HC Deb 13 July 1989 vol 156 cc622-7W
Mr. Goodlad

To ask the Secretary of State for Social Security in the light of his statement of 12 July on community care, what plans he has to improve health services for the mentally ill.

Mr. Freeman

I have been asked to reply.

I welcome the opportunity to outline Government policy towards the care in the community of the mentally ill and to indicate the initiatives that we propose to take to improve these services in England. These will, of course, be included in the White Paper on community care to be published this autumn which will set out the finer detail where necessary.

Until the 1960s there was little alternative for those suffering from serious mental illnesses such as schizophrenia to prolonged in-patient care in one of the large and often remote mental hospitals. Scientific advances in the 1950s, particularly the discovery that the symptoms of schizophrenia could often be relieved by drugs, together with the development of community psychiatric services, opened up the possibility that many sufferers could be treated on a largely out-patient basis. The vision of a new pattern of services on this basis, reflecting an already occurring fall in the number of hospital beds, and anticipating a further fall, was outlined by the then Minister of Health, Mr. Enoch Powell, in 1961. It was turned into detailed policy under Sir Keith Joseph in the early 1970s, though the White Paper "Better Services for the Mentally Ill"—was actually published in 1975.

The policy as stated in that White Paper, the development of locally-based hospital and community services, including facilities providing long term asylum for those who need it, and as a consequence the closure of very large mental hospitals, has remained essentially unchanged since, supported by successive Governments. It is founded on scientific and therapeutic advances, and the knowledge that, with the right supporting services, many sufferers can live fuller lives in the community than in institutions.

In our view, this long-standing policy is a civilised and humanitarian one which has benefited many patients who, otherwise, would have been destined to spend their lives in large isolated hospitals. It has also inspired many caring people to work in the psychiatric services. We know it can work. We have examples of services such as those in Buckingham and Hackney, which show what can be done through prevention, early intervention and well coordinated care at home working closely with family doctors. I am glad today to be able to reaffirm the Government's commitment to the policy, and our determination to ensure that it is properly implemented. There is no going back to the days when health service care for the mentally ill invariably meant long term institutional care.

Although there are some who question the policy itself, most concerns are about implementation: the pervasive sense that all too often community care means no care: that insufficient resources have been put in place to provide effective alternatives to the old hospitals, where bed numbers have fallen substantially. I would make two points about this.

While we accept that there are deficiencies, it would be wrong to minimise the substantial shift of resources from hospital in-patient provision to community-based services provided by health and local authorities. Over the last ten years for which information is available (1977 to 1987), the number of places for people with a mental illness in local authority, voluntary and private residential homes almost doubled (to 9,000) and there was a 50 per cent. increase in day centre places (to 6,000). On the health service side there has been a 44 per cent. growth in day hospital places (to 19,000) over the same period; the number of community psychiatric nurses has more than doubled since 1981, and it is estimated that the number of districts with a community mental health centre has doubled every two years throughout the 1980s.

We made quite explicit in last year's guidance to the National Health Service what has always been the intention: that hospitals should close only when proper alternative locally based services were available. When the Secretary of State discussed this issue yesterday with the chairmen of the regional health authorities he made it clear that he will not approve the closure of any mental hospital unless he is satisfied that proper alternative services are in place. This coupled with the requirement to introduce care programmes in 1991, means that no patient will be discharged from hospital without proper consideration of his or her need for continuing care and where needs are identified, plans to meet them.

Over the last few months we have been working, and will continue to work, collaboratively with individual regional health authorities to identify the progress that has been made and the problems that have been encountered. Our purpose is not to recriminate over any inadequacies in the past, but to identify what we at the centre need to do to help health authorities implement policy effectively. It is through this work, and discussions with the social services inspectorate and voluntary organisations, that we are building up a region-by-region picture of progress and problems, and I expect to have this around the turn of the year.

To enhance our capacity to undertake this work we have secured the services at the Department of one of the few general managers in the country with experience of developing locally based services and closing a major hospital. Mr. John Jenkins, who played a leading role in the development of services in Exeter and Torbay and the closure of Exminster hospital will be working with us in an advisory capacity from next Monday, and will play a key role in our collaborative work with regional health authorities and the development of any further initiatives or guidance that seem necessary.

I would now like to outline a number of specific policy steps. The first is guidance to health authorities on care programmes. Much concern has been expressed about the adequacy of continuing health service care for psychiatric patients discharged from hospital. Last year, through a health circular, a requirement was placed on district health authorities to initiate, by 31 March 1991, explicit individually tailored programmes for continuing health service care for all such patients. Later this month we will be formally consulting on guidance to authorities on developing these care programmes, which will emphasise the need for locally developed approaches including local registers of vulnerable discharged patients and regular reviews of their needs. We expect to publish the definitive guidance in the autumn. In addition, and we greatly welcome this, the Royal College of Psychiatrists has agreed to draw up minimum acceptable professional standards for assessing patients prior to discharge, and for follow up after discharge. A preliminary statement of good practice is expected from the college in late summer, to be followed by a more substantive one developed in concert with the other professions concerned. These two initiatives will, together, provide much clearer guidance on good practice than currently exists.

As part of our 1990–91 research programme, we plan to commission research which will assist us to evaluate the effectiveness of the care programme initiative.

The second is guidance on compulsory admission to hospital. Another area of current concern is in relation to arrangements for compulsory admission to hospital, and the related issue of compulsory treatment in the community.

On hospital admissions, there seems to be wide agreement that the law is adequate, but concern that its interpretation by practitioners is sometimes not. We believe that these problems will be much reduced once the code of practice for admitting and treating patients compulsorily required under the 1983 Mental Health Act is available. In April we set up an expert group under the chairmanship of Mr. James Collier, with Mr. William Bingley, on secondment from MIND to whom we are indebted, as the full-time executive secretary. Work is well advanced, and the code will be laid before the House this autumn.

We understand that in due course the Royal College of Psychiatrists will be giving us its views on the possible role of new legal powers to ensure compulsory treatment in the community. We will then explore this issue with all the interested parties involved. Without prejudicing the discussion, we would need to be very clear both of the benefits, and that they could not be achieved through voluntary means, before seriously considering asking Parliament to create provision for compulsory treatment in the community.

The third is health service resources. Although the issues that I have already referred to are important, we fully understand that underlying much of the current concern is the question of resources. Finance from mental hospital sites provides valuable capital for replacement facilities, but these facilities are needed before hospitals can be vacated. They in turn have to compete for resources with other priorities within capital programmes, and this may hold up the whole process. Existing arrangements offer one way of addressing this problem—with regions lending each other capital to match the timing of planned new developments. Another possible solution is for authorities to enter into agreements with developers to upgrade, purchase and build community facilities for the mentally ill, in return for which they would receive all or part of the vacated site. We plan to invite health authorities to identify sites where this approach would be suitable: the aim will be to bring about the degree of private sector involvement that maximises value for money.

We do understand the revenue burden of keeping open old hospitals which will close and new replacement facilities already open. Clearly the quicker older facilities can be closed the lesser the burden of double running and running inefficient emptying facilities.

The fourth is local authority resources. Proper social care for the mentally ill in the community is vital. Yesterday the Government confirmed that local authorities would continue to be responsible for the social care of the mentally ill and announced that from 1991 we would be instituting a new, specific grant to local authorities to encourage them to make the necessary contribution to the services required. To encourage joint planning of services, and proper collaboration in relation to care programmes, we are making this grant payable through health authorities as the Secretary of State's agent, on the basis of agreed plans. Further details will be set out in the White Paper on community care, to be published this autumn.

The fifth is quality of services. We are very concerned that the new hospital and community facilities that are developing should provide a good quality service. In the wake of scandals about the conditions in some mental hospitals in the 1960s and early 1970s, the health advisory service was established, to keep a watch on standards and encourage better services. I think that it is generally agreed that, over the years the HAS has been successful. We are now examining its work to identify how it might be done even more effectively, and in a way even more relevant to the NHS as it will develop following "Working for Patients".

The sixth is the contribution of the voluntary sector. We believe that a lot can be done, through Departmental grants to voluntary organisations, to increase the information, services and mutual help available to the parents and friends of patients. Current grants to voluntary organisations in the mental health field, including mental handicap, are being reviewed with a view to ensuring that we use the nearly £2½ million a year that we allocate in a way which best supports patients and their relatives and encourages new initiatives which are of clear and direct benefit.

There are some areas we need to explore more fully as a matter of urgency. I would like to refer to some of the issues that we are aware are causing concerns that we are beginning to address, and on which work will be undertaken in the course of the next year or so.

First, the need to improve the ability of general practitioners and others to prevent, detect and treat mental illness. The first of a series of departmentally sponsored conferences on these themes was held in May; others are planned for the autumn and next spring. In the light of these discussions we will be considering what practical initiatives need to be taken;

Secondly, the need to provide appropriate services for those among the homeless population who suffer from mental illness. The incidence of mental illness among homeless and destitute men and women in London and other cities has been linked by some to the fall in the number of hospital beds. Research funded by the Department shows that, most commonly, homeless mentally ill people have had care organised outside hospital but have lost touch with the service. We expect to reduce the future numbers losing touch through the measures to which I have already referred. But we need to address the existing problem, and will be doing so in the light of a recent study by the Policy Studies Institute, again funded by the Department, on schemes for delivering primary health care to single homeless people;

Third, the need for adequate arrangements in each health district for emergency care of people suffering from mental illness. In some places this is handled through the normal accident and emergency service; in others by specialist mental health emergency arrangements. We will be discovering the extent of arrangements and seeking to evaluate alternatives.

Finally, let me summarise what we are announcing at this stage. We reaffirm our commitment to the longstanding policy of locally based hospital and community services, including asylum; working collaboratively with the regional health authorities, we will ensure that hospitals are not closed before proper alternative provision is made; from 1991, we will require district health authorities to have care programmes for those discharged from hospital, upon which we will be issuing guidance, and we propose a new specific grant to local authorities, payable through health authorities, to help meet the social care needs of such patients; we are offering health authorities the possibility of, in effect, bringing forward the sale of hospital sites, to fund new facilities such as hospital hostels; we propose this autumn to lay before the House a code of practice for the compulsory assessment and treatment of patients suffering from mental disorder in hospital, and will consider, though from a very questioning standpoint, the possibility of new legislation for compulsory treatment in the community; we are reviewing the work of the health advisory service, to ensure effective oversight of the quality of locally-based services; we are reviewing our funding of voluntary bodies, to ensure that public funds are used in the most effective way to encourage the development and provision of services for patients and their relatives: we are looking at ways of increasing general practitioners' awareness of mental illness and how it can be treated; the extent and adequacy of emergency services for people with a mental illness, and what can be done to meet the needs of those members of the homeless population in London and elsewhere suffering from mental illness.

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