have asked the group. as its first priority, to consider the issue of the closure of the remaining long-stay mental hospitals. We are anxious to ensure that no more closures should go ahead without proper consideration of the needs of all the patients involved and that, as a result, there are proper plans to put in place the full range of services that are needed.
The noble Earl, Lord Howe, raised the question of the state of mental health services in London. The review of London's mental health services, which was published last week, showed that London's mental health services face greater problems than many parts of the country. In real terms, London health authorities have received increases in their 1997–98 allocations and will also receive real-term increases for 1998–99.
The Mental Health Challenge Fund has been used in the past to target some of the problems in London. London boroughs also receive core funding from the mental illness specific grant. Moreover, 85 authorities receive target fund support, including 23 London boroughs. The mental health task force also visited 12 London health authorities. An interim review in the autumn of 1996 showed that, despite some progress, barriers remained. A further review is currently under way and its outcome will be included in a national report to be submitted to Ministers in early 1998.
As the White Paper, The New NHS, sets out, we will be introducing new National Health Service frameworks to promote consistent access to high quality care across the country. In future patients with continuing health and social care needs will get access to more integrated services as a result of joint investment plans, which all health authorities are being asked to produce with partner agencies. We will also be exploring the scope for even closer working between health and social services through, for example, a pooling of budgets. 1 felt that my noble friend Lord Hunt spoke most convincingly on that point.
At this point I must say to the noble Lord, Lord Mottistone, that, even if our faces are new to him, his reputation and interest in this subject are not unknown or new to all of us. So he should rest assured in that respect. I am sure that the noble Lord will welcome the action that we are taking to stimulate public and patient involvement in the NHS. We have set out our vision in the White Paper, which proposes a stronger role for health authorities in communicating with the public and ensuring that the public has a greater say in decision-making about local health services. We envisage a greater emphasis on openness through the publication of more local information about strategic plans and on how local services are performing. A new national survey of patient and user experience will ensure that patients' views and concerns are listened to and acted upon.
The noble Lords, Lord Rowallan and Lord Hunt of Kings Heath, both addressed issues concerning shortfalls in the workforce. The White Paper emphasises that we attach the utmost importance to ensuring that 1253 mental health services are staffed adequately. In April 1996 new arrangements for non-medical workforce planning and commissioning were introduced. The Department of Health has emphasised the importance of staffing issues in planning guidance. We are concerned about the vacancies in psychiatry. We have been addressing this in collaboration with the Royal College of Psychiatrists. Psychiatry has a high priority for targeting available funding to create posts for training future consultants. Some £5.7 million was provided to implement the 1996–97 increases and a further £4.5 million for 1997–98.
There are already good examples of partnership working, including working with service users. I know that the noble Lord, Lord Rowallan, visited mental health facilities at Homerton Hospital in Hackney recently, as indeed has my honourable friend Paul Boateng. I think the noble Lord, Lord Rowallan, would agree that City and Hackney Health Authority has a positive approach to working in partnership with the local authority to develop mental health and social care services which address the broad range of needs of their communities.
There are also examples of innovative multi-disciplinary co-operation, for example the Vista Road Centre in Warrington, which provides a holistic approach to mental health, from listening and advice to medication and psychological therapy. The north Birmingham model provides a range of services—for example 24 hour cover for psychiatric and emergency treatment and outreach for people with severe mental illness—and it also involves several multi-disciplinary teams covering the whole of the local population.
The noble Lord, Lord Sainsbury, has made a valuable contribution, as one might expect from someone who has such a keen interest in this important subject. He was absolutely right to stress the need for the full range of services. This is at the heart of the work now being undertaken by the independent reference group on which the Sainsbury Centre is, I am glad to say, represented.
As regards reviewing the legislation, I have already said that we are considering the need for a review of the Mental Health Act. My noble friends Lord Sainsbury and Lady Young of Old Scone also spoke about assertive outreach. Assertive outreach teams currently exist in small numbers within mental health services. One such service is provided in north Birmingham and, as the noble Lord, Lord Sainsbury, will be aware, is funded from a combination of moneys from the Sainsbury Centre for Mental Health and the Department of Health. Assertive outreach may form one part of the range of provision including 24 hour staff, beds, psychiatric in-patient facilities and other elements of provision in primary and secondary care.
My noble friend Lord Hunt of Kings Heath questioned the virtues of mental health inquiries into serious incidents as they are implemented currently. I think he said that he would like us to consider an ombudsman to determine whether an inquiry was necessary. I acknowledge my noble friend's concerns 1254 about the effect of mental health inquiries. We shall certainly take into account his views as we develop our thinking around this issue.
The crucial point here is that we learn lessons when things have gone seriously wrong. Locally commissioned independent inquiries play a crucial role, but we need to develop a better understanding of the overall picture, and that is why we have the national confidential inquiry into suicide and homicide by people with mental illness to look into the factors leading up to serious incidents of this nature. We have asked the inquiry to make recommendations on measures which it believes should be taken to reduce the number of deaths.
But having good specialist mental health services alone is not enough to tackle mental health problems and inequalities in our society. The Green Paper, Our Healthier Nation, published last week is a major step in the Government's push to reduce inequalities in health. It forms the basis on which we can develop a health strategy.
The Government have identified mental health as one of the four priority areas for the strategy. The Green Paper proposes that we should aim to reduce deaths from suicide by a sixth by the year 2010. This will be a challenging target. To achieve it we shall have to consider not only how to improve services for people with severe mental illness but also other factors associated with poor mental health such as unemployment and stress in the workplace. Our Healthier Nation is being widely circulated as part of the consultation process to ensure that everyone can have an opportunity to influence the detail of the strategy, including those involved in the mental health field.
I hope that your Lordships' House has been reassured by the initiatives I have outlined this evening. They show that the Government are genuinely committed to improving mental health services in a flexible and responsive way. I should like to pay tribute to the valuable contributions which noble Lords have made tonight. If I have omitted to deal with specific points raised, I shall of course write to noble Lords.
We have had a useful, serious and well informed discussion on a topic of great importance to our society. I thank the noble Lord, Lord Rowallan, for providing us with the valuable opportunity to have this discussion. The noble Earl. Lord Howe, asked whether I would be prepared to meet the noble Lord, Lord Rowallan. I have done so already before this Second Reading debate. I shall always be happy to meet him to discuss any aspect of this matter. Therefore I am at his service for that.
We shall take the points raised tonight into account as we determine the future direction of mental health policy. However, I hope that your Lordships understand why this Bill is not, in our view, the way to advance.
§ 10.37 p.m.
§ Lord Rowallan
My Lords, I thank all noble Lords who have taken part in the debate. I wish also to thank Dr. Julian Lewis, Member of Parliament in another 1255 place, and Dr. Martin Deahl, who have been present throughout the debate, for the great help they have given me in producing the Bill.
Perhaps I may say this to noble Lords on the other side of the House, in particular the noble Lord, Lord Hunt of Kings Heath, and the noble Lord, Lord Sainsbury of Turville. I am happy to look at the broader picture. As I have stated—when noble Lords read Hansard they will see that I have stated it again and again—this is a starter for 10. The main point of the exercise was to have serious debate on the problems that the mentally ill face. I am grateful to the noble Baroness, Lady Ramsay of Cartvale, for the detail she has given the House in her reply.
Three points worry me. First, she referred to mental health as being one of the six medium term priorities in 1999. She referred to the aim to reduce deaths from suicide by a sixth by 2010. I appreciate that nothing happens today. But I feel that that is a long time to make the mentally ill wait for mental health services. I offered to put this Government's thoughts into my Bill. The offer remains. I hope that we shall be able to discuss it further at Committee.
It was nice to have the support of noble Lords on this side of the Chamber. My noble friend Lord Lucas of Chilworth gave us a marvellous red herring. Nevertheless, it indicated how many problems are associated with mental health. My noble friend Lord Swinfen spoke from the heart on similar subjects. It was nice to hear the speech of the noble Baroness, Lady Young of Old Scone. I thought that she was an expert on the RSPB. I am most impressed. She is a lady of many talents. I trust that we shall be able to debate her thoughts at great length in Committee.
But the biggest praise goes to the noble Lord, Lord Alderdice, who is in the front line in mental health. I agreed with every word that the noble Lord said. He had no notes. He simply gave us a wealth of personal knowledge, straight from the heart. None of us can 1256 afford to ignore his remarks. It is one of the wonderful freedoms enjoyed by this House that your Lordships are able to introduce Private Members' Bills and have them debated by Members with a huge range of knowledge, as we have witnessed.
The National Schizophrenia Fellowship saysThe rhetoric is all in place, however, what has always been missing, and is still to be delivered on. is the resources".Tessa Jowell, the Minister for Public Health, stated:Mentally ill people still live in the margins of our society. For too long our concern and the public resources it represents have been as marginal".The Health Service Journal states that the outmoded Mental Health Act 1983 is inadequate and needs replacing. Paul Boateng, the Under-Secretary of State, said:Mentally ill people must be cared for in safety and security. We must rebuild public trust and confidence in the mental health services".SANE says:In our view all too often, usually as a result of bed shortages. people are all placed together in a psychiatric ward regardless of the nature or severity of their condition. Sane believes this bill will ensure Health Authorities increase in-patient provision—thereby lessening the pressure on beds and reestablishing the true sanctuary aspect of psychiatric care. It is clear the measures contained in this bill envisage an entitlement to a bed for anyone who requires it, and to anyone a section 12 doctor decides needs in-patient care, thereby enlarging access to a group of patients who in the absence of these measures might otherwise have been sent away to cope at home".As I said in my opening remarks, in an ideal world we should have a new mental health Act. Sadly, we do not live in an ideal world. But we can, and should, make a start now. Sadly, I have not heard a commitment from the Government that there will be, in the short term, any move towards a new mental health Act. I commend the Bill to the House.
§ On Question, Bill read a second time and committed to a Committee of the Whole House.
§ House adjourned at eighteen minutes before eleven o'clock.