§ Motion made, and Question proposed, That the sitting be now adjourned.—[Mr. Caplin.]
9.30 am§ Mr. Tim Boswell (Daventry)I am delighted and honoured to introduce a debate on the provision of mental health services, a matter of general concern to all hon. Members. We know from statistics and claims made by specialist organisations that a significant proportion of people—probably more than one in five of the population—will be afflicted by mental illness at some stage in their lives. If we add to that the multiplier of their families and carers, it means that almost all of us will have a direct involvement in such illness, either as patients or carers.
Hon. Members will know from their constituency postbags that, although the matter is not the most vocal or immediately dramatic of our worries, it is very important. I am delighted to welcome to the debate the Under-Secretary of State for Health, the hon. Member for Tottenham (Mr. Lammy). I am used to debating learning disability with the Minister of State, the hon. Member for Redditch (Jacqui Smith), but I am sure that the hon. Gentleman will add an interesting angle to our discussions.
I can say genuinely that I do not intend to approach the matter in a partisan spirit; it is too important for that. I shall be critical of the Government's performance in some areas, but that is not the primary purpose of my discourse. We sometimes do ourselves disservice in this place by suggesting that there is a year zero when a Government start with a clean sheet and change everything. The history of social progress in this country—I speak with my specialist knowledge about disability—is one of improvements. People see a problem, or one develops. People then lobby and press for legislation. They press Governments and when such matters are brought to a head—a difficult process beginning with an improvement in understanding— we can move on to changes, either through private Members' or Government-inspired legislation. If we are really successful, the resources to support that legislation will be provided, too. It is not a guaranteed process, but one that has served us over the years.
It is worth pausing for a moment to consider the sensitive matter of mental illness and disability, and to consider how many light years we have come from the understanding of such matters of a century ago. I will not use the easy trick of complaining about our forebears but, at that time, "lunatics" were put away out of sight in an asylum, often for long periods and with minimal resources. It was a case of "out of mind, out of sight", a completely unacceptable approach.
I wish to emphasise the wide range of conditions of mental illness. I speak not as a doctor, but as an engaged layperson. This should not drive the debate completely, 218WH but let us consider the comparatively few situations when a patient in the community poses a risk to members of the public, a risk that is aggravated in most cases if medication is not taken regularly.
I ought to stress before I continue—it is easy to be misunderstood in this sensitive area—that the population that I have in mind is not identical to that with a clinical diagnosis of schizophrenia, although it has been suggested that schizophrenia might affect 1 per cent. of people at some stage of their lives. The people I am talking about—they are not exactly the same as those diagnosed with schizophrenia, although there are some similarities—are patients who pose some risk to themselves, but not to third parties.
Yet that is by no means the whole story, or even the most important part of it. Various types of anxiety and depression are prevalent, and seem to be becoming more so. I notice that the submission from YoungMinds referred to
"an unrelenting rise in teen mental illness".I also note that in the short period of two years between 1999 and 2001, bridging the millennium, pharmacists reported that there was an increase in the number of prescriptions for antidepressants of more than 25 per cent. to an annual figure of some 25 million. That is a huge increase in a short time, and I hope one that will not be sustained.We also need to consider the important impact of the ageing process, and the fact that a much greater number of older people are surviving to a great old age. Soon, there will 2 million people over the age of 85. Many of those—by no means all of them—will have some form of Alzheimer's or dementia problems. The fact that longevity is aggravating the problem requires particular kinds of provision.
Some Members know that I have been involved in a Front-Bench capacity—in which I do not speak today—in some aspects of disability and the benefits system. Mental illness is well on the way to becoming the major factor in disability issues, and in incapacity to work. For example, the overall figures for claiming incapacity benefit are not much worse than they were in 1997, but they were supposed to have fallen. The Prime Minister described the figure of 2.7 million claimants last year as a scandal, but I do not intend to go on about that this morning.
It is interesting to unpack the causes of those figures. The traditional main problems are muscular, skeletal and, to some extent, circulatory. Yet those are increasingly taking a back seat in favour of mental illness and stress problems. Within a more or less stable figure, the number off sick with mental illness has risen by a quarter. Of claimants of disability living allowance, which is obviously a wider category, the number claiming on account of mental illness has risen by some three quarters since 1997. I make no causative accusations about the nature of the Government during that period, but we face something of a stress epidemic. Stress is the characteristic disease of our time. It is significant, not only because of the distress that it causes families in the way of personal tragedies, but in the economic cost that it represents to the nation in working days lost and talents run to waste.
I realise that the Minister cannot give me final answers, but I hope that he will reflect that the benefit system is still not sensitive enough to encourage people 219WH who have a problem or history of mental illness back to work. I know that Ministers in the Department for Work and Pensions have acknowledged the importance of changing that, and I think that they are genuinely committed to working on the problem within the "Pathways to work" strategy. I acknowledge that there have been some genuine improvements in, for example, the linking rules, which apply when a person's benefit entitlement has been broken by a partial return to work.
However, I hope that Ministers will bear in mind three points, and that Ministers in the Department of Health will share them with their colleagues in the Department for Work and Pensions. First, there is a need to make sure that assessment doctors are not only trained in physical disability but have a sensitive understanding of the problems caused by mental illness or depression. Secondly, there is still a need for more flexible rules on part-time working. If someone has had a stress problem, it is not realistic to assume that they will just go back to work. The benefits system still has two modes; one is either on benefit or at work, and the two are mutually exclusive. That is not the way to get people with a history of mental illness or stress problems back to work.
Thirdly, Ministers need to be alert to any hidden deterrents to the resumption of work. It is all very well to say, "You can come off benefits because you are no longer incapable", but how about people who are understandably concerned that they may lose their disability living allowance automatically as a result? That would be difficult for them.
I should like to mention learning disability. I have said in the past, and will say again for the avoidance of doubt, that learning and mental disabilities are often confused with mental illness. Of course, they are not the same at all. We know that learning disabilities are long-term conditions. The Minister and I have several times constructively debated the "Valuing People" White Paper. I hope that we will shortly debate the Government report on that.
Although learning disability is completely different from mental illness, a learning disability, or indeed certain physical disabilities, may well predispose people to mental illness because of the frustration involved or the sheer agony of managing their lives. There is therefore a connection, and Mencap pointed it out to me. I pay tribute to it and other organisations for their briefings and, more generally, for their hands-on work in widening employment opportunities for people with such problems. As Mencap reasonably points out, the more that people find they have problems in comparison with their non-disabled peers, the more likely they are to run into mental health problems as well. I hope that the Minister will take that point back to his colleague.
On the "Valuing People" strategy, there are still problems with access to child and adolescent mental health services. Perhaps the Minister would like to say a little about how that strategy is being developed. Mencap and many others are worried about getting the right definitions into the new mental health legislation, and have specifically expressed concerns about informal detentions. The Minister is probably more familiar than 220WH I am with the Bournewood case. I hope that he can assure us that the gap will be filled, and that the issue will be adequately dealt with.
More generally in connection with draft mental health legislation, I attended a meeting in the House last autumn on the draft Mental Health Bill, introduced by the Government. I can fairly and moderately say that, in the 15 years that I have been in the House, I have never seen a piece of Government legislation that was so completely excoriated by professionals for being unsatisfactory. I hope that lessons have been learned from that about, first, the importance of adequate consultation with specialist interests; secondly, the need to be sensitive to the wide range of mental health conditions that I have referred to; and thirdly, and above all, the need for Ministers to make sure that any drastic remedies, including the removal of liberty, are confined only to the most pressing cases and those that pose the most urgent danger to the public.
I am sure that Ministers will think hard about the lessons that they should have learned from that. They will consider a well-amended Bill and make progress on that and on what they are planning. That would be helpful. They also need to remember the parallel legislation that is required about mental capacity and the ability to make decisions, which is extremely important.
Before turning to medical services, I want to touch on areas of vital support to people with mental illness and in which Ministers should take an interest from a departmental viewpoint. I hope that the Minister will comment. The first is the interface with social service provision. I refer not only to emergency situations, but to what happens on a day-to-day basis. The importance of housing provision is an integral part of the "Valuing People" strategy for people with learning disabilities. The strategy is even more necessary in the context of mental illness, particularly of a relapsing or remitting sort, and when housing for the mentally ill is to be put in residential areas. The proposals and the adequate safeguards must be explained. I have faced difficulties in my constituency, as I am sure have other hon. Members. The guidelines of the Department are helpful in that respect.
I turn now to the formal subject of the debate, which is health service provision of services for mental illness. I think that Ministers should report to us on their progress in meeting targets. The national service framework on mental health is the earliest of its type—the prototype—and it is now more than three years old. That is plenty of time for something to have happened. I notice that the national committee of the pharmaceutical service in a recent report comments that progress on implementing the standards is patchy. It refers to a recent report from the King's Fund—dealing only with mental health services in London—which states that only one third of primary care trusts have completed evidence-based guidelines. It is no good Ministers saying that they require evidence-based information, but that, for whatever reason, they have not received it.
The study also reports that implementation has been skewed towards handling severe mental illness, rather than to primary care for mental health. One of the points that is made several times—and rightly so—is that early intervention is critical in warding off some of 221WH the problems before they become serious, clinical matters that might even require hospitalisation. The Minister will know that community pharmacies are a sensitive issue for many of us. They have an essential role to play in ensuring that, when patients are living in the community, the drugs that they are prescribed are taken, as a result of which the community is safeguarded. That point must be highlighted.
I turn now to the NHS plan targets. I hope that the Minister will comment on the Department's claims in meeting them. I note that the mental health mapping atlas, which was published in June last year, pointed out that there were particular problems in providing a 24-hour service for mental health crisis resolution teams. Fewer than half the teams then established—52, from memory—were meeting that requirement. We all know that mental illness does not operate on a nine-to-five basis—even if the office does. A problem may become acute in the small hours of the night. It is simply no good fulfilling targets nominally, but not meeting them in substance. That is a major area of concern.
Finally, in this area of health provision, the Minister may like to comment on the progress in reshaping the service. For example, I note that in my own county, the Princess Marina site in Northampton will require expensive guarding for several years as the work has migrated elsewhere. That will result in a huge cost to the health service. I am not suggesting that it should not happen, but it is an example of the difficulties of restructuring.
In conclusion, I am sure that there is no lack of good will in this Chamber for making improvements in the provision of mental health services. There is certainly no shortage of ministerial warm words and initiatives on the matter. However, in our hearts, I think that hon. Members recognise that this is not a glamorous area of medical practice; it is perhaps not even one that clinicians would collectively place emphasis on in the absence of a steer from Ministers. Indeed, that was the point of establishing the separate mental health trusts and ring fencing the money allocated to them. We must shout—and the sector must shout—loud and long to get an appropriate share of resources. Ministers will be judged not only on their words, whether spoken or in documents, but on their ability to deliver effective services to meet a rising tide of demand and to deal with some real distress in the community.
Society will be judged by its commitment to include, support or care for those who are suffering and in much distress, and on whether patients, or those who care for them, share our common humanity.
§ Mr. David Drew (Stroud)I congratulate the hon. Member for Daventry (Mr. Boswell) on securing this important debate. It is good to talk about health delivery, rather than about systems and structures, which we shall discuss later. No matter what approach we take to how we do things, it will make little difference unless we implement them on the ground.
This service has traditionally been regarded as the Cinderella service. I do not come to it with any special expertise, but all hon. Members have their own experiences, whether through family and friends, of those who have undergone a period of mental illness. 222WH For the past two years or so, I have been meeting a group of mental health professionals who have taken me through the subject. I have, on the back of their advice, been able to talk subsequently to clients and carers about some of the issues. Matters came to a head over the Government's learning experience of its draft—I will not use the words "ill-fated"—Mental Health Bill, which contained serious weaknesses and was full of lost opportunities. Most people said that incapacity was the most important area for which to legislate; they said that we should try to define what was meant by incapacity and how we could help people who were so defined.
I shall draw on my experience of talking to a group of professionals, but I will do so generally, because those discussions are confidential. We have discussed matters across a wide terrain, including legal issues such as how and what happens when people are sectioned. That is the most difficult and the most extreme way of dealing with someone with a mental health problem. We have also discussed employment benefits, modern psychiatry and some of the issues relating to that and the supporting people approach, which is a good move in the right direction. I shall say more about that later.
I welcome the changes in the structure of the health service in my county, inasmuch as learning disabilities and mental health have been joined under the heading of the partnership trust. For all the possible criticisms of how primary care trusts were set up and how acute hospitals have been brought together, it makes eminent sense for learning disabilities and mental health to be dealt with jointly. The matter is approached differently in different parts of the country. Nevertheless, unless we give clear leadership on such matters, the resources will always go elsewhere and the perception will be that this is a Cinderella service. Some good things have come on the back of the changes. It is rare for a politician to hear universal acclaim for changes, but I have never heard anyone argue against how the trust has been created. The evidence suggests that the trust is working well, notwithstanding the usual budgetary constraints and the difficulty in attracting staff.
I will quickly touch on supporting people. I agree with the hon. Member for Daventry that issues such as housing cannot be underestimated in considering the quality of life of someone recovering from mental illness. Such issues are more than part of the process because people's quality of life entirely depends on them. I welcome the Government's initiative on supporting people, although there is a misconception that it largely concerns older people. I was fortunate enough to secure a debate in this Chamber to examine the initiative, which has led to a new approach to the elderly but also involves bringing together different services such as health, housing, employment and social care for vulnerable people—including those who suffer from mental health problems. One aspect of the initiative that seems to be working well on the ground is the proactive policy of finding supported lodgings, which are the only way to get people who have almost lost everything back into the community.
I shall now look at some of the problem areas. I make no apology for examining some of the ground covered by the hon. Member for Bosworth—[Interruptionj Daventry—I will get the constituency right in a minute. We must examine the different issues that need to be highlighted and prioritised. He has already touched on 223WH that of children and mental health. There have been dramatic increases in resources and prioritisation, but we are corning from a long way back. In the past, parents of children with mental health problems believed—this was also the authorities' answer—that the best approach was to ignore the problem for as long as possible in the hope that children would either get better or become so seriously affected that a dramatic solution would be needed. That was simply unacceptable.
§ Mr. Boswell:Yesterday, I went to a meeting of the parliamentary group on autism, where Baroness Ashton, who is a Minister, emphasised—it is no breach of privilege to say this—the extreme importance of early intervention. I am with the hon. Gentleman in saying that it is absolutely wrong to put such problems off because they need early examination and assessment, even if early action may not be necessary. It is essential that we change that mindset.
§ Mr. Drew:I agree with the hon. Gentleman and apologise again for getting his constituency wrong. I will get back on train now.
Counselling services are vital. They often struggle to find money to keep going, and the Cinderella service in that regard is counselling for young people with mental health problems. I hope that the Department of Health will pay attention to that issue because counselling traditionally exists within the domain of local government in general and social care in particular, but it is linked with health.
On drug treatment, we must feel pleased that, as the hon. Member for Daventry said, there have been dramatic improvements in the diagnosis and treatment of mental health over not only the past 100 years but the past decade. We can be proud of that achievement, but it has come at a price. Psychotropic drugs are often the most expensive because they are initially introduced in quite a specialised field. It costs a lot of money to bring them forward and the drugs budget often goes over any boundary intended to keep it within reasonable limits. We have no alternative but to find that money. That is important.
I never cease to be taken aback by the role of psychiatrists. Unlike in other areas of medicine, psychiatrists are still at the centre of all mental health treatment. That is a good thing. Clearly, it is a domain in which specialist knowledge is important. However, there must be accountability. As MPs, we have all had experience of people who feel that they do not get on with their psychiatrist. They believe that it is difficult to get second opinions, particularly in relation to tribunals, to turn around what such people see as a system that is stacked heavily against them.
On sectioning, I hope that, when the Government bring back the mental health legislation, we will consider carefully and sensitively the support on which an individual in the most extreme of situations is able to call. There has been quite an argument about who can be the "friend" of the person being sectioned and about what rights they both have. Given the somewhat difficult position of the community psychiatric nurse— 224WH who is in the position of issuing the order but is also there to advise the patient or client—the question is how to make things as feasible as possible without making them invidious. Those are big issues.
Thankfully, sectioning happens quite rarely. However, as the hon. Member for Daventry made clear, we know that on the back of our community approach to mental health there are difficulties when people do not agree or do not keep to their regimes of taking medicines. That means that a very difficult situation sometimes has to be faced.
On benefits and employment, I never cease to be amazed—I have shared this with my local citizens advice bureau—about the complexity of the system for people who are affected by mental health problems. It appears that, when people lose an appeal, more often than not it is because of the change in circumstances that appear in terms of the doctor's diagnosis—the person from the Benefits Agency Medical Service—added to what somebody may have put on their form. I would always argue that someone who has had mental health difficulties needs careful support in relation to how they fill the form in and access the benefits system. It is often very hard—although not a matter of life and death; I do not want to he that dramatic—when someone who has had an appeal turned down is reconsidered. We all know what happens. People tend to exaggerate their rate of improvement in the belief that that is the honest and right thing to do, but doing that can adversely affect them.
In one session, I was impressed by the work of the disability advisers and by how much more they try to bring people into the world of work through the stepping stones of voluntary activities, supported employment and then, let us hope, part-time and full-time work. It is a long-term process. We are not talking months; we are often talking years. That means a lot of engagement and a great deal of support.
Much has been done and much more needs to be done. The debate comes at a fortuitous time. There are three issues to consider. First, how can we put more genuine resources into the service so that we give it its correct priority, given the number of people affected? Secondly, how can we continue to change attitudes so that perceptions of mental health are no different from those for any other form of health? We all know that that problem bedevils this issue. If we see mental health as something that we do not want to talk about, it will always be seen as something not worth spending money on.
Thirdly, how can we continue to measure and gain the benefits of medical improvements, notwithstanding the fact that we are moving into an era of much more choice? When I talk to people who are suffering, I never cease to be amazed at how much they are aware of their choices. They want choice over drugs regimes and the type of treatment that they are getting. That can prove difficult, because this is the one illness for which people can be compelled to undergo a period of treatment to which they might not agree. However, that has to be done in as accountable a way as possible, so that when those people get better, they have some choice over how their regime is moved to a conclusion. If we can do that, 225WH we will have performed a great service to the people suffering from this illness and have moved the whole service into the 21st century and to where it ought to be.
Mr. Deputy SpeakerOrder. Before we proceed, it may be helpful if I point out to Members wishing to speak that it is desirable for the first of the Front Bench spokespersons to be called not later than 10.30.
§ 10.5 am
§ Mr. Mark Francois (Rayleigh)I begin my remarks by congratulating my hon. Friend the Member for Daventry (Mr. Boswell) on securing this important debate.
I should like to take the opportunity to raise specific constituency issues relating to the provision of mental health services. Before the debate I managed briefly to give the Minister private notice of one of them. Two mental health trusts operate in my constituency, the North Essex mental health trust and the South Essex partnership trust. The latter currently has its major facility in my constituency at Runwell hospital, which was first constructed in the inter-war years and added to later. The facility is rather long in the tooth, and plans have been outstanding for several years to provide alternative provision at Runwell and other sites in south Essex.
To summarise, three principal elements are involved in what is usually known as the Runwell re-provision programme. The first is to build a purpose-built low and medium-secure site at Runwell. It has accommodated low and medium security mental health patients for many years, so there is nothing new in that. The re-provision is taking place via the private finance initiative mechanism and the Minister will be aware that such things take rather a long time. There have been negotiations and discussions about the programme for years but construction has not yet started, although it appears that matters are finally beginning to gather momentum.
Secondly, acute services, currently based at Runwell, will be moved to Rochford hospital, just over the boundary of my constituency, in the constituency of my hon. Friend the Member for Rochford and Southend, East (Sir Teddy Taylor). A major refurbishment is intended for Rochford, which will allow the upgrading of a number of old wards so that acute patients can be moved to that facility. A planning application was recently approved by Rochford district council to allow that to go ahead.
Thirdly, what are colloquially known as EMI—elderly mentally infirm—services will be moved from Runwell to two new purpose-built facilities, one in the Southend area and the second in Rawreth in my constituency. Much of the remaining Runwell hospital site will then be sold off for housing redevelopment. That is, in outline, what will transpire.
Two specific issues arise from that, and I should like to take the Minister through them, having orientated him to this point. The first relates to the EMI facility at Rawreth. As I understand it from briefings from the trust, the idea is to have a modern purpose-built facility to cater for, as the name suggests, elderly mentally infirm patients, many of whom are physically quite weak and many of whom will be suffering from conditions 226WH such as the advanced stages of Alzheimer's disease. The trust already has planning permission for the facility, and construction is due to begin later this year.
I should declare a personal interest as the site is located in the local government ward in which I live—Downhall and Rawreth. Despite that, I say to the Minister that I am not being a nimby about the development, and I did not raise strong objections to it per se. However, I have one particular residual concern that I want to raise with the Minister. A local primary school is scheduled to relocate in a few years to a brownfield site adjacent to the EMI site at Rawreth. That means that primary schoolchildren will be playing in the playground not that far away from the facility.
I do not want the Minister to think for one moment that I am attempting to be alarmist about the matter, because I am not. I hope that he will take me entirely at face value when I assure him that I am looking for reassurance. I am sure that he can understand that there are areas for concern. I have discussed the matter in detail with the chief executive of the trust, Dr. Patrick Geoghegan, and he gave me his personal assurance that no one should be based at the EMI facility at Rawreth who would pose any threat to children at that primary school. I am grateful for that but I would like to cover the issue with the Minister as well.
I want to ask two questions. First, will the Minister assure me that no one who has any record that might suggest that they could pose a threat to children will be based at the EMI facility at any time? Secondly, will he also assure me that security measures will be in place? There must be physical security—the design of the building, exits, locks and so on—and 24-hour manning and adequate staffing. so that it will not be possible for any patient from that facility to go walkabout unsupervised by staff. I am assured that the people in the facility require 24-hour supervision, and I want the Minister to reassure me that there will be adequate staff and security measures in place to ensure that that remains the case. I would welcome the Minister's reassurance on those two points for reasons that I hope he can understand, and which hon. Members will appreciate are fully appropriate in the circumstances.
The second issue that I want to raise relates to the old Runwell hospital site. A low and medium-secure unit will be built in one corner of the site, and the bulk of the remaining land will be sold for housing redevelopment. The local community has known that that has been in the wind for many years, so it does not come as any surprise to them. An outline planning application was submitted to Chelmsford borough council a while ago, but rather than determining it immediately, the council is negotiating with the applicants about the fine detail of the application. That is being handled for the Secretary of State by an organisation called Inventures that is acting as the Secretary of State's agent in the matter.
An organisation called the Runwell hospital sports and social club is also located on the site, covering some 10 acres. The club arose as a sports facility for the hospital staff, of whom there were many in days gone by, but over the years the club extended its membership to members of the local community. Many people now use that facility for rest and recreation, and a number of sports are available there. To give the Minister a flavour, 227WH they range from outdoor sports such as football, to archery, bowls and others. A small clubhouse caters for the members.
Understandably, the club is anxious about its future because of the redevelopment, and a delegation from the club led by its chairman, Mr. James Fraser, came to see me at my constituency surgery last autumn to express its concerns and to ask me to take up the matter on its behalf. I subsequently wrote to Inventures and asked whether it could provide any long-term guarantees for the future of the club. I regret that, to date at least, it appears that it is willing to renew the club's lease on a year-by-year basis only.
Mr. Deputy SpeakerOrder. I am listening extremely carefully to the hon. Member. Unless I am missing something, he seems to be straying into an area of planning consent that is not the concern of the Minister who will reply to the debate.
§ Mr. Francois:I take on board your points, Mr. Deputy Speaker. If I am sailing too close to the wind, I shall tack back in, if I may put it like that. I hope that you will understand that this is a matter of genuine concern to my constituents. However, I shall quickly see whether I can get something out of the Minister, bearing in mind what you said; I would not wish to argue with you in any way.
The Minister understands the problem. I wonder whether he or another Minister at the Department of Health would be prepared to accept a delegation so that we can discuss the matter face to face to try to secure for the club a long-term future in which it will not be threatened. That facility should be retained for the benefit of my constituents and other people in the community who find it extremely valuable.
In summary, I would appreciate it if the Minister provided me with some reassurance about the EMI facility at Rawreth, not least because he must realise that, because the primary school is to move, the relocation of the facility may cause concern to parents who are thinking of sending their children to the school. It would therefore be valuable to have ministerial reassurance that all the angles have been covered. I would also be obliged if the Minister consented to receive a delegation so that we can discuss the issue that falls outside this debate and bring it to a satisfactory conclusion.
§ Dr. Julian Lewis (New Forest, East)I join others who have congratulated my hon. Friend the Member for Daventry (Mr. Boswell) on securing the debate. I particularly congratulate him on the measured and compassionate way in which he addressed the subject.
I should state for the record that I am not a medical doctor. Like the hon. Member for Stroud (Mr. Drew), my knowledge of the matter comes entirely from the experiences of friends, relatives and others who are close to me. Because of the prevalence of mental health problems in society, we all have such experiences on which to draw.
228WH I recall the Friday in December 1997 when I introduced a Mental Health (Amendment) Bill after having been drawn second in the private Member's Bill ballot. It was the usual set-up for business of that sort, with a sprinkling of hon. Members in the Chamber. I believe that, just a week earlier, the Member who had been drawn first in the ballot introduced his Bill to ban hunting with dogs. Hon. Members may remember that, on that occasion, the Chamber was heaving with people who were concerned to express their opinion on what is, of course, a very important issue about which people hold passionate beliefs. However, I felt then and still feel that there is a mismatch between the concern that is shown for desperate people and that shown for hunted foxes.
Even today, for this most important debate, there are only seven hon. Members in the Chamber: four Conservatives, one Liberal Democrat and two from the Labour party, including the Minister. I appreciate that time limitations and the fact that we are not considering legislation have something to do with that. Nevertheless, I believe that it indicates that mental health, despite its importance, is undervalued.
For the Minister's benefit, I wish to flag up early the two main issues about which I spoke way back in December 1997 and about which I shall speak today: the importance of separate therapeutic environments for the treatment of people who suffer very different forms of mental illness, and the importance of abolishing mixed-sex wards in psychiatric units.
As my hon. Friend the Member for Daventry said, traditionally, the problem was swept out of sight and people were sometimes over-zealously confined to institutions. However, we all know that the pendulum has swung in the opposite direction, sometimes too far, and that some people need the support of an institution, or at least the knowledge that an institution is available, for what I believe was called the revolving-door technique. People could be out in society but, if they felt an episode coming on, they could go into an institution for respite or treatment—it used to be said, perhaps flippantly, for an MOT service—to recharge their batteries and become stabilised before venturing out into the world again. One of the effects of the pendulum swinging to such an extent against the institutionalisation of people with mental health problems was that beds were then no longer available for those who needed them in the long term or on a revolving-door basis.
I shall give an example from my constituency, but will not go into constituency matters to anything like the extent that my hon. Friend the Member for Rayleigh (Mr. Francois) did with his customary assiduity. There was a large mental hospital on the Tatchbury Mount site in my constituency before I lived in New Forest, East. It had a very good reputation, but in succeeding years, more and more of the Tatchbury site, which was intended for the therapeutic welfare of people with mental health problems, has been taken over by the administrators of local medical services. I do not draw any conclusions from that about people's state of health, but it has been indicative of a trend and I am glad that a state-of-the-art acute unit is now being built on that site for clients in the New Forest area and beyond who may need an in-patient stay in years to come.
229WH There are two broad categories of sufferer from mental health problems. There are those whose affliction tends to make them aggressive or psychotic and those whose affliction or illness tends to make them vulnerable and delicate. What concerned me in 1997, when I introduced my Bill, was that in-patient facilities had been so contracted that, if someone fell into either category, there was no guarantee that if they were admitted they would not be cheek by jowl with someone in the other category of vulnerability. To be more specific, someone suffering from a potentially suicidal, depressive condition could have found themselves on the same ward as people suffering from illnesses that made them psychotic and aggressive. I cannot think of anything worse from the therapeutic point of view for someone in a state of extreme suicidal, clinical depression than to be in such an environment. A dilemma would arise for the doctors and families of people in that condition as to whether it was more risky to leave them out in society where they might kill themselves or to put them in an institution or unit where they would be cheek by jowl with people who were unlikely to encourage any form of rapid recovery.
§ Mr. DrewDoes the hon. Gentleman agree that that dilemma arises not just in hospitals but in prisons where there are the same pressures and people suffering from mental illness are also incarcerated?
§ Dr. Lewis:I do indeed. I have not studied the subject, but I strongly suspect that there are people in prison today who would be in mental hospitals, not prison, if there were more facilities for in-patient admission to those hospitals.
As I said at the outset, I am not medically qualified to comment on these things, but I want to make an observation about what is sometimes called depression, as it has increasingly made an impression on me as I have become acquainted with people who have suffered from it. There is a closer relationship between the physical state of the body—the chemical state of the body, in particular—and the state of mind of an individual than is commonly recognised.
It is unfortunate that the word "depression" is used in two entirely different senses. It is used in the purely psychological or subjective sense, when someone says, "I am feeling down","I am feeling upset","I am feeling unhappy","I am feeling extremely unhappy" or, "I am feeling depressed." Hearing that said in isolation always inspires the reaction, "Ah, well, if you look at it this way, cheer up, get your act together or show an effort of will, you can snap out of it." That is one category of depression, and the word "depression" is commonly used in that sense. For that reason, clinical depression is underrated because it shares the same descriptive term.
When people suffer from what I referred to earlier as potentially suicidal clinical depression, it can often have an entirely physical cause. My mind goes back to the histories that I used to read about secret agents in enemy territory who were captured and deprived of sleep night after night in order to break them down. The strongest and most courageous people would inevitably crack if they were deprived of sleep for a sufficient period of time.
Much of what passes for clinical depression today is actually caused by shock or trauma, or something that has upset the chemical balance of someone's 230WH constitution and destroyed their ability to sleep soundly so that they are in a state of mental decline. All the talking, counselling and cognitive therapy in the world will not do anything to help unless the chemical problem can be addressed. It is unfortunate that these two very different categories of "depression" are lumped together by a common terminology.
Finally, I want to talk about mixed-sex wards. In February 1999, I initiated a debate on this topic, in which I paid tribute to a group of women users led by Cath Collins and based at the Maudsley hospital. Even then, the women were campaigning for new local units that would ensure that people of opposite sexes in a vulnerable mental condition were not put together in wards in circumstances of intimate closeness and sharing facilities.
I recently heard that the women's continuing struggle over a certain unit that concerned them has been successful. That is progress of a sort, but I want the Minister to assure us that there will be no concealment of the figures that show which trusts have succeeded in doing away with mixed-sex wards in psychiatric units, and which trusts persist in trying to keep them going because they believe that it is normal for men and women to mix even in extreme circumstances.
In preparing for the debate, I had a quick look on the internet at newspaper cuttings about sexual assaults, including rapes, that have taken place in mixed-sex wards, and there are too many cuttings, even from the last year or two, for me to run them off my computer database conveniently.
I ask the Minister two questions. First, does he accept in principle that there should be separate therapeutic environments for the treatment of people with very different types of mental illness in in-patient units? Secondly, will he guarantee that, when inquiries are made into which trusts and health authorities have succeeded—and which have not—in abolishing mixed-sex wards in psychiatric units, the data will be forthcoming?
§ Mr. Paul Marsden (Shrewsbury and Atcham)I congratulate the hon. Member for Daventry (Mr. Boswell) on securing the debate. He set out carefully considered arguments, and has made some well thought-out points, which I sincerely hope that the Minister will consider. I also congratulate other hon. Members present, who have also made valid points.
Mental health problems are widespread, and even though things are improving there is still an element of the attitude that prevailed perhaps 20 years ago with cancer. No one wanted to talk about cancer, and if anyone put their hand up and said that they had cancer, a certain stigma attached, because people thought that it might be contagious in some way. Times are changing with regard to mental health, but there is still an element of that attitude now. That is why this debate is so important, and why it is important that the Government address some of the real. problems that are still out there. However, I congratulate them on starting to make real headway in addressing the problems.
MORI, the polling organisation, found that three out of five people reported knowing someone with mental health problems, and one in five reported experiencing 231WH three or more mental health problems themselves. One in three have reported depression. The charity Rethink undertook a survey last year, and found that a quarter of young adults have reported suffering from stress. It thinks that if there were better public understanding of mental illnesses, it would benefit young people particularly. It found that some 10 per cent. of young people will experience mental health problems.
Although the suicide rate is falling in the general population, it is not falling among young people, and that is of particular concern. The survey also found that young adults had to wait 18 months from the appearance of their first symptoms for a diagnosis of schizophrenia. The YoungMinds organisation highlighted a number of problems. It said:
"There is a major gap between government policy and service delivery."It highlighted that young people were particularly vulnerable to"Depression, eating disorders, behavioural problems"and"drug and alcohol abuse".YoungMinds said that that could lead to real problems, including children's being excluded from school and committing offences, and could even lead to homelessness.As the hon. Member for Stroud (Mr. Drew) highlighted, there are real problems in Britain's prisons. Ministers' parliamentary replies make it clear that, in the past six years, the number of suicides has increased from 41 to 94. Taking into account the increase in prison population, that means that people are 13 times more likely to commit suicide in prison than they are in the wider community. That is clearly related to the fact that on entering custody, 20 per cent. of men and 40 per cent. of women have previously attempted suicide. The social exclusion unit report of July 2002 found that 72 per cent. of men and 70 per cent. of women sentenced to prison suffered from mental health problems. The problems extend to other vulnerable groups such as rough sleepers. It has been found that perhaps half of rough sleepers suffer from mental health problems.
I praise mental health care staff across the country who do a fantastic job day in, day out dealing with some of the most vulnerable people, whether they are in the acute sector or in the community. Clearly, those staff are still under-resourced, which is a problem that goes back several years. The phrase, "a Cinderella service" still stands to a certain extent. It did not help that between 1989 and 1997, one third of NHS beds for people with mental health problems were cut. At that time in 1997, only one in five people diagnosed with schizophrenia had access to a community psychiatric nurse.
In recent times, the King's Fund has found that things are not getting much better. It has highlighted lack of funding and the problem of recruitment and retention of staff. It is worried about the political targets that have been set by Whitehall, and concerned that targets for mental health services, which are arguably less glamorous than other Government targets, lose out. The Government should be congratulated on introducing the national service framework, which was 232WH a stepping stone, but, as the hon. Member for Daventry said, we need an update. We need to know what progress has been made on that NSF.
The King's Fund also highlighted the need for early intervention to prevent problems from getting worse. It wants a much greater focus on care given by GPs and community health care. The national GP survey of primary care conducted by the Mental After Care Association—MACA—found that one third of GPs want to spend more time with patients but are unable to because of the pressures of work. The reason that GPs give is that 30 per cent. of their patients suffer from mental health problems.
I was concerned to learn that for young people in particular the average wait for their first out-patient appointment to see a psychiatrist is 6.6 weeks. Back in 1997, it was 6.4. Arguably, problems are not going away, but getting worse. In my constituency, covered by Shropshire, the average wait for children is nine weeks for a first out-patient appointment to see a psychiatrist.
The Mental Health Foundation has highlighted that there is a national shortage of consultant psychiatrists. I welcome the extra £140 million that has been outlined for the next three years for child and adolescent mental health services, but where is that money going, and will it deliver what we all want: a comprehensive mental health service?
The draft Mental Health Bill was a complete disaster. It was summarised well by the Mental Health Foundation when it said that it believed the proposed Bill to be
"fundamentally flawed. The proposals in this Bill are misconceived, unworkable, are likely to infringe individuals' human rights and undermine the more positive aspects of current mental health policy."I hope that the Minister will ask the Minister of State, the hon. Member for Redditch (Jacqui Smith), to go back to the drawing board and return with a new Bill. A Bill is needed because as the Mental Health Foundation said that it was deeply disappointed by such a missed opportunity.We need expanded capacity with increased funding for mental health services, so that there are more mental health nurses and specialist doctors. We need that new mental health legislation. We must improve the diversity of services, by trying to recruit people from the ethnic minorities who understand the cultural differences that exist in our society. I was told the story of a woman in a mental health hospital who, for reasons of privacy and her Asian background, sat on the toilet in reverse position. The reason for her behaviour was privacy, but mental health care professionals could have easily misinterpreted it as related to the mental health problem that she had. Such problems, possibly leading to misdiagnosis, would not arise if there were more people from different backgrounds with a greater understanding of diversity. We have to give carers more support and we have to ensure that we have joined-up services, including health, education, social services and the voluntary sector, if we are to deliver the services that people need.
With the Government leading the way, I hope that that will help to bring about the change in attitude that, as I said at the start, is so fundamental. That is where such a great difference can be made. Intervention can be 233WH made early if people feel confident enough to access mental health services and to talk about the problems that they are encountering. I hope that the Government will listen, in particular to those voluntary organisations that were so concerned about the Bill's proposals. I hope that the Minister can address some of my concerns.
§ Tim Loughton (East Worthing and Shoreham)I add my congratulations to my hon. Friend the Member for Daventry (Mr. Boswell) on bringing this subject to Westminster Hall today. The trouble is that it is an enormous subject and we do it only a little justice this morning. I congratulate the other hon. Members who have brought their own particular expertise, particularly my hon. Friend the Member for New Forest, East (Dr. Lewis), who has a great track record in the field, and the hon. Member for Stroud (Mr. Drew), who raised many points about conditions in prisons and the conditions and environment that affect people with mental health problems. I also congratulate my hon. Friend the Member for Rayleigh (Mr. Francois) on his ingenuity in raising some only slightly related constituency issues. I agree with all the points that hon. Members have made.
Despite many warm words from the Government, mental health is still a much neglected facet of the health service. In my role of shadowing the mental health brief, I see many excellent voluntary projects up and down the country, often run on a shoestring. I have seen many excellent and dedicated professionals in the service operating in increasingly difficult conditions. Too many people, young and old, are still being failed by the system. Mental health trusts are all too often at the back of the funding queue, and all promised growth moneys get swallowed up by debts inherited by newly formed trusts. That is why the Opposition have sought to raise the profile of the whole subject of mental health in Parliament. We organised a series of summits on it at Westminster last year and have used some of our Supply day debates for the subject.
We are now almost a year on from the highly misguided draft Mental Health Bill, which was an exercise more in coercion and law and order than in giving proper medical help and support to people with serious mental health problems. It had the world and his wife arrayed against it and it has not seen the light of day since, but a proper mental health Bill is desperately needed. My first question to the Minister is: when will we at last see the mental health Bill? Will it be the product of, and under the ownership of, the Secretary of State for Health, as it should be, or the Home Secretary, whose fingerprints were all over the first attempt?
The national service framework, as my hon. Friend the Member for Daventry said, set seven national standards for mental health services to drive up quality and reduce variations in services to patients and service users. That should include round-the-clock crisis teams for emergencies, more mental health beds and improved training for general practitioners. Yet in almost every respect, professionals and patients are just not seeing those improvements at the sharp end.
As many hon. Members have mentioned, there is a big problem with staff vacancies. About one consultant in three plans to retire early, according to a study by the Royal College of Psychiatrists. The problem is worst in 234WH inner London and north-west England. Dr. Andrew McCulloch, the chief executive of the Mental Health Foundation, has said:
This is a disaster in the making. The Government has no strategy for dealing with this. If we lose all these experienced older staff, it is very difficult to see how we could run a lot of the services.A draft Department of Health study on work force planning two years ago predicted that by 2005 there would be between 10,000 and 35,000 vacancies among mental health staff. The latest figures from the Royal College of Psychiatrists suggest that there are at least 800 key vacancies at the moment, and that many health trusts are having to use large numbers of agency staff—in some cases, up to 30 per cent. Findings of the Sainsbury Centre for mental health show that there are 25,000 registered mental health nurses—just 4 per cent. of nurses registered in the UK. Half of the UK registered nursing work force is now over 40 years old and only 4.7 per cent. of international nurse recruitment is for mental health.The Opposition health team has carried out a detailed survey and written to all mental health trusts up and down the country. We shall release the findings of that survey shortly. We asked about staffing levels, numbers of new category primary care mental health workers and numbers of operative assertive outreach teams. Some of the findings were alarming.
On staff vacancies, one trust reported 10 vacancies out of a total of 30 consultant posts, which is a 33 per cent. vacancy rate. Agency staff account for 22 per cent. of all nursing staff in another trust. Nearly every trust surveyed said that it did not currently employ a primary care mental health worker, while a few said that they had plans to appoint some in the coming year.
On assertive outreach teams and 24-hour cover, some trusts have just one team in place while others have five. Only 30 per cent. of the trusts that responded said that they had 24-hour cover with at least one team on call, and only four of the trusts had a full allocation of teams available for 24-hour cover. Some 80 per cent. of trusts said that they had no early intervention teams in their area.
I shall quote some of the comments contained in the responses:
"A high percentage of adolescents are picked up and treated by YOT; however the commissioners are not funding this service after August this year. This will leave a gap in service. We have no specialist Adolescent only services."Another trust said:There is a real danger that the particular needs of older people for access to good quality mental health will drift off the policy/ political agenda.Those are hard data from people at the sharp end.We asked another trust how many of the new category primary care mental health workers it employed; the answer was none. We asked how many assertive outreach teams operated in the trust; the answer was none. We asked whether its assertive outreach teams could offer 24-hour cover, seven days a week; the answer was no. We asked how many early intervention teams had been established in its area since July 2000; the answer was none. We asked how many crisis resolution teams worked in its area and whether all those teams offered 24-hour cover; the answer was none. 235WH We asked whether provision for adolescent mental health was adequate; the answer stated that it was very inadequate. We asked whether the trust knew how many GP practices had proper access to counselling services in their practice areas; the answer was no. We asked about the scope for community involvement on its mental health trust in the future; the answer was none. We asked whether it could offer its female service users a women-only day centre facility; the answer was no.
That survey was not untypical. It deals with one trust, which covers a large part of a county. There is a complete absence of any of the key innovations in mental health services about which the Government tell us so much. The innovations are not working in that trust and that is not untypical. There are many other specific areas of concern that I do not have time to go into.
YoungMinds, the organisation at the forefront of the campaign for better facilities for young people with mental health problems, has conducted a two-year, in-depth study of in-patient units for young people, which is published today. The study reveals a widespread lack of post-discharge provision for young people. Young people leaving in-patient services are not seen as a priority by community-based professionals. Many inpatient units are struggling with recruitment problems and the pressure caused by working with a lack of trained staff. There are many stories of children with severe health problems being treated alongside hardened drug addicts and alcoholics in adult wards.
There were 64,920 occupied bed days for patients under the age of 18 on adult psychiatric wards during 2001–02. That represents 36 per cent. of the total number of hospital occupied-bed days for that age group on both child and adolescent wards and adult wards during that year, which is unacceptable.
What are we doing to prevent mental health problems among our young people? The Department of Health's research among 15 to 21-year-olds reported that 86 per cent. of them knew someone who had experienced mental health problems. More than half of them knew someone who had self-harmed, but 97 per cent. of them knew little about mental health problems.
We have heard about the incidence of suicide and the national suicide prevention strategy, which was published in September. As Richard Brook, the chief executive of the mental health charity Mind, has said:
The problem with the suicide strategy is while it is good at looking at risk, it's not good at delivering services … There will not be the services for the vulnerable groups, particularly young men".We have heard about the alarming rise in the suicide rate, particularly among prisoners.What preventive measures have the Government taken to tackle depression and mental health problems in our schools and the stigma attached to mental health problems? What discussions have the Minister and his colleagues had with organisations such as the Charlie Waller memorial trust, which has done excellent work in combating depression? We must work on prevention at the primary care trust level, with 90 per cent. of depression cases being referred to and treated by GPs. Work is needed to raise awareness of reducing the 236WH stigma in schools, and we should appoint specialist trainers to work alongside health visitors, teachers and parents, and incorporate mental health and emotional health and well-being teaching in the school framework.
I could go on, and mention the problems of access to drugs for schizophrenia and so on. The subject is very important. The Government must raise the profile of the issue and match their warm words with serious actions and results for people, particularly young people, who desperately need mental health services throughout the country. I ask the Minister urgently to bring back as soon as possible a proper mental health Bill that will attack many of the problems that we still have, and not to let it be hijacked by those who would use a mental health measure as a way of locking people up rather than giving them the proper medical treatment that they need and deserve.
§ The Parliamentary Under-Secretary of State for Health (Mr. David Lammy)I congratulate the hon. Member for Daventry (Mr. Boswell) on securing this important debate, on his sincerity and on the measured way in which he raised the issue. It has been a good debate. It is fair to say that all hon. Members have discussed the issue in a non-partisan way, and we all welcome that. The issue is one of the most important in all our constituencies.
Given what has just been said by the hon. Member for East Worthing and Shoreham (Tim Loughton), I shall set out the context that we inherited in 1997 because it is fundamentally important. One would struggle to find an area of the national health service that was so undercapacity and subjected to such underinvestment. It did not command the attention of Government, or our communities and population in the way in which it should have done. That is the situation that we inherited. There was underinvestment in our mental health services, a host of damaging inquiries into service facilities, a demoralised and undersupported work force, and community services were in a sorry state.
We made it clear in that context that we faced a challenge, which the Government took very seriously. We said that we were going to prioritise that problem, and we did so. It is significant that, alongside the priority we gave to cancer and coronary heart disease, we made it clear that our mental health services needed investment and reform. The national service framework and many of the other developments that hon. Members have spoken about this morning followed. I want to talk about those, too.
The issue is fundamentally important when one considers that as many as one in six of the population is affected by a mental health problem, and many more families and children are indirectly affected. Hon. Members will know that I stand here as a Minister in the Department of Health and as a Member of Parliament representing one of the poorest constituencies in the country. I cannot do a surgery without seeing the effects of mental ill health. Each year, more than 600,000 people with serious mental health problems receive care from specialists, mental health and social care services.
As has been said, suicide is now the commonest cause of death among young men. Perhaps as many as a quarter of primary care consultations concern someone 237WH with a mental health problem. That is why the Government are committed to improving mental health services. Our clear and comprehensive programme of reform represents the best opportunity and provides the biggest investment to improve the lives of large and neglected groups of people.
Key to the programme of reform is the mental health national service framework—the first national service framework to be published in the sector. The Government are proud of laying down national standards that everyone who has a mental illness should expect all over the country. The aim of the framework is to deliver modern mental health and social services of a kind that people are entitled to expect in every part of the country. It will help to improve access to effective treatment and care, to reduce unfair variation, to raise standards across the country and to provide quicker and more convenient services for patients.
At the very least, we are talking about a 10-year programme of reform. The NSF sets standards for mental health covering health promotion, primary care, access to services, specialised services for people with severe mental illnesses, support for carers and the action needed to reduce the suicide rate. It provides a national standard base across the country. The hon. Member for New Forest, East (Dr. Lewis) raised some big future stuff. Of course, decisions must be based on the clinical decisions that people make on the ground. However, the hon. Gentleman talked about the separation of types of treatment. That is not the direction of Government policy or where we began our inquiry. The capacity constraints and problems were such that we simply had to lay down minimum standards to begin with.
§ Dr. Julian Lewis:Does the Minister accept the principle that it is wrong for people with very different types of mental illness to be lumped together on the same wards where they can harm each other's prospects of progress, or, indeed, harm each other?
§ Mr. Lammy:The hon. Gentleman will know that there is a long tradition of Ministers laying down 238WH standards and frameworks and taking expert advice. Decisions must be made locally and clinically. He will also know that the Government have done much to ensure that when local situations arise—I do not know his locality—people can raise issues through overview and scrutiny panels. We also have a new inspectorate and patient forums. The Government have put in place a number of mechanisms by which such situations and incidents can be dealt with as they arise—something that was not the case in the past.
There are further national service frameworks on older people—with a dedicated section on mental health—on children and on services for people with long-term conditions, which will build on and complement the work that is already under way.
My hon. Friend the Member for Stroud (Mr. Drew) raised the issue of investment, as did the hon. Member for Daventry. Underpinning the reform of mental health services is more than £300 million in new investment by 2004 to fast-forward the NSF and deliver our NHS plan commitments. The hon. Member for East Worthing and Shoreham cast some doubt on whether that money is reaching the front line. He will know that the first tranche of that money, the 2001–02 tranche, was ring-fenced—it totalled £75 million—ensuring that, from a low capacity base, local areas were able to begin to plan and to get the staff to build up to where we need to be by the end of the NSF.
§ Mr. Francois:Will the Minister respond briefly to the two constituency points that I put to him?
§ Mr. Lammy:I am sure that if the hon. Gentleman writes to my hon. Friends in other Departments, they can deal with the latter issue. The first issue is a local one and there are methods by which it can be discussed. I mentioned the overview and scrutiny panel. That should reassure his constituents, as it would in other areas. He should be aware of shifting the balance of power. We must not attempt to run local issues from the Department of Health but instead allow clinicians and local people to make decisions. He will understand that.