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11 Feb 1998 : Column 1224

8.32 p.m.

Baroness O'Cathain: My Lords, I wish to thank all noble Lords who have participated in this debate. It was extremely good. I now confess that I was dreading this evening because it is the first time that I have introduced a debate in your Lordships' House. It is an occasion which is as terrifying as making a maiden speech. I thank all noble Lords who have made it so much easier for me. I said at the outset that I wished the debate to be constructive, and that was certainly achieved. It was the House at its best, allowing us to benefit from the expertise and experience of all Members. What great and wide-ranging experience we have listened to this evening. The debate was constructive and critical in parts--but it was constructively critical.

My noble friend Lord Buckinghamshire said that the Chancellor of the Exchequer had missed a golden opportunity. I take mild issue with him. We still have four weeks and six days before the golden opportunity is missed. I took heart at the suggestion of the noble Lord, Lord Currie, and that of the Minister that the debate will be helpful in the final deliberations. The proceedings this evening will make most interesting reading in Hansard. But those who are not here will have missed out on the wonderful humour and the mind pictures generated by the noble Lord, Lord Desai, following the harassed mother down the supermarket aisle, trying to discover whether she would be able to put an ISA on her swipe card, while the children and the goods on display were distracting her. It was wonderful humour, accompanied by serious and radical economic proposals. How I wish that the noble Lord had been my professor of economics.

Three other humorous pictures will stay in my mind, two of them generated by the noble Lord, Lord Spens. First, there was the vision of him feeding all the data into his computer and then giving it a kick. I thought, my goodness, it must be much more robust than my computer, or do I suggest that his kicking skills are on a par with those of the England and Ireland rugby teams last weekend? I guess that I shall loathe him for ever for the second one. Every time I see the amount of £5,000 I shall want to divide it by 12. The other humorous point was the description of the VAT booklets concocted by the noble Lord, Lord Newby.

On a more serious note, in passing I was saddened by the contribution of the noble Viscount, Lord Hanworth, but I shall not feel personally guilty for the fact that by judicious saving through PEPS and TESSAs I have been greatly helped in coping with a huge drain on income by providing long-term care for a seriously disabled person for nine years. No one should think nasty thoughts about people who wish to relieve the state of a burden that it would have to shoulder were it not for such savings.

I thank the noble Viscount, Lord Runciman, for his clear description of the regulatory framework. I knew that I would learn a lot tonight and I certainly have about that.

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My noble friends on this side of the House were unstinting in their support and encouragement. Their contributions were all so good and varied and, remarkably, there was very little repetition. I thank them all.

Finally, I come to the Minister. He said that this debate was the most valuable contribution that he could have hoped for. I take slight issue with his remarks about the explosive cost to the Treasury. Surely there is an offset in the reduction in demand on the public purse from those who use savings to provide for their old age and long-term care.

I thank the Minister for his comprehensive wind-up. On a personal note I thank him and all noble Lords on the Government Benches for always pronouncing my name correctly. I beg leave to withdraw the Motion.

Motion for Papers, by leave, withdrawn.

Mental Health (Amendment) (No. 2) Bill [H.L.]

8.36 p.m.

Lord Rowallan: My Lords, I beg to move that this Bill be now read a second time.

The subject of mental health is a comparatively new one for me. Last year I was watching a programme on television, which I very seldom have time to do. It was "Panorama". People were talking about the way the mentally ill were treated. To put it bluntly, I was horrified by what I saw. As the programme continued it became obvious to me that three things were not happening that should be happening. First, the mental patient was not receiving enough attention either because there were no beds available for him to be an in-patient or because care in the community was not working properly. Secondly, the psychiatrist was under intolerable strain working with a lack of proper facilities at hand. Thirdly, the general public were in danger as a direct result of the mentally ill being in the community before they were ready.

Since that programme every one of the patients interviewed has subsequently been involved in some crime--mostly minor, I am glad to say, but nevertheless worrisome--or is back in hospital as an in-patient having been released into the community. In the case of one patient he has committed murder, and a particularly brutal one at that. It received a lot of media attention at the time as a young policewoman was sadly killed entering a house without her bulletproof jacket on.

In Victorian times we put the mentally ill into large asylums and forgot about them. Out of sight, out of mind. Now we do the reverse. We throw them into the community and forget about them, leaving them to fend for themselves where they can stop taking their medication and lose all the progress that they have made in hospital. The medicines that we offer them are old and have side-effects, like feeling as if one has Parkinson's Disease, where one loses control and feeling in one's legs and arms. But they can be long-acting, for up to six weeks, if taken by injection.

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Modern drugs are more expensive, do not have side effects but, most importantly, are only found in pill form and so are not long lasting. So the mentally ill have to use an old drug in the form of an injection every five or six weeks, with side-effects or a new one in the form of a pill daily, which they have to go to a chemist for on a regular basis and also to their GP to get a repeat prescription, whereas they can get the injection from the hospital they have attended quietly and without fuss and without their neighbours knowing that they are ill.

The Mental Health Act 1983 is the current Act dealing with mental health. It still deals with Victorian thinking and desperately needs updating. This amending Bill that we have before us today deals only with in-patient care. I would like to introduce further legislation at a later date to deal with out-patient care. In an ideal world we should have a new mental health Act. Sadly, we do not live in an ideal world. There are more important issues for a government. Please note that I say "a government" and not "this Government", because mental health should not be a political issue. What surely is required is the provision of an environment for this group of unfortunate people whereby they can relax and get better; where the psychiatrist and the nursing staff have the facilities and the wherewithal to look after them; and where the country as a whole has the belief that the best is being done for them.

At the moment all too often that is not the case. Psychiatrists do not want to put their patients, especially female patients, into some units as it is not a therapeutic environment for them to recover in. There are insufficient beds and thus some patients are put out on to the streets to allow someone who, on that particular night and at the moment the decision is taken, is judged to be in an even worse state. When it turns out that those patients should not have been released because they later have a relapse, as happens all too often, the media get hysterical and we endure lurid headlines.

Aftercare is difficult as there is so little supervision as the ill move from carer to carer, from health authority to health authority and get lost in the social welfare system. Would it not be better to have sheltered units with a nurse and doctor on hand in the same way as we provide sheltered accommodation for the elderly? In that way, all such patients could be in one area where their needs medically, financially, and environmentally could be watched over with simplicity. They could regain a sense of independence, find peace and tranquillity and yet have all the help that they could want on hand, in a sort of halfway house between in-patient care and care in the community.

In 1989 a White Paper Caring for People was published. It proposed agreements with developers to build new places for the mentally ill to live in exchange for their developing the old asylums. Insufficient bridge funding meant too little has happened and 40 per cent. of the old asylums remain vacant at an annual maintenance cost of somewhere between £10,000 and £330,000 each. What a waste of resources! In 1994 the then government wanted to ring-fence that money. It was not done.

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That, in simplistic terms, is the background to the problems facing the mental health services today. Add to that governments of all shades who do not view the mentally ill as a high profile group and it is easy to see why so little is happening except for debate, debate and debate. It is not debate we need; it is action. We know the mentally ill exist, but we do not want to admit that they exist by doing something concrete to help them. They are the forgotten society.

Then there is the problem of the non-integration of the charities involved. All do a wonderful job dealing with their own speciality in a vast subject that ranges from bulimia and anorexia at one end through schizophrenia to manic depression and total madness at the other. Each charity is determined to provide for the betterment of the mentally ill, but often they are conflicting in their advice and thinking on how to achieve that panacea. I was delighted, therefore, to receive the backing of all of them for Clause 2 of my Bill which states that there should be single-sex wards in all psychiatric units and security for the patients themselves. It is a sad fact that the mentally ill become sexually oriented. At a time of emotional crisis when a woman needs to feel secure in order to recover, the last thing that she needs is to be harassed, abused or raped by a man in the very place that is supposed to be safe and therapeutic.

In 1996 the mental health commissioners visited hospitals and psychiatric units all over the country. They found to their horror that in over 50 per cent. of the units that they visited evidence of harassment to women existed. Only 35 per cent. of women have access to women-only sleeping areas with separate toilet facilities; 27 per cent. have to pass through male areas and wards to get to their bathrooms; 32 per cent. have access only to mixed bathing areas; and 3 per cent. have to sleep with men in the same ward. What a disgraceful state of affairs--and hardly conducive to a healthy environment for recovery.

In January 1997 the National Health Service chief executive, Alan Langlands, set health authorities the task of providing safe facilities for patients in hospital. By August of that year, only 43 per cent. could report that they had met the standards. Paul Boateng, the Parliamentary Under-Secretary of State in the Department of Health and with special responsibility for mental health, has indicated to me that the remainder must provide those standards by 1999, but admits that most have indicated their inability to give a guarantee that they can do it in time.

The performance targets are not enormous. They are, first, to ensure that appropriate organisational arrangements are in place to secure good standards of privacy and dignity for hospital patients; secondly, to achieve fully the Patient's Charter for segregating washing and toilet facilities; and, thirdly, to provide safe facilities for patients in in-care hospitals to safeguard their privacy and dignity.

Surely all that this Bill does is to give the Parliamentary Under-Secretary the extra clout that he needs to force health authorities to provide those things as part of law--all, I should have thought, easily

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achievable in the suggested timetable, and essential for the betterment of the mental health service. The resources are there, if the recommendations in the Caring for People White Paper are taken up.

I have dealt with Clause 2, so perhaps I should turn to Clause 1. Some of the charities have indicated to me that they are not so happy with Clause 1 as they think it is restrictive. MIND would like Clause 1 to read, "To prepare a strategy for the provision of care for persons who require treatment for acute episodes of mental illness". I can go along with that. It is the nub of the problem, as all too often there is simply nowhere for the patients to go.

The Mental After Care Association, MACA, says that bed-blocking and bed shortages are not best resolved by increasing the number of in-patient beds. It wants to see a greater provision of a range of community-based mental health services, so do I--so do we all, I presume, but we cannot run until we are walking, and the provision of adequate in-patient care is a jolly good starter for 10. When we have that, we can turn our attention to out-patient care.

The National Schizophrenia Fellowship and SANE both like the Bill. Both deal with the biggest mental illness, schizophrenia. There is a 1 per cent. chance of having that dreadful disease at birth. Three or four people in every 1,000 experience some form of schizophrenia at any one time. It is the same the world over--black or white, rich or poor, civilised or pygmy--the statistic remains exactly the same. Fifty per cent. of all admissions to psychiatric hospitals are schizophrenics. Their mortality rate is two-and-a-half times higher than that of the rest of the population; 15 per cent. will commit suicide; 25 per cent. will commit grievous bodily harm to themselves; between 10 and 20 will commit murder, of which one-third will be of total strangers and two-thirds of parents, nurses, carers or someone they know. One in five of the prison population are schizophrenics--perhaps we should think about taking them out of the prison system--and so are one-third of those living rough.

With those figures in mind, can any of your Lordships be content with the current situation? I think not. Something must be done and that something must be done sooner rather than later--and preferably now. The Parliamentary Under-Secretary of State wrote to Julian Lewis M.P., stating:

    "While I agree it is important to ensure an individualised programme of care for each person who requires admission--and these principles are embodied in the Care Programme approach-- I do not believe that physically separate in-patient facilities is the appropriate way to provide in-patient care".

I say that this Bill--and I am supported by eminent and respected psychiatrists, such as Dr. Martin Deahl of Homerton Hospital in Hackney, Dr. Mark Salter of Bart's and Dr. Mike Harris of St. Andrew's Hospital, Northampton--is in line with the departmental policy of separating out different types of patient. It cannot be right that mothers with young children should be in the same ward as people with acute psychotic conditions or that people with psychogeriatric problems, who are especially vulnerable, should be in the same area as people with acute problems.

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In 1998 Peter Tyrer, professor of community psychiatry at Imperial College, London, published an article in the British Medical Journal. He is recognised as being the country's leading expert in community psychiatry. The gist of the paper was that based on a cost/benefit analysis rather than on clinical care quality, the cost of providing a service in Brent, which just happens to be Mr. Boateng's constituency, where beds have been reduced too far, was double that of providing an identical service in a neighbouring health authority which has a heavy community presence and a much larger number of available beds.

The principle is therefore transparent: although community psychiatry is good, it needs to be backed up with appropriate numbers of acute beds within each catchment area so that community services can have the beds as part of the total service. This Bill does just that in Clause 1. SANE says,

    "This Bill recognises in patient care should be tailored to the individual's needs, giving real choice to those currently denied help in hospital. Because of this crisis in inpatient care people with mental illness are being ignored and neglected and lives are being lost. These proposals may well prevent many unnecessary tragedies".

SANE has campaigned on the issue of beds--or rather the lack of them--for 15 years and feels strongly that patients must have the choice of where they want to be treated.

I remind your Lordships that through various Written Answers I have been told that no data are kept by the Government on how many mentally ill people commit crimes, nor how many commit them as a result of early release from hospital into the community. The Government should keep such records, as those involved in mental health care need them for future planning.

We have fewer psychiatrists per 100,000 people in London than in any other city in the world except Teheran and Bangalore, and because of exasperation with the system we have only 5,130 psychiatrists working full time with the mentally ill in Britain. There are 5,130 psychiatrists to deal with up to 6 million people, if it is accepted that one in 10 of the population are liable to have a mental problem during their lifetime. In practice most psychiatrists have 400 patients on their books at any one time, but 14 per cent. of all psychiatric posts--450 posts--are today unfilled. London has fewer hospital beds and a lower amount of available cash to look after the mentally ill than any other industrialised city in the world. What a sadness.

Most mentally ill people are not violent; most can walk unnoticed in the community; and most homicides and suicides are preventable. But these objectives can be achieved only with better care, better communication between the service providers and better risk assessments provided by better facilities in which psychiatrists can work. Then and only then can we ensure that there are fewer unnecessary deaths and at the same time the public will have their fears allayed and the ever-hysterical media can be silenced. We cannot wait for government-led primary legislation to upgrade the Mental Health Acts. However undesirable it may be to this Government, we must work piecemeal

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through the 1983 Act to provide what a modern society requires for its mentally ill minority. We must act now. This is the first step. It will help the patient, the doctor, the carer and the community at large.

Moved, That the Bill be now read a second time.--(Lord Rowallan.)

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