§ [Relevant documents: Fourth Report from the Health Committee, Session 1999–2000, HC 373, and the Government's response thereto, Cm 4888.]
§ Motion made, and Question proposed, That the sitting be now adjourned.—[Mr. Hutton.]2.30 pm
§ Mr. David Hinchliffe (Wakefield)
I appreciate the opportunity to discuss the report, which makes an important contribution to the mental health debate.
I thank the Committee for its hard work during the inquiry. I also thank the many witnesses who provided oral and written evidence. That was very helpful to the Committee's deliberations, as were the visits that it was allowed to pay to a broad range of establishments and agencies—I thank them too. Thanks are also due to the specialist advisers on the inquiry: Professors Bob Bluegrass, Tom Burns and Ray Rowden, Ms. Angela Greatley and Mr. Chris Vellenoweth.
It is not usual to express appreciation for the work of individual Committee staff, but I would like to thank Katherine Wright. Some of my colleagues will know her from her work in the House of Commons Library. She was seconded to the Committee for the period of the inquiry as a specialist assistant. I also thank all the Committee staff for their help.
I want to explain why the Committee undertook the inquiry. I was not the only member of the Committee who thought that mental health policy lacked co-ordination and that, occasionally, there were inappropriate placements. I had seen that in my constituency, which has two prisons, a regional secure unit and a psychiatric unit. I visit them frequently, and I have discovered that some people have been placed in the wrong institution. That is why I began to ponder how we might develop a better arrangement to ensure that such people were appropriately placed.
In an inquiry into the regulation of the private health sector, the Committee visited a private hospital in York. Everyone was struck by the preponderance of young black men in the hospital whose homes were 200 miles away in London. It seemed very wrong to us that they had been placed there, rather than nearer to their homes, and we felt that race and gender might be playing a part.
The Committee also felt that there were discrepancies in the ability of different areas to offer care in the community. For example, on a visit to north Birmingham, the Committee was impressed by the extent to which it was possible, through assertive outreach, to care coherently and constructively in the community for people with severe problems. However, other areas do not have enough in-patient beds. Sadly, my constituency is one such area: patients from Wakefield are placed in a private hospital in Cheshire because our in-patient facilities are under too much pressure as a result of a lack of appropriate alternative facilities in the community.
302WH The Select Committee was concerned that some people high up in the Government have commented that the care in the community policy has failed, and that the pendulum has swung too far from hospital to community. We needed to examine the reality of that claim, so we undertook a wide-ranging inquiry that looked at the transition points in mental health services and the ability of the different sectors to cope with patients. Our terms of reference were deliberately very broad.
The inquiry examined the definition of mental disorder because the Select Committee thought that the criteria that people with mental disorders had to meet to access services could be the first hurdle to overcome before patients ended up in the right part of the system. We looked at how users of the system regard its services. We considered the effects of the new national service programme and the delivery of general mental health services, and that included an examination of the current proposals to overhaul the legal framework of mental health that would allow compulsory treatment to be given in the community as well as in hospital. We considered proposals to create a specific legal framework for people with severe personality disorder who are deemed to be dangerous. Finally, we examined how the transition is managed between general mental health services and more specialised services—for example, those for children and adolescents and secure mental health services.
I stress that I recognise that that is a contentious area. If we consider our history of treating successive generations of people with mental illness, we can see that attitudes and definitions have varied considerably. A few years ago, I visited a museum in my area that was organised by someone who had worked for the Stanley Royd psychiatric hospital for a long time and I found a book that defined the diagnoses of patients who had been admitted to a Poor Law lunatic asylum in the 19th century. I was interested to see that a large number of mental health cases consisted of people suffering from "political excitement"—it was one reason for detention in the asylum.
As some hon. Members know, I worked for the mental health services in professional social work for many years. I will always remember the move towards care in the community that began in the 1970s, and the practice of removing people from psychiatric hospitals—women in particular—who had been detained all their lives because they had been deemed "moral defectives", even though they were not mentally ill. I have met more moral defectives during 14 years in this place than during all my years in the mental health services. My point is that definitions are value-based.
The Select Committee was well aware of the values that influence how we define mental disorder: definitions are frequently gender-based and race-based. We made one specific recommendation about definitions. We felt that there was a need to improve services for people with dual diagnosis; they are people who might suffer from a mental disorder and substance abuse, or a mental disorder and learning disabilities. We felt that such people were poorly served by the present arrangements. I am pleased to report that the Government agreed that greater priority should be given to that.
303WH We felt that it was crucial to involve users and carers in all aspects of planning and delivering mental health services. We found an acceptance of the role of users and carers, which was a welcome shift in emphasis from the attitude of recent decades. However, we were warned that the reality of such a consultation is sometimes suspect. Karen Campbell of the Manic Depression Fellowship was scathing about the limited impact that user involvement often has. She said in evidence to us:I think we have reached a stage, as people who use mental health services, of thinking, you ask us to come to meetings and listen to what we say, but very, very rarely—I can count it on two fingers—does what we say make a difference.We recommended that users should have much greater input in the training of mental health professionals. Again, I appreciate the fact that the Government have accepted the recommendation.
We were particularly concerned by the evidence that mental health services do not adequately meet the needs of ethnic minority patients. Some of my colleagues might speak in more detail about that. Our concern was not simply that black patients are more likely to be in the compulsory part of the mental health system, but that the services offered are often inappropriate or insensitive. Our recommendations included developing race awareness among NHS staff, designating NHS trust board members to take active responsibility for making services more culturally aware and expanding early intervention and interpreting services.
We looked at the effects of the national service framework and the delivery of general mental health services. The Committee was impressed by the impact of the framework, which was generally welcomed within the system as a positive development. However, we received evidence from a variety of witnesses about the low quality of much in-patient care. On some visits, we saw evidence that, materially, the system does not offer a great deal to patients in the wards, despite caring staff who were doing their best to function within the existing regimes. The system leaves much to be desired.
The Sainsbury Centre suggested to us that the pressures on acute beds were so great that the environment was untherapeutic, that services lacked clear goals and that links with community services were sometimes poor. We proposed that a capital modernisation fund aimed specifically at improving environmental standards on in-patient wards could make a significant difference to the quality of life for patients.
We spent considerable time looking at proposals to change the existing legal framework of mental health. We all accept that there is a need to modernise the law as it relates to the detention of patients within the mental health system. The current system is outdated. It is largely based on legislation passed in 1959—the Mental Health Act 1959—when the system was institution-based rather than community-based. We felt that any legislation replacing the Mental Health Act 1983 should have a broader remit than merely setting out when compulsion will be permitted; for example, through ensuring a right of access to a mental health assessment, an acceptance of the principle of reciprocity and a right of access to advocacy services. The Government are reviewing the latter point, and I hope that there will be positive proposals in due course.
304WH We support the philosophy underlying the recommendations of the expert committee on the reform of the 1983 Act, in contrast to the proposals set out in the Government's Green Paper. We saw some distinctions between the expert committee's recommendations and the Green Paper. We recommended in particular the inclusion of the principles of non-discrimination and respect for autonomy in any new legislation. We felt that further work should be done to investigate the viability of a capacity test and that there should be provision for the use of crisis cards and advance directives to help individuals in crisis to signal their preferences regarding treatment, which they might not be able to do at the time that they need treatment.
We felt that there should be greater emphasis on the importance of the health benefit for the individual if compulsion is considered. The legislation must be operated in such a way that patients would receive a demonstrable health benefit. We also felt that compulsion should be used only as a last resort.
We discussed the contentious issue of community treatment orders. As a Committee, we accepted the arguments about the benefits of such orders, which would compel individuals to accept treatment even if they are not detained in a psychiatric hospital. However, we felt that that should be coupled with the safeguards that were set out in the expert committee's report.
I recognise the difficulties facing any Government when addressing policy for the difficult matter of dangerous people with severe personality disorder. It raises enormous problems and challenges. The evidence that the Committee received about the Government's proposals was remarkably uniform, and mental health professionals expressed considerable doubts about the proposals on several grounds: first, the civil liberties implications of detaining people who are deemed to be untreatable, yet who have not committed an offence; secondly, the resourcing and staffing implications of setting up a third system between the Prison Service and the health service and, thirdly, the validity and reliability of the diagnosis of dangerous severe personality disorder.
The evidence that the Committee received from the Institute of Psychiatry was typical. It emphasised that severe personality disorder is not a clinical definition, and that the severity of a personality disorder bears no relation to how dangerous a person is. We welcome the recognition that the Home Office proposals on dangerous people with severe personality disorder are primarily a criminal justice matter, but we were concerned about the inappropriate use of a quasi-medical definition.
We were also concerned about apparent confusion over the term "untreatable". When I worked in mental health, I occasionally undertook compulsory admissions, and the issue of treatability has always been contentious. Two main conclusions were drawn from the evidence that we received: first, there is no professional consensus, either among psychiatrists or psychologists, on whether personality disorder is treatable; and secondly, the debate surrounding treatability is concerned with the lack of available resources.
305WH We rejected both options in the Home Office proposals because they seemed to be illogical and unnecessary to achieving the service enhancement that we agreed was necessary. We recommended that research should be initiated on the treatment of antisocial personality disorder, and that adequate facilities should be made available within the national health service for people who suffer from a recognised disorder and who would benefit from treatment. We also recommended that further thought should be given to the proposal of reviewable sentences that would provide for those who are deemed to be a danger to the public but who are genuinely not amenable to treatment within the NHS. We further recommended that a definition similar to that used in Scotland—serious violent and/or sexual offenders who may present a continuing danger to the public"—should be used in the English proposals to clarify that they are concerned with offending behaviour, rather than a mental disorder.
§ Mr. Philip Hammond (Runnymede and Weybridge)
I am sorry to interrupt, but I wish to return to the issue of capacity.
Since the Committee's report, the Government have produced a White Paper. Will the hon. Gentleman tell us what he thinks about the safeguards that the Government have proposed for people who do not actively object to treatment, but who are deemed to lack the capacity to consent to it? That is the issue of the Bournewood judgment. Is he satisfied with the Government's proposals?
§ Mr. Hinchliffe
The report makes it clear that the Government have not gone as far as we proposed, although I understand that there has been movement since the original Green Paper.
We were very impressed by the witnesses from the expert committee, who spent considerable time developing their arguments on that matter. It is a hugely complex area, and I recognise the Government's difficulty in ensuring that there is a system that addresses the acute problems that patients occasionally have. We also need to anticipate psychiatric provision in 10 or 20 years' time. As I have pointed out, policy circumstances change in that we may move further towards community provision—I hope that we will—and any new mental health legislation must take such change into account. That is extremely difficult and this is a tough area with which the Government must deal, but the Committee felt that the expert committee had offered a way forward that had not been picked up in the Green Paper.
When looking at the challenge posed by the transition between elements of the service—especially between services for children and adolescents and adult mental health services—we found that clear systems linking them were the exception rather than the rule. I should have liked to have had more time for that part of the inquiry, because the problems that we saw showed that much work had to be done. We felt that the present system offered the worst of both worlds.
The evidence that we found suggested that the lack of a nationally agreed target age for transfer does not enhance local flexibility; it simply creates a patchwork of 306WH incompatible services. We recommended that the Department of Health should consult on a target age for transfer that would allow local flexibility where necessary, but would prevent the current extraordinary position in which 16 and 17-year-olds might be eligible for neither service.
The most radical solution to the problem of transition was the proposed creation of a youth service to look at provision for young people aged between, for example, 16 and 25. We felt that that proposal was attractive in many ways; it would avoid the need for transfer at a time when adolescents are especially vulnerable, and could encourage the development of specialist services identifying the onset of psychosis in late teens. We therefore recommended the commissioning of research on the viability of such a service and, in the meantime, the monitoring of the adequacy of current transfer arrangements.
Finally, we looked at transitions between secure and general mental health services. The Committee was concerned about the human rights implications of patients staying far longer than necessary in the higher levels of security, because of a lack of appropriate provision elsewhere. We received evidence from both Ashworth hospital and Broadmoor that patients were being detained in those high security special hospitals when they did not need to be there. They could have been helped in low-security, even community, placements quite safely and to greater benefit to themselves.
Those human rights implications were raised with us more than once by senior staff, who acknowledged that there had been inappropriate placements on a wide scale. We recommended that the action already being taken to assess the needs of individual patients should be completed as speedily as possible, and that, if short-term funding was necessary to provide appropriate placements, it should be made available. We were also concerned at the apparent lack of hard information on the numbers and types of alternative beds required to deal with patients of the kind that we met, particularly in the special hospitals. We recommended that the Department should publish firm figures on the number of secure beds that will be available, separately identifying short-term medium-secure, long-term medium-secure, short-term low-secure and long-term low-secure beds.
I welcome the fact that the Government have commissioned a review of medium-secure provision and forensic networks of care that will identify gaps in capacity. However, the Committee significantly differs from the Government—and I have raised this point in the Chamber with successive Secretaries of State—in that it feels that the Government should seriously consider the recommendation of the Fallon committee that the three special hospitals should be replaced by eight smaller regional units.
Having been in Parliament long enough to have heard this recommendation being made in response to problems that have occurred in the three special hospitals on other occasions, I strongly support the Committee's view that the Fallon committee was right. The Government should look again at the issues raised by that and other inquiries. We found a widespread view that the three special hospitals had been allowed to develop independently of the rest of the NHS, leading to 307WH isolation and a culture that is sometimes more akin to that of a prison than a hospital, with the resultant recruitment difficulties.
Although our visits to Ashworth and Broadmoor made us sceptical about the so-called special expertise that is alleged as a benefit of the special hospitals, we felt hat the arguments for a genuinely regional focus to secure care were overwhelming. We concluded that reform and improvement to the special hospitals is probably not workable. I welcome the steps taken by the Government to link the special hospitals more clearly to the regions in which they are based, but we want them to go further and make much more meaningful the ability of patients to move through the system, be that up, down or wherever is appropriate to their needs.
After hearing the evidence, the Committee strongly supported the principle of an entirely separate service for women. Some of it shocked us, and my hon. Friend the Member for Romford (Mrs. Gordon), who visited Broadmoor with me, might speak about that in more detail as she spent more time with the women patients. We felt strongly that the Department should bring forward its women's strategy urgently. We know that it commissioned work, supported by an expert group chaired by Dame Rennie Fritchie, to examine issues surrounding women in high-security hospitals. It is a pressing issue, which I urge the Minister to examine as soon as possible.
We had serious concerns about standards in prison health care centres and supported the proposal of the chief inspector of prisons that any prisoner who needs specialist mental health services should be transferred to the national health service, if necessary under temporary licence.
I apologise for speaking at some length on what was a comprehensive inquiry, which found many positives. I picked up on some of the negatives because Select Committee inquiries work by drawing attention to negatives and pressing the Government to address them. I welcome the fact that the Government are already examining some of our points.
I commend particularly the staff that we met in a range of agencies and hospitals. They were doing an extremely good job in difficult circumstances with some very disturbed people. Having worked in the system, I have some insight into the problems that those people face. The House owes a great deal to those dedicated people, and we should recognise that far more than we do.
We should also strongly commend the user groups, which have developed relatively recently and have given a long-overdue voice to those who were frequently ignored. A number of patient groups gave evidence, and it was among the most moving and important that we heard in the inquiry. I welcome the steps taken by successive Governments in the direction of more civilised treatment of the mentally ill but much more still needs to be done. The Health Committee recognises that and I think that the Government do too.
I would like to express a personal view, having worked in the mental health system. Vast numbers of people who would previously have been institutionalised can now lead more normal, positive 308WH and meaningful lives through the efforts of successive Governments to create a more humane policy. Our present situation is summed up for me by the most memorable quotation that we heard during the inquiry. It came from David Joannides of the Association of Directors of Social Services. He said:Community care has not failed, it has failed some people.It is important that we continue in the direction of enhancing and strengthening community care, addressing the failures and protecting patients and the public. Hopefully, we will move towards a more civilised system than we have had in the past, even in my lifetime.
§ Mr. Simon Burns (West Chelmsford)
I am pleased that the Health Committee devoted one of its major reports of the past Session to mental health. All too often in the past, although to be fair not under the present Government or in the last few years of the previous Government, mental health was the Cinderella service of the NHS. It tended to get brushed under the carpet with regard to funding priorities and public and ministerial attention, because it is an unknown quantity and because of the stigma attached to it.
I hope that I will be forgiven for speaking on a narrow issue: paragraphs 63 to 66 of the Health Committee report, which concern stigma, and the Government's response. Other hon. Members will want to discuss other important issues and I do not want to duplicate their remarks.
I have been concerned for a long time about the raw prejudice and stigma attached to people suffering from mental illness. Most of us, as individuals, are genuinely caring. If we hear that a member of our family or a friend is suffering from cancer or has flu, we are naturally responsive. We want to find out how that person is and offer our best wishes for a speedy recovery.
Many people, however, do not understand mental illness. That fact, together with the way in which mental illness is categorised in society, makes people frightened of suffering from it—although 20 per cent. of the population will suffer from a form of mental illness at some point in their lives. Fear and ignorance mean that many families do not want others to know if a family member is suffering from mental illness. They fear the reaction that it will evoke. Many sufferers of mental illness want to hide it from their friends, perhaps from their family, and certainly from their employers, for fear of what may happen to them. It is unforgivable for a civilised society at the beginning of the 21st century to have such a prejudice, misunderstanding and fear. I welcome any move to open up the subject of mental health and break down those barriers.
Our report made a number of recommendations in that area. They include the crucial role to be played by education. If young people can be persuaded during their formative years to accept the problems of mental illness as they accept those of other illnesses, it will be a great step forward. The Government's response mentioned the initiatives being taken, through the Department for Education and Employment and the Department of Health, to start that process, which began last autumn I welcome that positive step forward.
309WH The matter cannot be resolved simply through education. Paragraph 63 of the report contains a quotation from Dr. Mike Shooter of the Royal College of Psychiatrists, which reads:The members of the users and carers group in the college, for example, have said to me when they have listened to the philosophy of a campaign like that,"—a campaign for greater education—that it is very laudable but in the end it will not help unless they"—the sufferers of mental illness—
can get insurance, unless they can get a job, unless they can get a mortgage without running up against the sort of institutionalised stigma we were talking about before.That statement is important because it opens up the reality of stigma, which is not just fear, prejudice and ignorance displayed through individuals' comments. That quote pinpoints the real-life, daily problems that people face and that can crucially affect the improvement of their quality of life and their chances of having a fresh start in society. Education is important, but we must do more to help people with insurance, employment prospects and day-to-day living needs. We cannot simply say, "Do more in education and the problem will be resolved", because it will not be.
Another problem will be understood by any Members of Parliament who have faced it in their constituencies. When a health authority's proposals to establish a hostel in a residential area are known, prejudice—completely ill-informed more often than not—immediately erupts in that area. It is time for all Members of the House and other elected figures at local and national level to stand up and be counted. It is easy to jump on to the political bandwagon of saying no to a hostel in a residential area, but in my experience, nothing more is heard about hostels after they have been established and proper supervision, with back-up services, help and support for their residents, is in place.
The horror stories put about before hostels are established to try to prevent their opening never materialise as fact, and never would. The prejudices of individuals who want to prevent hostels from being opened create a climate of fear that bears no resemblance to reality. It is time for politicians at all levels to have the guts and courage not to say no as an automatic, knee-jerk reaction to hostels. Integration into the rest of the community is important. I still passionately believe that care in the community is the correct policy. It is a civilised policy that has moved with the times. Long-term hospitals that tried to hide the problems of mental illness by locking people up and giving them an unacceptable quality of life were an affront to civilisation.
§ Mr. Hinchliffe
The hon. Gentleman is making a passionate and strong contribution The Committee has argued about the Fallon inquiry recommendations on moving more towards regional provision. In all seriousness, how do we tackle the difficulties that any Government would face in doing so? My area has a regional secure unit. I am on board with everything in the hon. Gentleman's philosophy, but how would he feel if one of the Committee's recommendations were a proposal to create a regional secure unit in Chelmsford? Politicians have to face such challenges.
§ Mr. Burns
The straightforward answer to my Chairman's narrow question is that my view would depend on where in my constituency the recommendation for the medium-secure unit was. I would have no problem with a hostel in a residential area—I accept that hostels are not medium-secure units—as it would basically be a house like any other house with multiple occupancy. A medium-secure unit would have to be put in the right place, as would a prison. One does not put them in the middle of residential areas. One can put such units in areas all around the country, with proper security and protection so that local communities can live side by side with them, just as they can with prisons. There is a prison in the hon. Gentleman's constituency and I have one in the centre of Chelmsford. It causes my constituents no problems, because it is secure.
I still believe strongly in the philosophy of care in the community. It is an affront to lock up the people that we are discussing. The Minister could confirm the irony that, under the old policy of simply locking people up, throwing away the key and hoping that no one saw the problem, there were more deaths and personal injuries among patients than there are now with them in the community.
I do not intend to make a party political point. What I am talking about happened under the Government in which I served, as it has under the present Government. The trouble with care in the community is that while fewer violent incidents are happening, the fact that they happen out in society and that public inquiries are held afterwards, means that there is greater publicity and public awareness. Sadly, such horrific incidents have happened—often as the result of blunders—that it is feared that such things happen all the time. Also, to return to the problem of stigma, members of the public are sometimes fearful of totally harmless persons who live in society while suffering from a degree of mental illness, because it is relatively new to encounter such people. In the past they would have been locked up, out of sight and out of mind.
As to the horrific incidents that have occurred, of which there have been too many, the policy of care in the community has to an extent gone out of synch. There has not been enough protection of the public in some limited instances. That fact has engendered a complete lack of public confidence and brought the policy into disrepute. We need now to build up public confidence in a principle that is right. I agree with the Government—and I would dearly have loved the previous Government to have taken the same line, had the parliamentary arithmetic and the time available allowed it—that matters need to be tightened up with respect to people suffering from mental illness who are allowed to remain free in the community. We got things wrong and the present Government have done so too; but, to be fair, it could be argued that the existing legislative regime has placed the Government in their present position.
The hon. Member for Wakefield (Mr. Hinchliffe) referred to the issue of untreatable patients, and I want to take a slightly different angle on it. The state should have more powers to protect the public from people who are untreatable. I remember vividly from my time at the Department of Health two instances when it was contacted about two individuals aged over 18—which 311WH was of course a fundamental issue—who were coming out of secure units. Because they had not committed a crime or caused any problems, there was nothing that the state could do to keep them in a secure environment to protect them or, even more importantly, the public.
In one case in particular, social services from the relevant local authority, the police, the consultants dealing with the individual and, for some odd reason, the Prison Service begged us to find a way to keep the young lady in a secure environment. It was only a question of time, in their professional judgment, before she would harm someone because of her illness, which was untreatable. It was deeply frustrating that there was nothing that the Department of Health could do. The law was the law, and because she had not offended, she was to leave the secure unit and return to the community. Ironically, in that case, the Home Office, to put it crudely, got everyone off the hook and managed to find some way within the law by which the lady could move from the medium secure unit to Rampton.
I accept that human rights and individual civil liberties are relevant and I should be the last person to say that we should brush aside an individual's civil liberties to satisfy the tabloid press or public opinion. However, we must never lose sight either of the civil liberties of the public or their right to be protected from people who are untreatable and particularly dangerous.
§ Mr Hammond
My hon. Friend used the term "untreatable" several times. Considering the Select Committee's recommendation that further research be done into the treatability or otherwise of personality disorder, and on examining the White Paper, that seems to be a key area that needs further exploration. Is my hon. Friend using the term "untreatable" after careful consideration? Has he reached the conclusion that people with this condition are untreatable, or does he have an open mind on that?
§ Mr. Burns
Rightly or wrongly, I use the term. As my hon. Friend knows, I am not medically qualified to answer his question. However, as someone who has had limited experience of dealing with these individuals, I have come to the conclusion that whatever research one conducts, there is a category of people in the country who are totally untreatable. Unless dramatic breakthroughs in medical science occur, there is no chance—in the short term—of finding treatment for such people. It is an unfortunate quirk of fate or of circumstance.
In conclusion, we must all—Ministers and Members of Parliament—work together to break down the stigma associated with mental health problems and ensure that raw prejudice, which in many cases is rather unpleasant, is tackled. That must be done, but not simply through education. The Government have a role, not in a nanny state way, but through trying to solve problems of employment, housing, insurance and so on. The state also has a role in dealing with community feeling, ensuring that fears are broken down and that people are better protected from those individuals who have done so much to undermine the basically correct policy of care in the community.
§ Mr. John Gunnell (Morley and Rothwell)
I rise to speak on the use of electro-convulsive therapy in the national health service, about which I have been concerned for a long time and which comes within the framework of the Select Committee's activities. In view of my impending retirement, this is probably my last opportunity to make this particular point, which is another reason for my wishing to speak.
The Minister will be aware that I made proposals for changes in the rules on ECT in a ten-minute Bill entitled the Electro-convulsive Therapy (Restrictions on Use) Bill, which I presented in December 1997. I subsequently withdrew the Bill, following discussions with the then Minister with responsibility for mental health, my right hon. Friend the Member for Brent, South (Mr. Boateng). He felt that it would not be appropriate to tinker with the Mental Health Act 1983, and that my concerns would be better raised when consideration was given to reforming the 1983 Act as a whole. We have now reached that stage, and I am well aware that Ministers have given consideration to the position of ECT in the range of treatments available or required for patients under the Act.
During Health Committee hearings and visits, ECT was not often raised as an issue. However, I recall one meeting with patients at a south London hospital in which an 18-year old woman spoke of the devastating effect of compulsory ECT treatment on her mental health. The use of ECT has now declined, but I am uncertain whether there are still patients who receive ECT without their consent and without another doctor being asked for a second opinion. That doctor should, of course, be independent of the doctor who requested the treatment. I believe that another professional opinion is required before treatment.
I am unaware whether exact records are now kept of all those who receive ECT, including whether they consented to such treatment and the outcome of the treatment in the short and long term—or at least in the medium term. It is important to have exact information on the effects of ECT to justify its continuing use. I am not alone in having such worries. A number of hon. Members, whose constituents had received ECT and who subsequently raised the matter with their MP, have talked to me about their concerns, most notably my hon. Friend the Member for The Wrekin (Mr. Bradley).
I want to raise a completely separate issue that arose after the Health Committee visit to Broadmoor. The Committee was impressed with the positive approach of the chief executive and of many of the staff whom we met. I was, therefore, concerned to receive a letter dated 31 January 2001 from Len Dunn, the honorary secretary of the Broadmoor hospital staff recreation club. He wrote about the threatened closure of the club. The letter has not been widely circulated, which is why I bring it to the attention of the House today. Mr. Dunn wrote:
I should like to draw your attention to the planned closure by the Broadmoor Hospital Authority of our Staff Recreation Club which has been in existence for nearly 140 years and is currently enjoyed by some 1,400 employees and their families.313WHBroadmoor Hospital Authority wants to demolish the club to make way for the relocation of its Training and Education Centre as part of its Hospitals' Estate's Disposal Strategy and has now issued proceedings against the Club. We are urging the Authority to reconsider its options.We believe that the closure will be highly detrimental to the recruitment and retention of staff, exacerbating an already severe shortage. It is a popular facility where hospital staff can unwind after the stress of a highly challenging job. It appears to 'fly in the face' of current government initiatives which advocate 'supportive family-friendly' practices. Furthermore it will be a considerable loss to the community as the club regularly hosts local charitable events.We maintain that there is ample room within the Broadmoor Hospital Authority to house both the Training and Education Centre and the Club. We are prepared to look at ways of contributing financially to assist with an alternative plan, and would welcome consultation and the opportunity to participate in meaningful negotiation.That letter spells out the concerns of staff working at Broadmoor—concerns that I share. The staff are important and have a highly challenging job; not many of us would want to do it. I imagine that the Minister has a copy of the letter, but if not, I can let him have one. What is his response to the letter? I am sure that the Minister appreciates the staff as much as we do and that he is as concerned about their well being as we are. I hope that he will respond to the request for consultation.
§ Mr. David Amess (Southend, West)
I congratulate the Chairman of the Select Committee, the hon. Member for Wakefield (Mr. Hinchliffe), on his speech. He spoke for us all about the unanimous report and covered all the issues, but that will not stop me from making my own points.
I was moved by the speech of my hon. Friend the Member for West Chelmsford (Mr. Burns) about stigma and I entirely agree with what he said. I also agree with the remarks of the hon. Member for Leeds, West and Morley (Mr Gunnell) about electro-convulsive therapy. I have one such case at the moment: someone, not in my constituency, was given the treatment and asked to sign for it when he or she were not in the right frame of mind to know precisely what he or she were doing. Eighteen doses of the treatment were given, and a relative of the patient involved is extremely upset about it.
The hon. Member for Wakefield and I share an interest in mental health because of our constituency experiences. Members of Parliament know that often the inspiration behind the many groups that are formed is someone with a loved one affected by an illness or trying to cope with a problem. Mental health groups are no different.
There are not huge numbers of votes for parliamentarians in discussing the state of our prisons, but we should discuss such a matter, even if it is not of great interest to our constituents. Mental health is like that, too: people do not want to get too involved in the issues. As a newly elected Member of Parliament I vividly recall visiting South Ockendon hospital, where I saw sights for which I was unprepared. I had gone along to a hospital event, where I bought bird baths, nesting boxes and so on, which all looked lovely, and then I saw how some of the people were cared for, which was pretty grim. I had not realised that people really were put in straitjackets and restrained.
314WH I agree with my hon. Friend the Member for West Chelmsford that in some cases it is difficult to know what is best for people, but restraining them in the way that used to be done at South Ockendon hospital is not acceptable. We must not forget that these patients are human beings, too.
We have all met people with mental health problems. Tragically, four weeks ago a friend of mine, a deputy head who was highly intelligent, committed suicide during school hours. I had no idea of his state of health. His wife told me that on the day he committed suicide he had received a letter telling him that he had been awarded the MBE. For whatever reason, he had a tremendous feeling of inadequacy. The 2,000 mourners at his funeral said it all: he was a fantastic chap.
At our constituency surgeries, hon. Members meet many people—I choose my words carefully—who seem a little unusual in the way that they present their case. One of our colleagues was nearly killed as a result of what happened at a constituency surgery.
Members of Parliament get depressed. I occasionally get depressed when I look at Labour Members, and when I look at the opinion polls, I feel even worse, but I am an optimist. I salute all the Committee Members for their efforts in producing the report. I agreed to be a member of a Select Committee because I felt that our debates on the Floor of the House had become a bit of a blunt instrument, and Select Committees were a sharper way of dealing with matters.
There is no point in our spending three hours in Westminster Hall debating these matters, and the Select Committee interviewing wonderful experts and having the help of the support staff—I went all round the country looking at all the different facilities—if a few weeks after our report is issued, the Government send us a nice reply and the whole thing is forgotten. That has always gone on, so I am not making a point about this Government. The Health Committee has dealt with these matters calmly and its recommendations are excellent, but I suppose that I would say that.
I should just like to highlight five of the recommendations in the summary. Point (f) states:There have been undeniable failures in service since the policy of care in the community was first launched. But we feel that it is both misleading and unhelpful to state that the policy of care in the community has failed"—this is a unanimous report agreed by all members of the Committee—
as the Government has done on a number of occasions. We urge the Government to make clear in the language it uses … that care in the community is a positive policy and one which it supports.When the Conservative Government delivered care in the community, I thought that it would cost a huge amount of money and I wondered whether we had thought it through. It has indeed cost a huge amount of money but the Health Committee certainly supports the policy.
Paragraph (h) refers to joined-up government. I hate that expression. It means everyone working together. Sadly, not everyone in the mental health services in south-east Essex is working together. I sought the opinion of a number of individuals in the area. A consultant psychiatrist said:reducing suicide rates is a very important issue. Southend…needs…semi-informal services…which can really rise to the challenges of the mental health problem in the community.315WH A patient who harms himself says:The day I left hospital I felt really alone. I couldn't phone the ward for support and felt alone. Instead I had to phone the Samaritans who told me to take up knitting.The Samaritans do a splendid job, and it is unfortunate if someone said that. I received a letter from a constituent who said:I have no idea where my husband could go for help now, as every door seems to be closing in his face and his mental state is becoming more fragile as a consequence".A general practitioner said:
David, there is a lack of consultants and conditions in the wards at Rochford are pathetic and I strongly feel that it needs urgent attention.There are gaps in the services in south-east Essex and the various agencies clearly have a problem talking to each other. I do not have a magic wand but if the Minister and his officials care to look at our recommendations and can deliver some of them, it would make a huge difference.
I recently received a letter from a constituent who said:In 1999 I had problems and because I could not talk about them I was taken to Runwell hospital".I know that at least three hon. Members know that hospital. It is an old asylum that has been threatened with closure for 10 years. Nothing happens. Most of the buildings are a disgrace to the modern national health service. I do not suggest that there are huge pots of money, but someone needs to come up with a solution to the problems at Runwell. My constituent continues:I hated it in there. In December 1999 I was allowed to return home on the condition I accepted help from a Mental Health Team Co-Ordinator and, that I had a CPN give me an injection monthly. I didn't want someone from Mental Health to visit.My constituent now learns that she is no longer to receive help from her splendid support team.
Opposition Members talk endlessly about point (p), which deals with staff shortages. All hon. Members have received a briefing note from the Royal College of Psychiatrists, which underpins that recommendation. The Royal College said:The proposals, if implemented fully, would have significant implications in terms of personnel and training. In the light of the 14 per cent. vacancy rate for consultant psychiatrists there is much work to do in attracting people to the mental health professions;The proposals would also be extremely costly financially—we are concerned that care and treatment will be based not on the needs of patients but on what can be 'afforded'.Point (s) of our recommendations states:
We are aware that the National Institute for Clinical Excellence… is currently considering guidelines on the management of schizophrenia".Hon. Members have also received the briefing note from the Zito Trust, which tells us that NICE has recently announced the details of its inquiries into the treatment of schizophrenia. The Zito Trust believes that it is an opportune moment for that debate—perhaps the Minister will confirm whether that is right. The Zito Trust states:NICE will be appraising atypical anti-psychotics. Atypical drugs for the treatment of schizophrenia dramatically improve patient outcomes, have fewer debilitating side effects and result in 316WH better compliance for patients. In nearly two thirds of patients, older typical medicines are associated with some terrible side-effects (including muscle tremors, rigidity, uncontrollable movements and restlessness which in many cases continue even after the treatment has ended). These side effects are one of several causative factors leading to patient non-compliance that can have serious consequences for both patients and the general public.The trust is concerned that
pending NICE's guidance being launched many patients will be denied the effective, newer treatment they deserve. It is our view that this will put at risk patients who will have a lower quality of life because of inappropriate treatment and it is our deep concern that they may fail to take their medication as a result.The final point is point (t), in which the Committee talks about a range of suitable accommodation—an issue that my hon. Friend the Member for West Chelmsford touched on. The Health Committee report is very worth while, but if it ends up covered with dust and with no one taking a blind bit of notice of it, we will have wasted our time.
Dealing with people with mental health problems is a huge challenge. All the time one meets people who are in a deep depression; their carers are in despair that they cannot get the right help. Such help and support may not exist. I am sure that the Minister and his team will meet positively the challenges raised and the solutions recommended by the Health Committee's report.
§ Mrs. Eileen Gordon (Romford)
I echo my hon. Friend the Member for Wakefield (Mr. Hinchliffe) in thanking all the witnesses who took the time to give us evidence and the special advisers and Clerks who worked with us on the report. They did a great job.
I was proud to be a member of the inquiry. Hon. Members will probably share my heartening experience that whenever the issues are discussed, I find that people welcome the report as an advance in the dialogue on mental health issues. That has been recognised by the Government, health professionals and, perhaps most importantly, by user groups, which very much welcome the report's recommendations. I suppose that every member of the Committee who took part in that long inquiry had different impressions of, or headlines for, the things that they saw and the people to whom they spoke. I shall highlight some of the impressions that were left with me.
Many changes are taking place in the national health service, both in the structure of mental health facilities and in provision. With my hon. Friends the Members for Hornchurch (Mr. Cryer) and for Upminster (Mr. Darvill), I met representatives of the North East London Mental Health trust on Tuesday. After April, it will be responsible for providing mental health care for more than 1 million people. I was impressed by the trust's values and by what it intends to do, which echoes the work that we did and the Government's response.
Perhaps I can digress for a moment to pay tribute to Sandra Knowles, the chief executive of the Barking, Havering and Brentwood Community Health Care NHS trust. Despite the fact that she is doing away with her job by handing it over to the North East London Mental Health trust, she has worked tirelessly to ensure a seamless transition for staff and service users. Her team has worked incredibly hard and I hope that, on 1 April, the users of the services will not notice a difference.
317WH I reiterate what the hon. Member for West Chelmsford (Mr. Burns) said—for too long, mental health services have been a Cinderella service. It is a case of "out of sight, out of mind." We had a huge institution in Brentwood to serve the local constituencies—Warley hospital. Thankfully, it is on its last legs and new provision is being made. It was the most awful place and had an impact on the whole community. Even as children, we were warned about Warley hospital. If we went to Brentwood, we would run past it. As the hon. Gentleman said, a stigma has been attached to mental health and is still prevalent.
Much has happened since the start of our inquiry. I very much welcome the national service framework that has been established by the Government, because we are all trying to move towards a holistic approach to people who need mental health care. That can only be good for them and the rest of society. A major issue to emerge from the report was the way in which we involve the users of the services. For too long, professionals have been telling people what is good for them. Increasingly, however, users have a strong voice and make their views known. They are being heard, and I hope that they will be listened to and have an input into policy.
I was shocked that the holistic approach had not been used up to now, which is shown by employment and housing issues. People with a mental illness may have episodes of illness. They may be well and, with a little help, find a job. They may be in work, paying rent and making their way in life, but then have an episode of illness, which means that they have to stop working. That has an impact on housing and disability benefits, for example, and they have to go through a cycle of reapplying for benefit each time. It should be recognised that these people have been there before, that it will be a pattern, that they will not work permanently, and that circumstances are difficult for them. People who are ill and have to go through this process are at their most vulnerable and are often unable to cope.
I hope that the advocacy service will take off, so that people will have someone to help guide them through the process. Through the Government's initiatives on one-stop shops, people can have their benefits sorted out in one place rather than having to trudge from one office to another, each time having to explain what is wrong with them over and over again, which is obviously distressing.
§ Mr. Hammond
The hon. Lady has spoken about people who are able to go back to work but subsequently have another period of mental illness. It also works on the other side of the equation. One of my constituents is a severe schizophrenic and a double amputee as a result of an accident that occurred while she was in the care of the mental health trust. She is an in-patient sometimes, but lives in the community at other times. Every time she comes out of hospital, she has to go through the whole bureaucratic process again, filling in enormously long forms. The system does not seem to recognise that such people are unable, by definition, to cope with that problem every time they return to the community.
§ Mrs. Gordon
As I said, it is a real problem that has not yet been solved. It seems common sense to get to know and understand each individual as a person. It is 318WH sensible to have someone at the one-stop shop who recognises a person and knows what help might be required. It should not be necessary to go through the process over and over again. Carers also have to go through the process with the people they care for and it is extremely distressing.
The role of primary care in mental health issues is important. We know about special hospitals and prisons, and the statistics are interesting. One in four GP consultations has a mental health element and 90 per cent. Of mental health problems are cared for in the primary care sector. We must therefore ensure that GPs and any specialists who work with them are aware of the issues. We do not want people told to go away and take up knitting, as the hon. Member for Southend, West (Mr. Amess) mentioned. Some GPs truly understand the issues and can deal with mental health within their surgeries, but many others do not.
With the formation of primary care groups and primary care trusts, GPs are able to work together and share information on best practice. The new mental health trust in our area will mean that mental health issues and care will move up the agenda. If one in four people has mental health aspects to their problem—stress, for example—it should be picked up at the primary care stage. We all know that the earlier a problem is diagnosed, the easier it is to deal with.
The hon. Member for Chelmsford, West has already dealt well with stigma, but I want to discuss one example. Someone told me at a local MIND meeting that, while waiting at a bus stop, she got chatting to the person next to her. After they had exchanged views about weather or the lateness of the bus, she mentioned that she had not been well, and when asked what the problem had been said, "I have been in Warley hospital," which as I have explained is a local mental health facility. The other woman immediately turned her back and moved away. Such unfounded fear of mental illness still exists. It was unnecessary and cruel for the woman I met to have had to suffer that. We must do more to educate the public about mental health problems. In my locality, MIND does an excellent job of informing people of the facts about mental health.
§ Mr. Hammond
Does the hon. Lady agree that we need to get the public to distinguish between the great majority of people who suffer from mental illness and the tiny minority of them who are potentially dangerous? Does she think that the Government's proposal to create a new definition of mental disorder that embraces not only people with mental illness but people with a learning disability will be helpful in reducing the stigmatisation of the whole group?
§ Mrs. Gordon
I hope that any measures that the Government take will focus on reducing stigma and educating people. That is so important. As the hon. Member for West Chelmsford said, we must start early in schools to provide information. People suffer from stress; we have enough stress in this job and it is the same for many people in other jobs.
§ The Minister of State, Department of Health (Mr. John Hutton)
I did not intend to interrupt my hon. Friend's remarks but it is important to put the record straight. I hope that she is aware that the definition of 319WH people who are to be treated compulsorily that we propose in the White Paper "Reforming the Mental Health Act" will not include people simply because they are learning disabled. The idea that it will is completely wrong.
§ Mrs. Gordon
I thank my hon. Friend for clarifying that point.
The voluntary sector has already been discussed, but I want to mention its important work. It emerged in the evidence that the Select Committee heard that voluntary bodies are always walking a funding tightrope. They may have annual funding and every year—or, for a three-year project, every three years—they must undergo the same process, wondering whether they will be given the money. Local groups live on a knife edge most of the time, worrying about the following year's grant and what services they will be able to provide. I hope that the Government will examine that issue and give voluntary groups some security with respect to the future. They make an invaluable contribution to patients' care.
My hon. Friend the Member for Wakefield mentioned the women's services. I visited the services at Broadmoor and Ashworth. The staff there were doing their best and working hard. Much good work was being done, but it was repeatedly highlighted that most of the women patients should not have been there—it was inappropriate for them. It is so sad that people should be in Broadmoor—however caring the staff are—when they do not need to be. Indeed, some women are moved to medium-secure units but because those facilities are also inappropriate they eventually end up back at Broadmoor. There is nowhere else to go.
Many of the women in special hospitals have been abused sexually or physically for most of their lives. However, women form only a small part of the population in medium secure units, so when they are moved there, they tend to be put in mixed units or even on the same wards as men. They find that threatening. The units are debating whether to have women-only accommodation or a mixed structure with separate facilities for women, so that they can retreat into a comfortable and safe environment. That needs to be sorted out, because the director of women's services at Broadmoor told us that 60 per cent. Of the women in her care could be looked after in the community or on assertive outreach. It is shocking that those women can be locked away when they could be in medium or low-security facilities.
As there are so few women in that sector, they are put in special hospitals and, as we know from the three cases that were mentioned, they can end up far from their communities and sometimes from their children. When we were at Broadmoor, we heard that, after the Fallon report, heavy restrictions were placed on the men because of the various incidents that had occurred there, with visiting children being abused. Obviously, the staff had to tighten things up and put in more security. However, the women in the women's unit suffered the same security despite there being no evidence that they would have harmed the children. Indeed, it would have helped their rehabilitation and their prognosis for better health if their children and friends with children could 320WH have visited. Those restrictions were inappropriate. A separate strategy is needed for women in special prisons and secure units. Women's groups have the necessary knowledge to help decide the best way forward.
I wish that we had had time to cover other areas. It is an intense report and we covered much ground. We dealt with the problems of the transfer from child services to adult services, caused by the fact that adolescents are kept in fairly small units but when they suddenly reach the cut-off date they are sent to somewhere harsh like Broadmoor. I hope that we can revisit that aspect, because we need to take a more intensive look at it. Nevertheless, I am pleased with the report and the Government's response and I am glad to have been a part of it.
§ Mr. John Austin (Erith and Thamesmead)
I am sorry that my hon. Friend the Member for Morley and Rothwell (Mr. Gunnell) has had to leave us, because he said that today's speech may be his last contribution in the House. I hope that it is not. I knew the hon. Gentleman before I became a Member. We all recognise the enormous contribution that he has made not only in the House but for the benefit of the people of west Yorkshire, as my hon. Friend the Member for Wakefield (Mr. Hinchliffe) knows.
§ Mr. Hinchliffe
I am grateful to my hon. Friend for referring to our hon. Friend the Member for Morley and Rothwell (Mr. Gunnell). His contribution to the Committee's work was remarkable. He has had a great deal of experience in health and social services matters. He chaired a social services committee and served on the Health Committee, and his contribution was positive in every inquiry.
§ Mr. Austin
I welcome the way in which my hon. Friend the Member for Wakefield introduced the debate. I also thank the hon. Member for West Chelmsford (Mr. Burns) for his balanced and rounded speech, and for his concentration on the border issues of mental ill health, especially stigma. Public safety issues are important, and no one wants to underestimate the tragedy of homicides and suicides, but all members of the Committee share concern at the fact that media focus on such events prevents a rational discussion of issues such as the location of hostels for people who present no real risk to anyone in the community. Those people are probably vulnerable individuals themselves. That focus also makes it more difficult to tackle the stigma problem.
The Committee is concluding its major inquiry on public health issues. The most important determinants of health are economic, social and environmental. Access to employment, training, housing, security and social interaction are key elements for the promotion of good health. Those who lack them are more likely to suffer physical and mental ill health. However, those who suffer mental ill health have more difficulty in accessing them. As the hon. Member for Runnymede and Weybridge (Mr. Hammond) and our report said, such people face difficulties in re-accessing the benefit system.
My hon. Friend the Member for Wakefield referred to unequal or inappropriate treatment on grounds of race and ethnicity, and my hon. Friend the Member for 321WH Romford (Mrs. Gordon) referred to the same problem in terms of gender. Witness after witness gave evidence of the fact that health services, especially mental health services, suffer from institutional racism. As my hon. Friend the Member for Wakefield pointed out, patients from ethnic minorities tend to access services later than their white counterparts although they may be more severely ill. They are more likely to be detained than treated as informal patients, are over-represented in the secure system and are often provided with inappropriate or insensitive services. They are more likely to receive physical treatments, and less likely to be offered counselling and other non-physical treatments.
That is not news. Our inquiry has not suddenly uncovered that information, as it was well documented 10 or 15 years ago by people such as Roland Littlewood, Maurice Lipsedge and Aggrey Burke. We met Roland Littlewood during the course of our inquiry when we visited NAFSIYAT. Little seems to have changed for the better in terms of discrimination and institutional racism. I am glad that the Government have begun to consider the matter, especially in the wake of the Macpherson inquiry.
Our inquiry found that many of the most appropriate services for ethnic minority communities seemed to be provided by voluntary and community-based organisations. My hon. Friend the Member for Romford pointed out the severe difficulty in continuity of funding. We made a firm recommendation on that, and I am pleased that the Government have taken it on board in their response. I agree with her on gender issues, and ask why there are so many women in special hospitals whom even my right hon. Friend the Secretary of State for Health admits should not be there. That is also recognised in the White Paper, which is pleasing. We have heard that the director of women's services at Broadmoor believes that 60 per cent. Of the women in her care could be looked after in a less secure environment.
As my hon. Friend pointed out so vividly, women who are difficult to manage but are not dangerous are spiralled up the system because of a lack of segregated facilities in medium secure units. The choice appears to be between a mixed ward with male sexual abusers in medium-secure units, or transfer to a special maximum-security hospital. That cannot be appropriate or right. My hon. Friend also referred to the gender-blind approach of the security directions on child visiting, following the Fallon inquiry into Ashworth. It was clearly aimed at men, yet women at Rampton and Broadmoor are now restricted in seeing their own children, without any consideration being given to the therapeutic implications. That cannot be right, and I hope that it is being dealt with.
The Committee also considered issues relating to caring for people in the community. There have been some reports, including a study at York university, on the success of assertive community treatment. They show that that form of treatment maintains contact with more patients, cuts hospital admissions, and reduces time spent in hospital with no evidence of clinical harm.
The Committee was impressed when it visited both north Birmingham and St. George's hospital in south-west London, where assertive outreach programmes are combined with the use of the newer atypical anti-psychotic drugs, which were referred to earlier, as well 322WH as psycho-social interventions and home treatment. That combination is achieving real results. I welcome the commitment in the Government's recent White Paper to an additional 170 assertive outreach teams with 24-hours-a-day, seven-days-a-week access to services. I recognise that performance varies across the country, and that more research must be carried out into which forms of assertive outreach work.
Questions have also been raised as to whether community care has failed, or whether it has gone too far. It was said earlier that, although care in the community has not failed, the absence of such care has often failed vulnerable people. The late development of the appropriate care in the community packages has led, unfortunately, to the question being raised as to whether the shift from hospital-based care to community-based care has gone too far, or whether tragic incidents such as the murder of Jonathan Zito in 1993 were the result of the closure of in-patient units before the development of adequate community provision.
Those widespread concerns in the 1990s contributed to the passing of the Mental Health (Patients in the Community) Act 1995. That Act contained an element of compulsion since it created a new power of after-care and supervision. However, it stopped short of requiring patients to accept treatment. In practice, the power of conditional discharge has not been widely used, perhaps because of the absence of community support facilities rather than because of the absence of a power of compulsory treatment.
The passing of the recent human rights legislation will be an interesting challenge for the mental health services. Last summer, before the implementation of the human rights legislation, the Court of Appeal ruled that local councils should pay for after-care services for some categories of long-term psychiatric patients. The human rights legislation could, in certain circumstances, require local councils and health authorities to meet the conditions of mental health tribunal discharge orders.
Last year, a case was brought against a health authority by a woman who had been held in detention in hospital for more than a year after a mental health tribunal had directed her release because the health authority had failed to find a forensic psychiatrist to supervise her after care. In a similar case in 1997, a patient with schizophrenia took the United Kingdom to the European Court of Human Rights in Strasbourg. He had been detained for several years after the release date ordered by the tribunal because the local authority could not find a suitable supervised hostel. The council was found to be in breach of the European convention on human rights for its failure to fulfil the tribunal's conditions within a reasonable period.
Until recently, the only real remedy available to people was the long and arduous process of taking the United Kingdom to court in Strasbourg. Their only other form of redress was by way of judicial review, but ultimately, in judicial review, the court could decide only whether the authority had acted reasonably and had little power other than that of being able to encourage the authorities to explore alternative solutions. Mental health tribunals do not have the power to compel authorities to comply with the conditions of discharge.
323WH Now that the human rights legislation has been incorporated into British law, any individual can apply to the British courts. That will have an impact on mental health services and their delivery and will, in some cases, ensure that services are available to meet discharge criteria and free up much needed in-patient beds. However, I fear that without additional resources, those authorities may end up having to rob Peter to pay Paul. The Government must therefore be aware of the resource implications of providing an adequate care in the community system.
When my right hon. Friend the Member for Holborn and. St. Pancras (Mr. Dobson), the former Secretary of State, said in 1997 that community care had failed, his choice of words was not helpful. However, he was not asking for a return to the old system, with the reintroduction of the water-tower asylums—or the bins, as they are more appropriately known in the trade. He set up the independent reference group's review of community services and recognised, as do the Government, that locking up patients in long-stay institutions is often harsh and harmful. He said that he was looking for a third way. That was perhaps the only time that the right hon. Member for St. Pancras and I looked for a third way; a way that comprised the provision of acute beds, more secure facilities, more 24-hour crisis teams, hostels—as the hon. Member for West Chelmsford said—supported accommodation, home treatment teams and assertive outreach.
My hon. Friend the Member for Wakefield referred to the evidence that we received on people with dual diagnosis. That is of real concern to the Committee and I hope to all hon. Members present. My hon. Friend referred to people with a dual diagnosis of mental disorder and substance misuse or mental disorder and learning disability. Despite their different circumstances, both groups face the common problem of what is known as "pass the parcel"—it is someone else's problem. Young Minds told the inquiry thatthe division between drug and alcohol services and mental health services creates widespread problems throughout the mental health system".As the National Schizophrenia Fellowship put it:they are deemed too 'mad' to go into an alcohol or drugs unit or too 'high' to go into a mental health service".Turning Point gave us evidence that people with alcohol or drug and mental health problems also find it difficult to access primary care services so that their physical health needs are not addressed.
It is not an easy issue with simple solutions. One NHS trust put it bluntly when, referring to the problem of patients with dual diagnosis on a general ward, it said:you have people with other conditions who do not want young men out of their heads on wards.Those who misuse drugs or alcohol also have a right to treatment. Since some may be the people for whom compulsory treatment is considered, a human rights issue arises if they were previously denied access to appropriate services. Substance misuse is often implicated in acts of violence, both homicide and suicide.
§ Sitting suspended for a Division in the House.324WH 4.28 pm
§ On resuming—
§ Mr. Austin
I was referring to the problems faced by people with a dual diagnosis. The Health Committee received two studies, one from Maudsley, the other from Lewisham. The first showed that 40 per cent. of alcohol-dependent patients had some form of mental illness, and the second that 58 per cent. Of people accessing mental health services had a dual diagnosis of substance misuse. Although the national service framework acknowledges problems of co-morbidity, it provides little guidance, which led the Committee to recommend that the Department of Health should require joint working and co-ordination between mental health and substance misuse agencies. It also recommended that working with people with a dual diagnosis should be made a requirement within the remit of assertive outreach services and that the duty of partnership imposed on the NHS and local authorities under section 27 of the Health Act 1999 should include substance misuse and housing services.
I want to say more about drug treatment. In delivering a unanimous, cross-party report, the Committee called upon the National Institute for Clinical Excellence seriously to consider the outcome of treatment from a user's perspective, including the benefits of making compliance with drug treatment less onerous. Our report was published at the same time as the publication of a survey by the Zito Trust, showing severe gaps and weaknesses in the provision of services, with patients being denied access to the most effective treatment—21 per cent. Of United Kingdom health authorities restricted the use of atypical anti-psychotic drugs that are known to have fewer side effects and result in better compliance.
Notwithstanding the outcome of the NICE investigation, I share Jayne Zito's concern that patients who are non-compliant, often because of the horrendous side effects of typical medicines, are denied access to atypical medicines, which, as Jayne Zito said, improve compliance lead to reintegration into society and can result in significant savings.
The Government believe that independent advocacy services are important—it is a subject dear to the heart of my hon. Friend the Member for Wakefield—as shown in the White Paper, which was published before the passing of the Health and Social Care Bill. The White Paper refers to the patient advisory liaison service as the gateway to specialist advocacy services.
The Minister knows the importance that hon. Members attach to the assurance that the advocacy services should be independent, and be seen to be so. In view of the amendment to the Health and Social Care Bill on the location and provision of advocacy services, which the Government accepted, the matter will have to be addressed before we consider a mental health Bill.
§ Mr. Hammond
The hon. Gentleman is talking about the Health and Social Care Bill as if it were a fait accompli. The Bill is still under consideration in the other place and, depending on the timing of the dissolution of Parliament, may not make it to the statute book.
§ Mr. Austin
Whether or not the Bill reaches the statute book in this or a future Parliament, I hope that the 325WH Minister will acknowledge the commitment to the important principles of independent and available advocacy services in the Health and Social Care Bill.
The hon. Member for Southend, West (Mr. Amess) drew an analogy between the Prison Service and mental health services in terms of community interest. That may be valid, but there is a clear distinction: most of us know something about prisons, but few hon. Members have a loved one, a friend or a relative, who has been in the nick. However, I suspect that every one of us has someone close to them with personal experience of the mental health services. It is not only our constituents who have such experience.
I have two prisons in one in my constituency, and there are prisons in the constituencies of my hon. Friend the Member for Wakefield, the hon. Member for West Chelmsford and the hon. Member for Isle of Wight (Dr Brand). Many people are in Belmarsh prison in my constituency because of the failure and inadequacy of the mental health services to address their needs.
I have been a critic for many years of the inadequacy of the psychiatric and forensic services in prisons, but the new regime at Belmarsh prison which I visit, is a beacon of light in the development of services, and the Committee was very positive about it.
The media have concentrated on the small number of difficult-to-manage patients but that should not divert us from the need to raise the standards of mental health services generally. The Government's NHS frameworks may need even more resources than they have already generously made available, but if they are implemented, we may at last see the tag "Cinderella service" removed from mental health.
§ Dr. Peter Brand (Isle of Wight)
It is always a great privilege to speak on behalf of the Liberal Democrats on Health Committee reports. It is rare that I do not fully endorse a report, but then I have also had the privilege to serve as a Committee member. I must congratulate the members, staff and advisers on the excellent way in which the Committee works. Our chairman, the hon. Member for Wakefield (Mr. Hinchliffe), keeps us in order and gives his own opinion, but at the end of the day allows consensus to emerge, which is right. Our recommendations are based on evidence. That is why it is important that we look at the areas in which the evidence clearly points to a recommendation that is not always picked up by the Government in the way that we would like.
The timing of the report is excellent. The hon. Member for West Chelmsford (Mr Burns) and others have talked about the continuing stigmatisation of people with mental health problems. I suppose that it is a step forward from being totally excluded and marginalised, but it is still awful that we cannot accept that mental illness is not the fault of the person who has it—we should not have a blame culture—not is it an infectious illness. It is a condition brought on either acutely, like any other acute illness or chronically, due to the pressures created by society and social conditions.
Also, it is timely to talk about mental health because we can do so much more to support people and prevent illness, as well as to treat them. I strongly endorse the report's recommendation that our service to people with 326WH mental illness, and those recovering from or at risk from it, should be better integrated. I am slightly concerned that we should not move too much into a medical model for doing that important work. Of course, treatment often involves pharmaceuticals, but they should be an adjunct to everything else that we do.
Sometimes the war against mental illness seems to be seen as a form of chemical warfare—it seems that, provided that one drugs people into quietude and submission, there are no problems. A number of hon. Members have talked about the use of up-to-date drugs. It is wrong to describe the new anti-schizophrenic drugs as atypical drugs. They should be described as modern drugs that allow people to function as well as be in control. The points made by the hon. Member for Morley and Rothwell (Mr. Gunnell) on electro-convulsive therapy were extremely valuable in that context. ECT can be extremely helpful in certain limited conditions. It can be life saving; it can also be a means of blasting out people's anxieties and memories and making them extremely quiet, so that they are no longer a nuisance.
There must be a way to ensure that people have a say in their proposed treatment—not only in the context of compulsory treatment orders, but perhaps more importantly, in the context of having uncertain competence about giving permission. It is too easy for clinicians to persuade people who are not admitted under a section that a certain form of treatment is best for them without giving them an option to consider alternatives. The issue of competence is extremely important in that context. I am glad that the hon. Member for Runnymede and Weybridge (Mr. Hammond) picked up the point when the hon. Member for Morley and Rothwell was talking about ECT because it applies just as much to drug treatment.
Just as drug treatment can be appropriate, it is also important that other quality-of-life issues are properly addressed. I am pleased that at least four of this afternoon's contributors made strong reference to the need to consider social support. There is a need for cross-government thinking on how the benefits system delivers its services. At my surgery on Friday, I saw someone who must go to a tribunal because his benefit is being cut from 60 per cent. to 40 per cent. or something similar. That man is agoraphobic. He worked himself up for a month to go to the mainland for a medical examination by the benefits system. When he arrived, he was told, "Well, we're overbooked this afternoon. Here's some money for your ferry fare. Come back in two weeks' time." That service is being run on behalf of the service provider, not the people who need it.
I hear far too often that the medical branch of the Benefits Agency is totally insensitive to the people whom it serves. As individuals, the people in that agency may be perfectly nice, but the systems that they employ are like the ones that we had in general practice 30 years ago, which are rightly not acceptable now. If the Government employ an agency, they should consider the way in which it delivers services.
It is important that rules and regulations are not too restrictive. For example, before housing benefit is paid, it must be verified by a housing officer. If someone in the community struggles hard to be able to meet anyone but has developed a degree of trust with his community psychiatric nurse and psychiatric social worker, either of 327WH them, who often make the placement in the first place, could do the verification job well. It is now done by yet another body. There is no doubt that red tape and a jobsworth attitude are sometimes involved. I cannot blame the people concerned, because they work to a strict set of rules, but that reduces the amount of social and supportive housing that is available.
Two weeks ago, I received a letter from Dr. Ram Seth, who is a wonderful psychiatrist on the island. He is despairing at the situation of two of his patients. They are in-patients, but should no longer be in hospital and he cannot find anywhere for them to go or anyone who will have them. I regularly meet social landlord providers who say that they would like to continue doing that business but they need a little more support. Somehow, the joined-up thinking by Government has not been worked out properly.
While I am talking about joined-up government, I also make a plea for the Minister to talk to his colleagues with responsibility for employment, especially the therapeutic earnings arrangements and the current limit. The hon. Member for Romford (Mrs. Gordon) mentioned the difficulties of moving in and out of employment. It is not in anyone's interest for someone to take a job unless he knows that he can continue to do it for a time. If a psychiatric patient or recovering patient is very vulnerable, the last thing that we want is an on-going set of disasters. Someone may try hard and take on a job. After two or three weeks, however, he may find that the judgment was not right and he should not have tried it. It is not merely a question of his going back to the day centre and getting his support. The person is also without funds until that is sorted out. It may be six weeks before he has anything to live on, which is an enormous disincentive for people to go forward.
I am also concerned that we do not see day centres entirely as places for the acute or severely chronically ill. I must declare an interest. My older brother runs a day centre. It is successful and it allows people to keep in touch with a supportive facility even when they have gone back to work. With our new arrangements, which try to target help towards those who are more severely ill, his case load is being studied to see who can be thrown out. Where do vulnerable people go when they are thrown out? I have a problem with this. The medical model for allocating resources does not cut across the social support, which is not always as easy to define as some of the medical support. The medical profession does not have a good record on defining things. Psychiatry is full of diagnoses and opinions about the meaning of diagnoses. I will touch on that issue with reference to personality disorders and treatability.
On co-conditions, the hon. Member for Erith and Thamesmead (Mr. Austin) described drug dependency and alcoholism well. An enormous opportunity is missed within the Prison Service to tackle people with those problems. Community psychiatric nurses travel all day to find out whether they can provide help to a person through assertive outreach, yet at the same time, people with just such needs rot in our prisons without the support that they should have. Enlightened—and some extremely good—prison regimes exist. There are good prisons on the island. However, it is not reasonable to expect the job in question—running therapy groups 328WH for people with drug or alcohol problems, or with sexual deviations—to be taken on largely by prison officers in addition to their custodial and occupational therapy work. That approach cannot be sustained.
I now find that prison officers are breaking down because they cannot cope with the strain. They provide a service that should be resourced through the national health service—and properly. I am glad that the report mentions the present arrangement, which is difficult for health authorities in areas where there is a substantial prison population. It is impossible to contribute the resources that are needed. Even for something relatively simple and accessible, such as counselling services for which people are available in the job market, the money simply is not there. I hope that the Minister will suggest what progress the review on the funding of prison medical services has made. That matter is of great concern, not only on the Isle of Wight but generally in areas with substantial prison contacts.
In prisons, there are many mentally ill people who are not treated. Prisons are also the waiting list for secure hospitals. The bizarre situation is that people who, if treated, could return to the community are in prison with people who should be not there but in secure units and who make the lives of other prisoners and prison officers extremely difficult. On our special hospital visits we saw that there is a waiting list to discharge people and a waiting list to admit people—although the waiting list to admit is not created until there is a vacancy.
§ Mr. Austin
Does the hon. Gentleman agree that one of the problems that he has identified has been tackled at Belmarsh to a large extent by forensic psychiatric services being provided for the prison on a commission basis by the local medium-secure unit?
§ Dr. Brand
That is an extremely valuable point. It is one of the models that we have to work through. It is vital that the prison medical services, the special units and the secure hospitals all work to the same regime and that they have clear financial accountability for the jobs that they take on. I am afraid that rigidly separated budgets will result in a lot of defensive fencing before decisions are made.
What progress is being made on the extra beds in secure units that the Minister spoke about in Committee—and, indeed, on specialist units for women? The points made by the hon. Member for Romford were so telling. We are putting women in an impossible situation by allowing Broadmoor to become a haven or asylum. I am not against asylums—in the true sense of the word as places of safety—but they need not be places in a secure hospital.
Two difficult human rights issues are tackled in the Health and Social Care Bill. One is the compulsory treatment order in the community, which is an extension of the present powers. At the moment, people can be compulsorily detained but not necessarily treated; they can refuse treatment until a tribunal has heard the case. At the moment, that does not extend to the community. Those who are in the community can be taken into hospital, but treatment cannot be forced upon them.
If treatment is to be forced on people in the community, it is important that the patients, if competent, should have a choice of what that treatment 329WH should be. They should have the opportunity, before an episode of illness, of saying what that treatment might be. Patients' carers should have an input, as should those support organisations to which patients belong. That is why the advocacy service is important. In this instance, I would not like the advocacy service simply to deal with complaints. It should help people expertly to make choices that they may find difficult to understand. If we are to deny people the liberty to say no, it is important that proper checks and balances are put in place. That is even more important if we are talking about denying people their freedom.
I am uneasy about locking people up because of their personality. As has been said, a severe personality disorder does not necessarily relate to the dangerousness that a person presents to society. I am glad to say that a body of medical opinion believes that treatments can help people come to terms with their personality disorders and allow them to interact better with society. More work needs to be done with what are normally described as talking therapies—I believe that they should be called listening therapies—including the psychotherapeutic approach that allows people's behaviour to be moulded over a long period of time to reduce risk. In that sense, using hospital psychiatric facilities is appropriate, but I would be unhappy if people were put in prison, or a quasi-facility—as if it were an oubliette—because we do not like their opinions or thinking patterns. That is dangerous.
I fully support the Fallon concept of reviewable sentences. It would be interesting to hear whether the Minister has talked to his Home Office colleagues and whether he can think of an individual who has not committed some offence, no matter how minor, and presents a major risk in line with the descriptions of people with dangerous personality disorders. Such individuals must be extremely rare. They may have committed offences as juveniles. Something will have happened to have brought them to the attention of the authorities.
Some people may be so unfortunate that they cannot cope and need to be imprisoned or put somewhere secure. From that location, they can be reviewed, and they should have the right to go back to court to say that they do not represent the risk that they used to and want to be let out. Reviewable sentences are a much better way forward than putting someone in jail.
§ Mr. Hammond
I am slightly confused, but perhaps I have the wrong end of the stick. I thought that reviewable sentences related to offenders who might subsequently have their incarceration period extended because of the threat that they presented. Is the hon. Gentleman suggesting a form of reviewable sentence for someone who has not committed an offence, or have I misunderstood him?
§ Dr. Brand
I am sorry if I did not make myself clear. I am saying that some people commit offences that may be relatively minor, but those people may present a clear threat and so would be given indeterminate sentences. An arson attack that does not do enormous damage, for instance, might suggest a disturbed personality. In such circumstances, a reviewable sentence may be appropriate if the cases are not deemed a priori for the mental health services. I hope that there are not many 330WH such cases. The Government estimate a figure of, I think, 2,300, and it might be interesting to know how many of those people have some court record.
I must pay tribute to successive Governments for making enormous progress on the way in which mental health is regarded. It is important that we do not simply say that mental health has to come into the mainstream, as we must also resource it. Much is now being done to work more closely with patients. I single out my friend Roger Fordham, who runs a patients' group on the Isle of Wight. He is a terrific worker for his patients and colleagues in the day centre. Such people are an enormous resource, but we should not over-use them. It is important that we do not narrow our horizons too much to one willing individual. We must ensure that we use everyone who has a contribution to make.
I have also been impressed with the work of the Zito Trust. The report comments on the mandatory homicide inquiries and their effect, and makes the sound recommendation that they be sent to a specialist branch of the Commission for Health Improvement. I cannot think of any lasting positive outcome of such an inquiry other than the Zito Trust—it is an unofficial body, but it has done excellent work. It is a forward-looking organisation that is not centred only on victims, as it considers the needs of the people who committed the dreadful offences and other people in the same category.
No such improvements can be achieved without adequate resources. As has been said, we are short not only of psychiatrists but of psychologists and psychiatric nurses. The idea that general practitioners could be trained to be more skilful and do more mental health work is no solution as GPs are already over-burdened with work.
More time is necessary to bring more people on, but I hope that in the interim, the Minister will recognise the enormous contribution that can be made by lay counsellors, social workers, carers and other people in supporting roles. It is wrong that units are still being shut down or restricted because we cannot afford the people to run them. Those are the units that support people and keep them out of hospital and out of our prisons.
§ 5 pm
§ Mr. Philip Hammond (Runnymede and Weybridge)
As perhaps the only Member speaking today, apart from the Minister, who was not a member of the Committee, I should like to congratulate it on tackling a difficult and complex subject and producing a report that, as I am sure its readers will agree, is an extremely useful reference document covering a wide area. I am also grateful for the tone adopted by the hon. Member for Wakefield (Mr. Hinchliffe). All hon. Members have adopted a constructive tone, acknowledging that it is a matter of building on the efforts of successive Governments and that society has come a long way during the past 30 or 40 years in terms of how we deal with people who suffer from mental illness. We still have a long way to go, but we have come a long way, and the issue is not primarily party political.
Since the publication of the Committee report, a lot of water has passed under the bridge in terms of Government documents. The NHS plan came out 331WH shortly after the report, and the Government's response to the report, the Health and Social Care Bill and the consultation responses to the Green Paper "Reform of the Mental Health Act 1983" have all been published, as was the White Paper, in December. We must consider the Committee's recommendations in the light of what has taken place since the publication of its report.
We have, as yet, seen no sign of legislation. The Government have stated on many occasions and reiterated in all the documents that I have listed, that mental health is a high priority for them. Since there is potentially still a year of this Parliament left to run, I hope that that high level of commitment and the importance that the Government attach to mental health will be expressed in the form of a Bill. There is broad consensus that new legislation is needed. There is also a fairly broad consensus that such legislation is more important than some of the other legislation that has filled the legislative programme. I hope that the Minister will have something reassuring to say about that.
The title of the report is "Provision of NHS Mental Health Services", and although I do not want to be picky, it is probably appropriate to mention at the outset the independent sector. The Government have stated that they wish to work more closely with the sector in future to ensure effective provision of NHS services to NHS patients. The independent sector plays a significant role in the delivery of mental health services, particularly medium-secure services. In London, I understand that one independent organisation provides more NHS in-patient psychiatry than any NHS trust in the London region.
Without wishing to be churlish, I detected in recommendation (uu) of the report a tinge of hostility to the involvement of the private sector and what seemed like an aspiration to reduce private sector involvement. Will the Minister say something about the future of private and independent sector providers of mental health services? Do they have a future in mental health provision in the NHS? If they were to receive a negative signal, it could have unfortunate consequences, so I hope that the Minister can say something reassuring about that. What proportion of the additional beds and facilities that the Government have announced are expected to be provided directly by the NHS and what proportion will be NHS-funded facilities provided by the private sector?
§ Mr. Hinchliffe
The hon. Gentleman knows my general views on the private sector, which I shall therefore not need to discuss. When we produced the report, the Committee was concerned that some of the private establishments that we examined were offering a service, but their existence obstructed the development of a better service in the NHS. Earlier, I referred to a private hospital in York that offered secure facilities that were full of young black men from London. My personal view, which was shared by the cross-party Committee, is that we must place those men in appropriate facilities in their communities, which is a point made in the report.
§ Mr. Hammond
I am grateful to the hon. Gentleman. I know his views on the private sector generally, so I 332WH understand why he does not feel the need to discuss them today because you, Mr O'Hara, would certainly rule the language out of order. I have heard what he had to say and I look forward to the Minister's comments.
There is a capacity issue. We have all seen what is happening in the care homes sector, and I am sure that the hon. Gentleman would not want anything similar to happen in the medium secure mental health sector by virtue of careless talk. I hope that the Minister will want to reassure quality providers that there will be a role for them because I would not want to spoil the tone of consensus on the issues that we have discussed today.
When my hon. Friend the Member for Woodspring (Dr. Fox) responded to the presentation of the White Paper by the Secretary of State in the House, he welcomed the general thrust of Government policy. More care delivered in more appropriate settings must equal better outcomes. We also welcome the Government's determination to address the question of stigma, about which my hon. Friend the Member for West Chelmsford (Mr. Burns) and the hon. Member for Romford (Mrs. Gordon) have spoken eloquently today.
The Committee noted that the focus of attention on high-risk patients—the bulk of the White Paper deals with such patients, which inevitably focuses press attention—conveys a highly misleading impression of mental health services. Earlier, I intervened on the hon. Lady to ask about the Government's proposed new definition of mental disorder that covers any disability or disorder of mind or brain, whether permanent or temporary, which results in an impairment or disturbance of mental functioning. Perhaps the Minister will want to clarify the position because I took his earlier comments to mean that that definition would not include people with a learning disability. However, my understanding is that it will include people with a learning disability, although that alone will not make them vulnerable to compulsion.
The point that I raised with the hon. Lady related to stigma. I have raised the issue before, but I perceive that many people in the community do not distinguish between either learning disability and mental illness or the vast majority of mental illnesses and the tiny number of patients who may be a threat to themselves or to others. I raised this question with the hon. Lady, and I shall address it again to the Minister: does broadening the definition of mental disorders help to de-stigmatise this area? How can it be managed to ensure that the effect will be positive in terms of reducing stigma?
My hon. Friend the Member for Woodspring welcomed the proposed reform and simplification of sectioning procedures, although he raised some practical concerns. If and when we see a Bill, we shall examine carefully how the Government intend to overcome them. We also welcome the proposal for community treatment orders, subject, as always, to the establishment of the appropriate safeguards. Doubtless there will be much devil in the detail that will need scrutiny. It is clear that community treatment orders are building on the success of care in the community and must constitute the way forward. My hon. Friend the Member for Southend, West (Mr. Amess) and the Select Committee itself concluded that it would be unhelpful for the Government to give the impression that care in the community has been a failure. I should point out that the Minister has gone out of his way to emphasise 333WH that he does not consider care in the community a failure, but in a press release dated 29 July 1998 the current Secretary of State's predecessor said:Care in the community has failed.One cannot express oneself much clearer than that, and the Government and the mental health community might have to work hard for some time to repair the damage done by that brief statement.
We support much of the thrust of the Government's White Paper and their response to the Select Committee report, but in due course I shall raise some specific issues about which we are not quite so happy. Like hon. Members in this Chamber, who are all experts on this subject, I hope that others will keep in mind the proper balance between general mental health services and issues relating to high-risk patients. The hon. Member for Romford said that approximately one in four GP consultations involve a mental health element. Ninety per cent. of patients with mental health problems are cared for entirely within the primary care system, which points strongly to the need to focus resources on early intervention and identification of problems.
We also know that four in every 1,000 people have a severe mental health condition, such as schizophrenia, and some 11,500 people are detained in hospitals and homes under the Mental Health Act 1983. In the light of those figures, if the proposals in the White Paper are implemented and legislation is enacted, how many people are expected to be treated under compulsion in the new regime that the Minister envisages? Concern has been expressed that numbers might increase significantly. On the question of moving people to units with lower security levels where possible and in the light of recommendation (xx) and the Government's response to it, what reduction in the population of high-security mental health units does the Minister expect? In the Government's response to recommendation (r), reference is made to 1,000 new "workers" in mental health at primary care level. What does that mean? What type of people and level of qualification are we talking about?
The Select Committee has rightly recognised that funding and resourcing is a principal area of concern. Although it welcomed the ring-fenced funds that have been drawn from the modernisation fund, it recognised that the overall level of funding is of the greatest importance. It also noted variations in the percentages of health authority allocations that are spent on mental health, and herein lies one of the problems. The Government say loud and clear that they regard mental health as a top priority, but they have set targets for health authorities and NHS trusts that have a somewhat headline-grabbing potential. The inevitable result is that health authorities are tempted to divert their resources towards meeting those targets that, in their view, the Government believe should be addressed first. The worry is that mental health will remain the Cinderella service while it must compete with other, high priority, high-profile, life and death, blue-light issues that the Government, rightly, have raised. The Government say that mental health is a priority, but most of the electorate, if asked what are the principal objectives in the health service, would probably say cancer and coronary heart disease if they have been listening to the Government. I should be surprised if many of them would say mental health.
334WH I want to refer to one or two specific matters and then to speak briefly about dangerous severe personality disorder. We all recognise that staffing is the main constraint in implementing the Government's mental health plans and the NHS national plan. The Committee identified precisely the concerns in relation to psychologists and occupational therapists. The Government's response to the Committee's recommendations (p) and (r) was inadequate and I am surprised that the hon. Member for Wakefield did not mention that. It referred to the total number of nurses and other health professionals whom the Government hope to have in place by 2004 under the NHS plan. It did not refer to the specific requirements for staffing our mental health services.
I have some questions for the Minister. First, can those NHS plans be met? We have seen the reports of the Audit Commission and National Audit Office, which refer to the difficulty of meeting those plans with the current high drop-out level among trainee nurses. Secondly, what proportion of those people will be directed towards mental health services? If the NHS plan is not achieved on staffing, what reassurance can the Minister give that mental health services will not suffer the brunt of under-availability of qualified staff? Pay is often said to be the main grouse that causes problems with recruitment, particularly to mental health services, but job satisfaction, morale, conditions and, above all, being allowed to get on with the job are also important.
I want to leave the Minister plenty of time to reply, so I shall omit several important matters and say a few words about the Government's proposals on compulsion. I referred to the Bournewood judgment during an intervention and I should be grateful if the Minister would elaborate on how the new regime will deal with patients who have not objected to treatment but who are deemed not to have the mental capacity to consent to treatment. The Select Committee suggested that it might be a good idea if we had a better definition of capacity. I am slightly concerned that in practical terms those people are treated compulsorily. If they are correctly assessed not to have the ability to consent, the regime that will control them when they are inside the system should be more akin to the regime of a voluntary patient than to that of a compulsory patient. The Minister knows that I have a particular interest in that matter because the Bournewood mental health trust is in my constituency.
Turning to patients with dangerous severe personality disorder, I must say at the outset that the Opposition recognise that it is a very difficult problem and that part of the challenge, if we are to de-stigmatise mental illness, is to identify those who are a danger to the public and to assure the public that they are being appropriately dealt with. We can then re-educate the public about the way in which they think about the 99.9 per cent. of mentally ill people who are not a danger to anyone, except perhaps themselves occasionally.
After much consideration and a lot of soul-searching, the Opposition have concluded that we simply cannot support a regime that locks people up, not for the purpose of treating them in a therapeutic environment, but as a form of preventive detention. There is presently inadequate evidence to suggest that the predictive power of diagnosis is sound enough to contemplate the 335WH enormity of incarcerating someone without treatment and without any realistic possibility of being released back into the community. The Opposition are extremely wary of the Government's proposals for dealing with dangerous severe personality disorder patients.
To conclude, I emphasise that what unites us is much greater than what divides us. There is a considerable sphere of consensus. I have explained some of our concerns. If a Bill is introduced before the end of the Parliament, we look forward to engaging constructively with the Government on the practical issues that it will raise. I hope that we can proceed as we have hitherto—in a consensual way to ensure that the progress made over the past 30 or 40 years continues in future.
§ The Minister of State, Department of Health (Mr. John Hutton)
First, may I say that I am glad that a doctor is in the House this afternoon? I may need to ask the hon. Member for Isle of Wight (Dr. Brand) to help me with the problems affecting my voice.
I hope to respond fully to all the issues that hon. Members have raised. We have had an excellent debate about the future of mental health services and I agree with virtually everything that has been said. Anyone listening to today's proceedings would conclude that a substantial consensus exists about what needs to be done to ensure that all our constituents have access to the first-class mental health services that we would want for ourselves if we ever suffered from a mental health problem.
My hon. Friend the Member for Wakefield (Mr. Hinchliffe), who has a close interest in these matters, made an excellent speech. He and I agree on many aspects of the problem, particularly on the need to improve community mental health services. We have made that a priority for investment, reform and modernisation during the past three years and I can certainly give my hon. Friend the assurance that that will continue.
I also welcome the speech of the hon. Member for West Chelmsford (Mr. Burns), who did my job in the previous Conservative Government. I agree with him about the need to tackle discrimination, stigma and ill-informed prejudice. I pay tribute to him for the stance that he has adopted on this issue, which is not always easy. The hon. Gentleman was on more dangerous ground in respect of jumping on political bandwagons, but I respect his courage in raising that matter as well.
I greatly enjoyed the brief contribution of my hon. Friend the Member for Morley and Rothwell (Mr. Gunnell). This may be the last opportunity to hear my hon. Friend speak in the House. I hope not, because he is an outstanding Member of Parliament and a distinguished member of the Health Committee who brings personal integrity and compassion to these subjects. I pay an enormous tribute to him as an individual. I hope that I will have the chance to hear more from him in the future.
I can assure the hon. Member for Southend, West (Mr. Amess) that we intend to improve mental health services. We responded positively to the Health Committee's report, which is a mark of our continuing 336WH contribution to this issue. We have no intention of producing a response to the report and then forgetting about mental health services. The hon. Gentleman asked a specific question about the National Institute of Clinical Excellence and the use of atypical anti-psychotics, if he will forgive me for using that expression. NICE is reviewing the whole treatment of schizophrenia and has not yet produced its final appraisal. The Government will examine it carefully when it is produced, which I hope will be as soon as possible.
My hon. Friend the Member for Romford (Mrs. Gordon) is actively involved in mental health issues in her constituency and has a special concern to ensure that patients and users are effectively involved in planning their care and treatment. We share that commitment. It is strongly and fully reflected throughout the national service framework, which has been well received not just in the NHS but outside with user and patient groups and in local authorities. She was right to stress, as did the hon. Member for Runnymede and Weybridge (Mr. Hammond), the need to improve our investment in care. Anyone who has read the NHS plan and looked at what Ministers have been saying will know of our strong commitment to improve front-line primary care services. As has been widely remarked, that is where the majority of patients can be safely and appropriately treated. It is where they want to be treated. It is the responsibility of us in the NHS and our partners in local authorities to ensure that those services are available.
I congratulate the Health Committee on an excellent report into mental health services and I welcome its close interest in the subject. Like all members of the Committee, the Government want to see those vital NHS services improve and expand so that we can begin to meet more effectively the mental health needs of millions of people in our country. As hon. Members have rightly pointed out, this is a big challenge and much needs to be done, but with the Committee's encouragement, we have made a good beginning to that long overdue programme of investment and modernisation.
In 1997, when the Government took office, we made improving mental health services one of the top three clinical priorities for the NHS. Given the condition of mental health services and their importance to the health and well-being of the nation, that was absolutely the right thing to do. Our programme of modernisation—[Interruption.] That crack in my voice reminds me of the time when my voice used to go up and down.
§ Mr. Hutton
Yes, many years ago. I thank my hon. Friend for that generous observation.
Our programme of modernisation has involved three distinct elements. First, we needed to improve investment in mental health services and in doing so, to focus on the immediate priorities. Those included new and improved community-based services and secure beds. I will try to respond to questions about the numbers of secure beds in a moment. Secondly, we needed to set clear national standards in relation to 337WH service provision and access to services that have quite often depended on where a person happened to live. The first of the national service frameworks has, I believe, begun to tackle this unacceptable state of affairs and has been widely welcomed. Finally, we needed to bring the mental health legislation up to date, and we have now set out in the White Paper how we intend to do that.
This is clearly a major programme of reform that will take years to complete. I know that the Committee has strong views on those three issues as well as on other matters, with which I will deal in a few moments. As my hon. Friend the Member for Erith and Thamesmead (Mr. Austin) wisely pointed out, it is important that we recognise, as I am sure that the Committee does, that good mental health is not just the preserve of the NHS. The NHS has a crucial role to play, given the expertise and specialist care services that we provide, but wider issues have a key bearing too. The Government's successful economic Policy of creating new jobs and securing economic stability positive will make a positive impact on promoting good will the extra investment that we are making in other front-line public services such as services.
Mental health services have often been described as the Cinderella service of the NHS. We all know why. The proper range of services has not always been available to provide the care and support that people need when and where they need it. There has been inadequate care, poor management of resources and under funding.
The Department of Health's memorandum to the Health Committee on public expenditure demonstrated those problems clearly. From 1991–92 to 1995–96, expenditure on mental health services fell in real terms by £69 million. Given the pressure on mental health services throughout that period, it was clearly not helpful. More worryingly, the memorandum showed that NHS in-patient provision had fallen by almost 18,000 beds between 1987 and 1996. I accept that 15,000 of those were long stay NHS beds and we welcome the progress that has been made in those areas, but 3,000 of those beds were acute in-patient psychiatric beds and we could not afford to lose them. That is why we decided that the first national service framework should cover mental health services. The NSF published in 1999 will, we hope, help to drive up quality and remove the wide and unacceptable variations in provision that we inherited.
§ Mr. Hammond
The Select Committee report drew attention to health authorities' different spending levels on mental health from their general allocations. Does the Minister have a view on that? Does he intend to issue directions or give guidance on the appropriate percentage to health authorities or does he think that it is different in every case?
§ Mr. Hutton
I will certainly not give guidance or instructions to health authorities that identifies the percentage that they should spend on mental health. That would not be right. The hon. Gentleman would be the first to criticise me if I did so, I because he is always complaining about Ministers' alleged micro-management of the NHS. Those issues must be resolved locally. Local priorities and local patients' needs must 338WH be reflected. We expect spending on mental health services to continue to improve and to reflect the national priorities that we have set.
Since 1997, expenditure on mental health services has increased by £466 million. For those who like to number crunch, that is a 16 per cent. increase. The NHS plan, to which I shall come later, will invest more than £300 million over the next few years in new community and primary care based mental health services. It sets out our plans to recruit a further 8,000 staff for mental health services over the next few years—more nurses, doctors, primary care workers and other support staff.
I think that the hon. Member for Runnymede and Weybridge asked about the extra 1,000 primary care workers identified by the NHS plan. They will be largely graduate psychologists. We hope to be able to provide brief, psychologically based therapies in primary care settings, which will certainly take a lot of pressure off many hard-pressed local GPs. All those measures will help to ensure that mental health services are no longer the Cinderella service of the NHS.
Our response to the Select Committee report attempts to highlight the extensive amount of work that is under way. The Committee's decision to launch an inquiry into mental health services stemmed from the strong impression that patients often ended up in the wrong part of the mental health care system or sometimes could not get treatment where and when they needed it. That is also our view. Over the past three years, therefore, the Government have set in train developments substantially to increase the range of local provision, so that by next April an extra 500 local secure beds and 320 extra 24-hour staffed beds will be available.
In addition, regions—particularly London, whose mental health services are under severe pressure—are using their own capital resources to develop schemes to provide locally based NHS services for the large number of people in private-sector secure provision, which is often far away from their homes. The hon. Member for Runnymede and Weybridge asked me to comment on the provision of secure accommodation in the private sector. We will continue to use it; we want to develop strong and continuing relationships with the private sector. As my hon. Friend the Member for Wakefield made clear, however, the problem with much private-sector provision is that it is in the wrong place and is therefore of little use to patients. The inner cities and conurbations, such as London, need more locally based services. We certainly intend to increase the provision of long-term secure beds and community staffing. There will be more investment in services for dangerous people with severe personality disorder. Those developments should help to ease the pressure on various parts of the system and enable people to be treated in the most appropriate setting.
§ Mr. Hammond
I am grateful for what the Minister has said, but will he elaborate on the increase in secure facilities? Will that be done by direct NHS investment or by contracting with private sector partners under the terms of the concordat?
§ Mr. Hutton
The numbers to which I have referred are for NHS beds, but we look forward to close 339WH relationships and partnerships with the private sector, which provides 30 per cent. of all secure beds. We must use that resource and will continue to get good value for money in doing so.
In response to particular comments made by the Committee, the Department has stressed to all chief executives of mental health services the importance of ensuring that all patients discharged from specialist services should receive clear information on how to re-access them in the event of a further onset of illness. We have set up a new national working group to develop guidance on good practice on dual diagnosis, which was a concern of the Committee. A further investment of £1.25 million will be available next year to provide a range of training in substance misuse for those who work in mental health services.
We have ensured that the needs of people with mental health problems and learning disabilities will be covered in the forthcoming learning disability White Paper. We have developed new model service specifications that reflect best evidenced-based practice for crisis resolution teams, assertive outreach teams and early intervention services. They will be launched at a conference for chief executive officers and directors of social services later in March.
We have started to address long-standing concern about the quality of in-patient care, which will be a major focus of our work in future. As the hon. Member for Runnymede and Weybridge, my hon. Friend the Member for Wakefield and other members of the Select Committee will be aware, the Standing Nursing and Midwifery Advisory Committee recently made several wide-ranging recommendations relating to the experience of users of acute in-patient facilities. NHS trusts and health authorities are expected to respond to the recommendations as part of their health improvement plans and national service framework implementation arrangements.
The acute in-patient care collaborative recently launched by the NHS executive offices of the Trent region and the northern and Yorkshire region will be a seminal piece of work that will, I hope, bring about real service improvement in other parts of the NHS. The purpose of the work is to improve user experience of mental health acute in-patient care and achieve better outcomes through the process of assessment, admission, stay and discharge by sharing good practice. There is plenty of good practice in the NHS, so we have another opportunity to learn from and share that experience. I believe strongly that there is nothing wrong with the NHS that cannot be put right through the use of its best qualities. I want to see such progress made in all regions, not only the two that I have named.
As the Committee knows, the Government are committed to removing mixed-sex accommodation, and ward sisters and charge nurses have been given new resources for improving the general environment on their wards. That will certainly include acute in-patient psychiatric wards. We now need to consider carefully the general ward environment and the physical conditions of all such wards as part of our continuing work to modernise and improve the NHS.
340WH We take mental health promotion seriously, which is why we have brought it centre stage by including two new standards in the national service framework that will require health and local authorities to develop and implement coherent mental health promotion strategies. We shall support them in that endeavour by developing a mental health promotion framework that will draw together the evidence base for effective practice and highlight examples of good practice elsewhere.
The Department continues to work in collaboration with users of mental health services, the voluntary sector and professional bodies with a view to reducing discrimination. That relates to a point made by the hon. Member for Runnymede and Weybridge. I have recently approved the appointment of a communications consultancy to develop a new national campaign that will be launched later this month. It will be aimed at tackling stigma and discrimination faced by people with mental health problems and supporting their social inclusion. I hope that the campaign will have an innovative and exciting new style that will involve employers in a central role. I should be happy to share the details of the campaign with the Select Committee further, and would welcome its members to the launch. I shall ensure that they are invited to it.
As part of the NHS plan implementation arrangements, local services from next year will be required to include occupation, housing and benefits in care plans for the most severely disabled. My hon. Friend the Member for Romford was especially concerned about such issues. An employment group has been set up to consider ways to promote greater opportunities for people with mental health problems to access suitable employment. With the Department for Education and Employment and the Department of Social Security, we are planning new job retention and rehabilitation pilots this year to test the effectiveness of different health and employment strategies in reducing the number of people forced to give up work through prolonged illness or disability. The mental health pilots will take place in north and south Cheshire and the Wirral, and we will look for early lessons during the next two years in how we can take the initiative forward.
The mental health taskforce will shortly consider a wide-ranging report on ethnicity and mental health services provision. Many hon. Members have raised the subject of ethnicity today, and we take it seriously. NHS services must serve the whole community, not only sections of it, so people from black and ethnic minority communities must and will have better access to more effective services in future. A work force action team has been established to set a programme of work in several key areas with the aim of producing a national picture of the work force, education and training issues to support the implementation of the NHS plan. We have set up a new national working group on early intervention that involves clinicians from both adult and adolescent services. The new early intervention services will have no age barrier and will target children as young as 14.
On some issues, however, we have taken a different view from that of the Committee. There would be no point in pretending that we agreed with every recommendation in the report, as we did not. We have not accepted the recommendation to close the high- 341WH secure hospitals and replace them with smaller regionally based units. My hon. Friend the Member for Wakefield will be aware of the difference of opinion between us on that matter. Our policy for high-secure services is to secure the safety of the public, staff and patients and to ensure that the best possible services are offered to patients who need to receive care and treatment in a high-secure setting.
The three high-secure hospitals provide a unique service for people with the most severe types of mental illness, personality disorders and learning disabilities. We need to maintain those facilities and the valuable expertise of their staff in dealing with a challenging group of patients with complex mental health disorders and the opportunities for therapy and activity that are available on the existing large sites. I do not share the view of the Committee that the service provided by those hospitals cannot be improved. I believe that it can. Ending the professional isolation of the three high-secure hospitals from the wider NHS will be one way to bring those changes about.
§ Mr. Hinchliffe
I speak with some experience when I use the term bins. I spend much of my working life in the bins. My view of the three remaining special hospitals is that they are the three remaining bins of our psychiatric system. I should like the Minister, in the short time left to him, to demonstrate how, under the current institutional framework within which the special hospitals operate, we can move from those establishments remaining bins.
§ Mr. Hutton
I know that my hon. Friend has strong views on that subject, and I respect him for it. The existing organisational arrangements that he described are now being changed. He will be aware that later this year, Rampton and Broadmoor will form part of new NHS trusts. That is an important move. Other changes are under way that will support that reform.
Many hon. Members spoke today about the inappropriate use of those high-secure services and the consequential increase in waiting lists for those who need that type of specialist service. We have allocated £25 million of new resources to transfer people who need lower levels of security. I was asked how many people I thought were inappropriately housed in the high-secure hospitals. As many as 300 or 400 people are in high-secure hospitals who should not be there. The money that we are making available will ensure that more appropriate provision is made for them.
These are difficult issues. Everyone knows that the high-secure hospitals have had a difficult history, but I do not believe that the way to resolve the problem is to close them. That would be a serious mistake. We have 342WH the opportunity to develop the expertise necessary to end their professional isolation and to improve the pattern of services that are provided to people in those hospitals.
I am conscious of the fact that I have only two or three minutes left to respond to an extremely wide-ranging debate. I suspect that my officials will soon start to get concerned, because I shall no longer refer to my notes. I shall try instead to draw upon one or two themes and concerns that hon. Members have expressed during our well-informed debate.
Much concern was expressed about the mental health reforms that we propose in the White Paper. We heard the rather surprising confession that the Opposition now oppose our plans to improve public safety and patient services for people with severe forms of personality disorder. I am genuinely surprised that the Opposition have taken that view. I dare say that, in the weeks and months ahead, we shall be given further clarification. It is my humble opinion that few Conservative policies last more than a couple of weeks. Perhaps that is another policy that will be refined and changed as the mistakes become apparent.
We—not only Members of Parliament, but our community and society as a whole—must address the fundamental problem, which is that those services often let people down and there are no effective treatment or services available for them. We have to put that right. I believe that we can.
I take issue with the hon. Member for Runnymede and Weybridge who suggested that we cannot treat those people and that we propose to warehouse them indefinitely or detain them in facilities where they would be denied effective treatment and services. That is not so. The hon. Gentleman should consider what has been happening in Holland for many years, where effective treatment opportunities are available for people with severe forms of personality disorder. We believe that people in this country should have access to such services.
An equally pressing public protection issue must be addressed. It will not go away. Difficult though those matters are, we are conscious of the civil liberties issues involved. However, it is absolutely right to provide new forms of public safety and public protection while at the same time—it is important that the hon. Gentleman understands this—offering better levels of service and direct intervention treatment, that will modify behaviour which will allow those people to—
§ It being fifteen minutes to Six o'clock, the motion for the Adjournment of the sitting lapsed, without Question put.