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Lord Hunt of Kings Heath: My Lords, before moving to the Statement on mental health, I wish to take this opportunity to remind the House that the Companion indicates that discussion on a Statement should be confined to brief comments and questions for clarification. Peers who speak at length do so at the expense of other noble Lords.
Parliamentary Under-Secretary of State, Department for Health (Baroness Hayman): My Lords, with the permission of the House, I shall now repeat a Statement being made in another place by my right honourable friend the Secretary of State for Health. The Statement reads as follows:
"Last year, we published our proposals for radical reform of the National Health Service. Last week, we did the same for social services. The strategy document we are publishing today brings together our proposals for far reaching changes and improvements in the treatment and care which both provide for people who are mentally ill.
"We are doing this to emphasise that mental health is not some marginal responsibility of the NHS and local social services. Far from it; it must be at the heart of both. That is because mental illness is not an
"Mental illness is as common as asthma--it affects as many as one in six adults at any one time. It ranges from a high level of anxiety or deep depression to severe and enduring illnesses, like schizophrenia, which affect one person in a hundred. Mental illness is extremely disturbing to sufferers and their families. It can leave people without insight into the consequence of their actions. That is very frightening. Mental illness is little understood. Those factors combine so that mental illness carries a stigma. The stigma in turns frightens sufferers and their families and can lead to the postponement of the treatment they need.
"Partly because of this, mental illness does not receive the prompt, effective and sympathetic attention it both deserves and needs. As a result people who are mentally ill, their carers and the professional staff responsible for their welfare have suffered from ineffective practices, an outdated legal framework and lack of resources. We want to deal with all those aspects to bring about a dramatic change for the better in the treatment and care of all those who are mentally ill. In particular we want to make sure that proper attention is given to the disturbing growth in the numbers of young people who are mentally ill and to the particular needs of certain ethnic groups.
"Most people who suffer mental illness are vulnerable people who pose no threat to anyone but themselves. Their condition may make it hard to keep a family together or to hold down a job but their behaviour is mild and inoffensive. Most of them are not getting the low intensity support they need. And that is partly because the whole system is in crisis, mainly because it is not coping with the small minority of mentally ill people who are a nuisance or a danger to both themselves and others. And this is where the policy of care in the community has failed. Its failure to deal effectively with the most severe cases has dealt a blow to all mental health efforts and lost the confidence of the public.
"Discharging people from hospitals brought benefits for some. But it has left many vulnerable people who find it difficult to cope. Others have become a danger to themselves and a nuisance to others. Too many have been left wandering the streets and sleeping rough. A small but significant minority have become a danger to the public as well as themselves.
"This cannot go on and we are putting in place a new strategy to tackle the problems faced by patients, professionals and public alike. We have to take steps to tackle the most extreme manifestations of mental illness because, if not, the other people who are mentally ill will not get the attention they deserve and need.
"Similarly there is a small group of people with an untreatable psychiatric disorder which makes them dangerous. At present neither law nor practice are geared to cope with them. They cannot be taken into a mental hospital if they will not respond to treatment. They cannot be put in prison unless they have committed an offence. And if they are sent to prison they can be a danger on their release. The Home Secretary and I are therefore considering proposals to create a new form of renewable detention for people with a severe personality disorder who are considered to pose a grave risk to the public.
"This raises all sorts of ethical and practical problems but we are convinced that the safety of the public must be the prime concern. People whose mental illness poses a threat to others are in a very small minority but we must be able to deal with them. Their illness is often an even bigger threat to themselves and our new system shall be better both for them and the public.
"Our mental health strategy goes much wider than this and there are huge developments in both policy and practice. We shall put in place a national service framework which will spell out for every part of the country the range of services which are needed to treat and care for the mentally ill and how best to deliver them. We are being advised on this by an external reference group chaired by Professor Graham Thornicroft from the Maudsley Hospital. I thank him and his colleagues for all that they are doing.
"In the meantime we are getting on with the improvements that are unarguably needed. There is a pressing need in some parts of the country for more mental health beds and for 24 hour services to be available. We want the services that are provided to be safe and sound and supportive: safe to protect the public and the most vulnerable patients; sound to ensure that patients get the best and most appropriate care and attention; supportive by working with the patients, users, carers and local communities to help mentally ill people live as independent lives as possible. This works best where patients and carers are involved in shaping services to meet local needs.
"These services, which back up informal carers, will be provided by the NHS, social services and voluntary bodies. All must work together to ensure people who are mentally ill get well organised and unified treatment. Proposals in the forthcoming NHS Bill and local government Bill will promote this.
"This year the planning guidance issued to the NHS was issued as joint guidance to the health service and social services to emphasise the need for them to work together. The national institute for clinical excellence which we shall introduce, will issue clear and authoritative guidance on the most effective drugs and therapies for use in treating mental as well as physical illness.
"At the same time that these general improvements are being made to the NHS, we are going ahead with much better support for patients and carers. These include: access to NHS Direct 24 hours a day; 24-hour crisis teams to respond in emergencies; more mental health beds of the right sort, in the right place; more hostels and supported housing; home treatment teams; improved mental health training for GPs and others responsible for primary care.
"New developments in the NHS including health action zones and the obligation on health authorities to prepare and implement health improvement programmes will all contribute to improving mental health treatment and care.
"I would like to pay a particular tribute to all of those who care for people with a mental illness. A great deal of this caring is done by parents, children, friends and neighbours. It is also done by dedicated professional staff. Their work can be very stressful and is sometimes dangerous. We owe them a great debt. They have to deal with the consequences of policy failures and shortcomings in the law and lack of resources.
"What needs to be done will clearly cost money. Last week I announced that we had found an extra £185 million to invest in mental health services provided by council social services. Today I can announce that that sum will be more than matched by our extra investment in NHS mental health services which will total £510 million over the next three years. That brings a total investment of around £700 million extra in mental health services over the next three years on top of the £3 billion already going in.
"All this is investment for change. The Government and the public will expect to see this extra investment make a discernible difference, helping people right across the range of mental health needs. At the end of three years we expect to see: more 24-hour staffed beds; more secure beds; access to new drugs; assertive outreach teams where they are most needed; more day and respite care; more supported accommodation; improved services for children and adolescents. All these and many more services will ensure that when people have a mental illness they and their families can turn to top quality professionals to offer the best possible treatment and care, a system that is safe and sound for both patients and the public".
The first of those is the long-awaited review of the 1983 Mental Health Act. I welcome that review. The law should reflect the conditions of the present day. It manifestly does not do so at present. However, it appears from what the Minister said that the Government's starting point for that initiative is the widely perceived need to contain those psychiatric patients who are likely to pose a danger to the public.
We all recognise that that is an important issue. The debate in your Lordships' House on 19th October introduced by the right reverend Prelate the Bishop of Lincoln highlighted the appalling and distressing consequences of a failure to contain and supervise a paranoid schizophrenic who murdered a young man, Christopher Edwards, in prison in 1994. Such cases cry out for something to be done. The question is: what?
Government Ministers have been quoted as saying that care in the community has failed, praying in aid cases of the kind to which I have just referred. I notice that there is a section in the strategy document which has that sub-heading. During the debate in October, I argued that that is a mistaken view. Indeed, it is a view which seems to wish to convey the impression to the public that all mentally ill people are dangerous. To be fair to the Statement, it does not do that. But it is important to remember that a relatively small number of mentally ill patients pose a danger to themselves or to others. The vast majority are individuals who are quite harmless and whose lives have been transformed by the introduction of the care in the community policy. In fact, many thousands of men and women have been enabled to leave institutions and live supported, but essentially independent, lives perfectly successfully. I simply do not agree with the part of the Statement which says that the whole system is in crisis.
Violent or potentially violent patients are, as I said, an important issue in framing a mental health policy; but they are not the only ones. Equally, it is important, when we speak of mental illness, not to blur the distinction between the mentally ill and people with personality disorders. We welcome the current Department of Health and Home Office consideration of a new approach to help people with personality disorders outside the use of the Mental Health Act. We are also pleased to note the recognition that healthcare services in prisons need improvement. Clearly, any proposals emerging from either of these initiatives ought to be subject to the widest possible consultation.
The other strand of thought which seems to underlie the Government's initiative is the belief that the only safeguard against the possibility of violent behaviour is to lock people up. It is not. There are two principal reasons why the system breaks down. The first is the discharge process. All too often the root of the problem resides in poor decisions having been taken by psychiatrists on the discharge of patients from hospital. Patients who are clearly unable to cope with returning to society are nevertheless let loose. To the extent that
The other main reason for the system failing is the inadequate availability of the latest psychoactive medication. That is something the Government could expedite straight away, but there was only a passing reference to it in the Statement. A recent report by the National Schizophrenia Fellowship and the Maudsley Hospital demonstrated that over 50 per cent. of patients were not even receiving Clozapine--a drug developed in 1975--and were instead receiving medication developed much further back in the 1950s which carries with it serious and damaging side effects.
Even less available in general terms in the health service are two more modern drugs--Risperidone and Olanzapine--which are not only more effective in controlling schizophrenia, but are also much less likely to result in serious side effects. The cost of such drugs is of course higher, but that does not account for the fact that such patients are less likely to require in-patient care than those on older medication. The National Schizophrenia Fellowship and Maudsley study found that patients were five times less likely to take their own life and much more likely to comply with medication when prescribed the newer products.
This last point is crucial to an understanding of the alternatives open to the Government in this area. Compulsory treatment should be a last resort. It will do damage to the relationship of trust between patients and medical staff; and it can only encourage the view--referred to in the Statement--that all mental illness has a stigma attached to it. From a purely practical standpoint the business of keeping track of patients (especially in urban areas) is likely to prove extremely difficult. But the key point is that devising compulsory mechanisms does not tackle the root causes of why the problem exists in the first place. Does the Minister have any comment on the type of psychoactive drugs which should be available under the NHS or must we wait for the National Institute for Clinical Excellence to pronounce on the question of best practice?
I worry too about assertive outreach teams whose job it will be to police any compulsory procedures. What representations have Ministers received about those ideas from the nursing profession? How are the new arrangements likely to affect recruitment? There is already a shortage of psychiatric nurses and many more will be needed to implement the policy. What nurse will want the task of seeking out patients, restraining them and returning them to hospital against their will? It is an invidious brief for a nurse to be given. The noble Lord, Lord Hunt, said in the debate on 19th October that,
It is absolutely right and proper that care in the community should be looked at closely to ensure that it is working properly. We welcome the ingredients of the three-year programme. We welcome the fact that, contrary to previous government Statements, the policy is now seen to be relevant and appropriate for the vast majority of mental health patients. It is particularly reassuring to note the emphasis placed in the Statement on additional resources to be directed to mental healthcare services in the community. Can the Minister confirm my understanding that the extra resources represent new money? Can she also confirm what I thought might have been an addition to the text of the Statement handed to me that service users and their relatives and carers will be given a say in what new services are planned and funded?
I believe that in mental health, perhaps pre-eminently among all fields of healthcare, it is not enough to give patients what we think they need; we must also give them, as far as possible, what they want. I very much hope--though I am not yet confident in all respects--that the measures announced today will achieve that aim.
Lord Clement-Jones: My Lords, from these Benches I thank the Minister for the Statement. We also welcome the White Paper mentioned in the Statement. This is an extremely important topic. The Statement states that one in six people suffer from some form of mental illness. It is therefore no surprise that some forecast that by 2020 there will be more people suffering from mental ailments than physical ailments. It is inevitable, as a result, that society as a whole is waking up to the implications. One sign of a truly civilised society is how it deals with mental health issues. That means not only in terms of what treatment is available, but also what rights those suffering from mental problems have and how the rights of the individual are balanced with those of the community.
In a sense today's White Paper may be either too early because it predates Professor Richardson's report, which will no doubt come in the spring, about the review of the Mental Health Act. It also predates Professor Thornicroft's external reference group report which will prepare the national service framework. But also, in a sense, it may be too late--too late in terms of being a late announcement of the resources that will be available following the July announcement by the Government giving a foretaste of their strategy. Nevertheless, from these Benches we welcome the Statement and the strategy. We welcome the priority being given to mental health and we welcome the review being undertaken of the Mental Health Act. But we hope that the Government are not anticipating the conclusions of Professor Richardson's review.
We welcome the concept of assertive outreach designed to ensure that individuals suffering from problems do not fall out of the care net, provided this does not become aggressive outreach. We also welcome the "partnership in action" approach which is designed to break down barriers between health authorities, social services and other providers. Liberal Democrats have been strongly supportive of that approach in many areas, particularly in Somerset where a county-wide mental health strategy has been agreed, and a joint commissioning body and single integrated mental health and social care provider created. But there is a huge job to be done in bridging the mistrust between health authorities and social services. The Minister will no doubt have seen a recent report from the Centre for Mental Health Services Development which shows that lack of trust and the hurdles to be overcome.
However, we do not welcome statements by Ministers that care in the community has failed. It is noticeable in the Statement today that such language has been rather toned down. We now hear that care in the community has failed a small minority of mentally ill people. That is much closer to what has actually happened. The original, bald statement that care in the community has failed caused considerable anger among mental health professionals. The implementation of care in the community has undoubtedly failed in several cases. A number of tragic circumstances testify to that, such as the case of Jonathan Zito, and we are, of course, all aware of the very hard cases involving Michael Folkes and Christopher Moffat.
We do not believe that the philosophy of care in the community has failed. It has not been tried or resourced properly. We do not welcome some of the punitive language used by Ministers. We must not return to the bad old days of thinking that every mental patient needs locking up in an institution. As has been well shown, alcohol and drug abuse are much more potent indicators of criminality than is mental illness.
With proper care and supervision, many patients can take their place in the community without danger to the public. The "safety plus" approach adopted by this Government must not mean treating all mental patients as criminals. We would be concerned if the Government shifted the emphasis unduly back to institutional care. The devotion of undue resources to medium secure units could mean, in practice, the simple locking up of more young black men who already constitute 80 per cent. of those in that type of secure unit in London and just under 50 per cent. elsewhere.
We are concerned about the clarity of responsibility for the commissioning of mental health services. Who is responsible: the region, the primary care group or the health authority? Ministers have said that the national service framework will make that clear. However, that
We are also concerned about whether the Government are giving adequate attention to the abolition of mixed-sex wards in mental hospitals. Surely that is even more important in such hospitals than in ordinary hospitals.
We believe that the key is more resources to the whole spectrum of care. Even the previous government started to move in the right direction on mental health at the end of their time in office. The essence is a balance or spectrum of different types of care. What they did not do was to devote adequate resources to mental health; hence all the current problems.
As we know, one of the key causes of high profile cases involving homicide and suicide has been the breakdown of care plans because of overstretched teams and lack of available resources; in other words, more resources are needed to provide more effective care and supervision. I welcome the addition of the extra resources announced today after years of under-funding. However, I am somewhat baffled, even after reading the White Paper, about precisely what figures are involved. The noble Baroness may remember the confusion about the precise additional sums involved in the comprehensive spending review. We would welcome clarification of precisely what additional funding is involved. We must improve the generality of services and bring poor services up to the standards of the best. That is why we support the principle of a legally enforceable right to a minimum standard of treatment.
Resources must be ringfenced for mental health. There are some 5,000 potential long-stay patients who need 24-hour care in the community. Psychiatrists have enormous caseloads and we are something like 400 psychiatrists short. For every five GPs there is only one community psychiatric nurse. Each community psychiatric nurse has an average of 80 patients to care for, of whom 35 to 40 are psychotic. We need more, and better trained, community psychiatric nurses. I am not convinced that that is properly addressed in the White Paper.
There is a shortage of acute beds. A recent Sainsbury Centre report referred to a "care vacuum" in psychiatric wards with overworked, undertrained and inexperienced staff. Another recent Sainsbury Centre report showed that in London almost 50 per cent. of nursing staff are casual and hired from agencies. Outside London the figure is 30 per cent.
The Statement mentions the joint venture between the Home Office and the Department of Health. We believe that focusing on mental health in prisons is of enormous importance. There is an extremely good case for integrating the services. We hope that the joint venture bears fruit in that respect.
The noble Earl, Lord Howe, mentioned the funding of atypical anti-psychotic drugs. As the noble Earl said, the Maudsley Hospital and the National Schizophrenia Fellowship drew attention to postcode rationing of drugs such as Clozapine. We welcome the pledge of another £120 million for more effective drug therapies. However, we do not know whether that will seriously address the problem. We would welcome assurance on that point.
We welcome the recognition that mental health forms a central part of primary care objectives and that the health improvement programme is a vital tool. Consultation on the HIP must include the community, the voluntary sector and service users. The Government must recognise that public education is vital, and we seek assurance on that point. As we recall, one of the key objectives adopted by the Department of Health in 1993 was to reverse the public's negative perception of mental illness. That is more vital now than ever. New legislation, whether designed to make treatment more effective or the public more secure, is not enough. For treatment to be effective and for the right treatment to be available, we need the confidence of the community. We must increase understanding of mental health problems within the community and among individuals affected. How do the Government recognise that? And what do they plan to do about it?
Baroness Hayman: My Lords, I thank both noble Lords for what I believe was a basic welcome for the additional resources for these services and the recognition of their importance. Perhaps I may give more detail on the financial issues about which the noble Lord, Lord Clement-Jones, asked. We are talking about £700 million of new money being made available over the next three years in addition to the £3 billion which is already going into mental health services. That is £510 million of NHS money to complement the £185 million announced last week for social care services.
As far as next year's money is concerned, we are talking about investing £146 million. Some of that will be via targeted allocation to health authorities; some will be available as central funds and will need to be bid for; and some will be available through the mental health grant to local authorities. It is a complex situation. We shall be giving more details next week. I reassure the noble Lord that that money will go towards mental health services and, in that sense, it is ringfenced through its various funding streams.
I turn to the theme that ran through the contribution of the noble Earl, Lord Howe; that is, the issue of not stigmatising all people who suffer from mental health problems because of the very real danger that a very small minority of those patients pose to themselves and other people. My right honourable friend tried to make it extremely clear in his Statement that we recognise that such patients comprise a tiny minority of all the people who need to use mental health services in the course of any year. However, I should tell the noble Earl that,
The same applies to the review of the Mental Health Act, to which the noble Earl referred. Perhaps I may reassure him in that respect. There is the issue about community treatment and the people who are outside an institutional setting who do not comply with medication and, therefore, become a danger both to themselves and to other members of the public. However, that is not the only area of concern. We need a root and branch review of the Mental Health Act because it does not reflect current patterns of care where the majority of care is not provided in a hospital setting but within the community. We are not only looking at community treatment orders, which are an important part of the process; we are looking much more broadly at the workings of the Act so as to make them reflect more realistically the patterns of treatment that people receive. I hope that that will prove to be a reassuring element of Professor Richardson's review.
Obviously there are difficulties to overcome and balances to be made here, as in the area of acute personality disorders to which the noble Earl also referred. It is important for us to strike a balance between the civil liberties of individual patients and the protection of the public. There are no simple answers. However, because there are no simple answers, I do not believe that we should be deterred from going into areas where we have only too tragic evidence of the failure of the system as it stands at present. This will need careful review and that is what it will have. We must ensure that we have a balanced approach, but we are determined to take action to improve the legal framework which is in place at present.
On the issue of assertive outreach services which was raised by the noble Earl, I can tell the House that there are very positive examples of where this is going on successfully--for example, in north Birmingham--and where it has been supported by all the professionals involved, including community psychiatric nurses. We want to look at how we can transpose that good practice elsewhere, where it is appropriate. But, again, it is one strand where we have the possibility of actually providing the right range of service within the community and preventing a crisis which can damage both other people and the patients themselves.
As far as concerns the point about the need for local government and health services to work together, I can confirm that there have been difficulties in that area in the past. We have clearly said that we recognise that the institutional barriers do not reflect the needs of patients. We have to start off with the needs of patients. That is why the national priorities guidance this year was issued jointly to both health services and local authority social services. That is why the legislation on the local authority front and the NHS front will aim to provide a framework in which joint working in the interests of patients can take place, whether it is through pooled budgets, the commissioning of arrangements, or whatever, to ensure that the needs of patients are actually met across the institutional barriers.
The noble Lord, Lord Clement-Jones, asked for clarification as to the commissioning of mental health services. At present health authorities are responsible for commissioning specialist mental health services. Primary care groups will be free to take on responsibility for commissioning services and will be accountable for their performance. However, the important area here is the national service framework. The noble Lord was slightly critical of the fact that we have produced the White Paper before the national service framework is finalised. Some findings have emerged in that respect and we are beginning to see the way forward. It will be a very potent weapon in ensuring that we do bridge some of the gaps between the best and the worst provision and make sure that high levels of quality care are available throughout the service.
That leads me to the availability of the new generation of anti-psychotic drugs, which was raised by both the noble Lord and the noble Earl. From next year, the Government will ensure that extra resources are available to assist in meeting the demands for new drugs by targeting health authorities with the highest levels of mental illness. We recognise that we must look at the costings in the round and that these drugs may be more expensive than other drug treatments. However, if we consider their potential for saving admissions, they may in fact prove to be very cost effective. That is why it is important that the National Institute for Clinical Excellence will assess them as well as other interventions and produce and disseminate clinical guidelines as well as clinical audit methodologies. Although these drugs are suitable for some patients, they are not suitable for all patients. We have to look at the range of interventions available.
I turn now to the issue of staffing. A point was made about the need for training and, indeed, for better trained staff. That is very much taken on board in the funding both as regards improving the training of local authority staff and also staff within the health service. We are beginning to see greater numbers of trained staff coming through in the medical profession where there were great shortages in the past. We have to look at the training both for clinical psychologists and for nurses specialising in mental health. The Government are looking very carefully at the situation with a view to ensuring that some of the additional places being made available will cover that need.
Finally, I move on to the issue of mixed sex wards. Perhaps I may reassure the noble Lord in that respect. We recognise the great difficulties which such wards cause for patients, especially as regards mental health facilities. I can reassure the noble Lord that there is absolutely no going back on the Government's commitment to tackle the problem. As he may be aware, on two occasions where it was planned that new facilities would have mixed-sex wards my right honourable friend has intervened to ensure that they did not.
Lord Thurlow: My Lords, like the noble Earl and the noble Lord who have already spoken, I most warmly welcome the Statement, which I hope and believe represents a very important milestone in meeting the deficiencies that have become so apparent to all of us ever since the 1983 Act. Those of us who were involved in the discussions in 1983, and since then, have always taken the line that, as the noble Lord, Lord Clement-Jones, emphasised, community care has not failed; indeed, it has never been given a fair trial. We hope that the fairly massive resources that the Government will be putting into mental health over the next three years will do much to repair the situation.
I am most grateful not only for the content of the Statement but also for the process adopted by the Government in reaching their conclusions. They have taken their time and have consulted in the widest possible way. We await with hope and interest the results of the studies that are still in process. It seems to me that the whole package represents an enormously important step forward in remedying manifest deficiencies.
Of course we all have questions, but then this is such a wide canvas. One particular question I wish to ask the noble Baroness is whether she can give any indication of timing for the increase in new 24-hour nursing beds. When this was introduced by the previous government we first of all had fairly optimistic statements, but it all turned out to be a very slow affair. Although, I am sure, those which have come into operation have done excellent work, we need far more. I would like some indication of the timetable.
I warmly welcome the prospect of more beds in hospitals. Many of us have been gunning for them for years. We have deprecated the mad speed of the closure of the big hospitals. One hopes that that is a matter of the past.
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