§ 3.31 p.m.
§ Dr. Gerard Vaughan (Reading, South)
In choosing the topic of provision for the mentally sick for this very short debate, we seek to discuss three particular aspects. First, we in the Conservative Party attach very great importance to improving the care of the mentally ill and we are specially studying the implications of the Government's recent White Paper. Secondly, we want to draw attention to the apparently appalling situation, recently reported by the Daily Mirror, in the Birmingham area, partly because of our anxiety about Birmingham and partly because we suspect that other areas are in a similar situation. Thirdly, there is still great anxiety over the way in which dangerous patients are discharged back into the community.
These are all very large subjects, and I hope that the Government will not see today's debate as an excuse to hide from a further full day's debate on their White Paper. The White Paper "Better Services for the Mentally Ill" is, in our view, very important. The Government have a clear duty, if they really care about the mentally sick, to give us a proper, full debate in the near future on it. We have been pressing for this and we shall continue to do so.
The White Paper says that there will almost certainly be no additional resources for mental health provision in the next 20 years. If that is the case, improvements will have to come from a better use of existing resources.
§ Mrs. Elaine Kellett-Bowman (Lancaster)
Is it not deplorable that there seems to be so little information about the resources which are to be put into 30 this sector? In response to repeated Questions, the only answer we got last May was that information was not available about capital expenditure.
§ Dr. Vaughan
It is not for me to answer for the Government. As my hon. Friend knows, the Government's position is that there are not likely to be additional resources and that, in fact, there may be quite significant cut-backs. Therefore, any improvements for the mentally sick will, at best, have to come out of existing resources.
Quite rightly, there has been a great deal of criticism of the White Paper, which has been described variously as a monumental damp squib, as having a dangerous lack of purpose and as showing practical flabbiness. These comments are probably true. Even the Secretary of State for Social Services in her foreword lost heart and said that she wondered and queried how useful it would be to publish the White Paper.
I think that it was useful to publish it because it tells us with depressing candour that very little progress has been made since the enactment of the Mental Health Act 1959. I was working in psychiatry at that time and I remember the high hopes we all had that psychiatry was about to come in from the cold. Those hopes have certainly not been fulfilled.
I was working in a 2,000-bed psychiatric hospital, a whole private world cut off from ordinary life. We were filled at that time with enthusiasm at the thought that in future patients would remain in hospital only if they needed the security of the hospital's surroundings or if they were actually going to receive active treatment, and that all other patients would eventually go out into the care of the community. Of course that has not happened, not because of psychiatric inertia but because the local authorities were not given the incentive and the resources to carry out their tasks. There has been far too much talk of old, stale, faded policies rather than a practical and imaginative look into the future to see what can be done.
The Minister of State said recently that he thought there had been far too much special pleading in this sector. When 5 million people consult their doctors with mental symptoms each year, when 31 31 local authorities have no residential accommodation at all, when 63 local authorities have no day care facilities, when 24,000 patients do not have full personal clothing of their own, when 645 children under the age of 15 are in general psychiatric hospitals—the Minister will have seen, as I have, children of 12 or 14 wandering disconsolately amongst grossly deluded and often very degraded adult patients—and when 32,000 patients have been in hospital for over 20 years, I would say to the hon. Gentleman that, if it is special pleading to keep ourselves constantly aware of this situation, let us have more special pleading.
I very much welcome the activities of organisations, like MIND, which have constantly brought these problems before our notice. I am afraid that all too often today the saying "Out of sight, out of mind" really means "You are out of your mind, so I will keep you out of my sight."
The White Paper says that an extra £38 million a year is needed. How ironic it is that that figure is almost identical with the income which will be lost by closing down pay beds. We in the Conservative Party know where our priorities would lie on these issues. The criticism of the White Paper is very widespread because it contains no recommendation at all for the short-term and immediate future. Indeed, it is filled with phrases such as "more assessment is necessary", "research is required" and "better liaison is needed".
There is a great danger that, the Government having produced a White Paper of this kind, people will feel that something has been done and complacency will settle down again. Since the Government seem unable to take action, we will tell them that we can suggest action which would not involve major extra expenditure. If necessary, we can give them pointers as to directions in which they could go.
The first pointer I would give is a psychological one. The Government should follow the White Paper with a short, sharp document on immediate proposals for the next five years. This would immediately regenerate enthusiasm in the mental health field. They should inquire immediately into the Birmingham cases and say that for patients to be dis- 32 charged with no proper follow-up but to be allowed to wander around the streets or to go into Salvation Army hostels is totally unacceptable. One does not even have to go to Birmingham. One can walk the streets of Westminster and see these cases. With this debate in mind, I actually passed three patients today, between Horseferry Road and this place, who were clearly deluded and were wandering along the pavement talking to themselves.
In our view the Government should re-examine the Crossman scheme whereby certain patients were able to carry their hospital costs into the community service. We shall never achieve a community service while spending £300 million a year at the hospital end and only £15 million at the personal social services end. I suggest that this figure is quite staggeringly low. The whole basis of mental health has been to try to transfer patients from hospital into the community. We are now facing a standstill in real terms in local government spending.
I pose the question: where do we go from here? It will be false economy if local authorities cut back on support services for the mentally ill to such an extent that many who could be looked after in the community have to be looked after at greater cost in a hospital. This is a most urgent problem. We should like to see immediate steps taken to improve the collaboration between hospitals and the local authorities, with hospital units being directly involved in small districts, in small sections of the community, and nurses being used much more in the community together with health visitors.
More than this, however, we believe that the rôle of the local authority should change. Local authorities should see themselves much more as identifying needs, showing people locally what should be done and how to organise themselves to do it, and then leaving other bodies, particularly the voluntary organisations, to get on with it. We see this as a great opportunity for local groups to help locally. For example, the local trade union branches and the churches could give massive help in day care. I think that the trade union movement could do a great deal to help to rehabilitate and contain these patients within the community.
33 It seems to me quite unrealistic to say, as the White Paper says, that there must be a massive housing programme, with high-standard—many of us would think excessively high-standard—purpose-built hostels, because in the foreseeable future we are unlikely to have them. Instead, we should concentrate perhaps on bed-sitters, unstaffed hostels and temporary buildings which would be cheap and easy to arrange, and would totally transform the situation. We on this side of the House would like to see an immediate paper giving clear guidance on achieving proper community action and more emphasis on voluntary help, and we would like the Minister to make a proper start on co-ordination between local authorities and the hospital service.
It is disappointing that the White Paper did not consider reviewing the Mental Health Act 1959. While I do not agree with all the points that Larry Gostin makes in his book "The Human Condition", there seems to be a strong case for reviewing the work of the mental health tribunals and for re-examining the rights of psychiatric patients.
§ Mr. Leslie Spriggs (St. Helens)
May I ask the hon. Gentleman a question? He has referred to the 1959 Act. Will he tell the House what steps he took to try to get a Conservative Government to review that Act?
§ Dr. Vaughan
The hon. Member is clearly unaware that Mr. Crossman, for example, said that the Conservative Government had on the whole a very much better record for looking at this problem than Labour Governments had. He was quite congratulatory about the amount of attention that we had given to this matter.
Finally, there is the difficult question of discharging dangerous psychiatric patients into the community. In my area and that of my hon. Friend the Member for Abingdon (Mr. Neaves), we have been concerned recently about the case of Dunlop who was convicted of 34 sexual offences against children, was transferred from Broadmoor to an open psychiatric hospital and was then allowed to live in a home where there were very young children. This appears, with hindsight, to have been a cavalier and mistaken decision. I know at first hand how difficult these decisions can be, particularly for 34 the doctors concerned, but in my view we need to tilt the balance rather further towards protecting the community, and we should look much more carefully at the criteria for discharging into society patients with long records of dangerous behaviour.
I urge the Government to speed on with the Butler recommendations. I am particularly interested in the possibilities of an indefinite sentence for certain kinds of disorders. This has been used for many years in some Scandinavian countries, and I have actually been to Herstedvester, which is an indefinite sentence psychopaths' prison in Denmark. Many people think that this is one of the solutions we need to explore in our community, and the Butler recommendations seem to support this view.
I also hope that we shall pursue rapidly the setting up of an effective independent advisory body to reconsider possible discharges. I do not think that it is right to leave the decision in the hands of a doctor whose personal professional responsibility must tilt itself towards the patient whom he is trying to help rather than towards society.
The mentally sick are a much talked about but much neglected group of patients. I believe that they represent a challenge to which the Secretary of State should rise. We hope that she will not only produce a report, a consultation document, with real action it it, but will ensure that in the very near future we have a further debate on this subject.
§ 3.48 p.m.
§ The Minister of State, Department of Health and Social Security (Dr. David Owen)
I welcome the opportunity to discuss the White Paper "Better Services for the Mentally Ill". Despite some of the things which the hon. Member for Reading, South (Dr. Vaughan) has said about that White Paper, I think it has been remarkable how warmly it has been received, if for no other reason than for its extraordinary frankness. I think it is rare for a Government document to be quite so open about the deficiencies of a service, to be quite so blunt about the gaps, and to be quite so realistic about assessing failures to achieve as much as everyone hoped with the passing of the Mental Health Act in 1959.
35 The harsh facts are stated quite clearly, as the hon. Gentleman said:Mental illness is a major health problem, perhaps the major health problem of our time. … At least 24 million working days are lost … each year by people suffering from mental ill-health. Some 5 million people each year consult their general practitioners about a mental health problem.I have no quarrel with anybody who wishes to argue the case for mental health. I myself used to be a member of the executive of the National Association for Mental Health. But what calls for special pleading, if special pleading it be, is the need to see mental illness and care for the mentally ill against the background of the financial restrictions facing us, and, what is more, to see mental illness in the context of National Health Service and personal social service expenditure.
I must say that I get a little concerned about the way in which everyone in this place espouses every cause, especially when it is praiseworthy in itself, and demands more resources though without facing the challenge of trying to define our priorities. A lot of things are highly desirable in this field, and the difficult choice lies in determining that which must have first priority.
For 16 years or more we have all, both inside and outside Parliament, paid lip-service to the need to care for the great majority of the mentally ill within the community, yet, as the hon. Gentleman said—and as the figures in the White Paper show—in 1973–74 nearly £300 million was spent on hospital services for the mentally ill whereas only about £15 million was spent on personal social services for the mentally ill, and of that sum £6.5 million went on day and residential facilities. Yet in March 1974, 31 local authorities as then constituted had no residential accommodation and 63 had no day facilities.
It is, however, no good for us, in the House or in the Government to blame local government, for one can point to many years under both Administrations when local government has requested loan sanction for capital facilities which have exceeded that which the central Government felt able to finance. The central problem, therefore, is one of determining the priorities for mental illness within the 36 whole health and personal social services budget.
If we are to fulfil our aspirations towards community care, we have to face our inability to recognise sufficiently strongly the necessity for joint planning and joint financing of the health and personal social services for the mentally ill—and not just the mentally ill, for we must bear in mind here the combination of needs and services for the mentally handicapped, the elderly, the disabled and children.
We do not yet have a unified service, despite the National Health Service Reorganisation Act 1973. I accept that as a reality. It would be mere escapism if I were now to reopen the arguments about structure or to advocate yet another reorganisation. What is now required is that we face squarely the problems of mental illness, recognising that we have to act within the structure which we have, and seeing provision for health and personal social services as one, working across the arbitrary administrative boundaries which exist and refusing to accept the narrow distinction between, on the one hand, the National Health Service and, on the other, local authority personal services.
Almost every policy initiative taken by my right hon. Friend the Secretary of State and by the Government over nearly two years now has had that aim of unification as its central objective. It was for this reason that we attached importance to increasing the local authority membership on area health authorities, so that district councils responsible for housing will now be able to have representation on area health authorities. Who can doubt the crucial rôle that housing plays in health and social service problems generally, and especially for the mentally ill—whether sheltered housing for the mildly mentally disturbed elderly person or for the long-stay patient when first discharged from hospital into the community.
We hope soon to introduce changes in the hospital advisory service so that it can set a report on a psychiatric hospital in its wider setting, reviewing the community service for the mentally ill in the whole catchment area. For that reason, we have stressed the importance of the role of the joint consultative committees. 37 If we cannot achieve through them the joint planning objectives with health and local authorities, then in 15 or 20 years the strategy envisaged in the White Paper for a radical change in the balance between hospital and community care will have failed to be implemented. With the experience of the past 15 years before us, there could in such circumstances be no encouragement for the next 20 years.
The White Paper envisages over a 20 to 30-year period an adjustment of capital investment to an average of around £30 million a year on health services and £8 million a year on personal social services. Many people will argue that there should be a more radical shift, though not, I hope, by reducing further capital investment plans for the hospital sector, which was already deprived over the past few years—for it was believed that the long-stay hospital would automatically be closed, and then, when it was not, it was still not given the resources necessary—but by finding larger resources for the social services for the mentally ill.
There is, however, a danger of all of us becoming too fixed on capital investment at the expense of revenue investment and what must certainly be envisaged over a period of years is a substantial increase in the revenue allocation for the mentally ill through the social services budget.
The White Paper—and my right hon. Friend's introduction, in particular—is realistic, saying that over the next few years we must be honest and admit that very little extra resources can be available, but that is not to say, as the hon. Gentleman seemed to imply, that over the next 20 or 30 years, after the country's economy makes its upturn, as we hope it will, the mentally ill and others suffering mental handicap cannot expect a preferentially increased share of any resources which may be allocated to the health and personal social services.
The problem in the short term is how to achieve that aim when the social services budget, together with the health budget, faces a period of severe restraint. There is also the problem of getting things right at the local level. The allocation of funds, including funds for the social services, is made centrally in the rate support grant, so that the problem of apportionment and getting things 38 right in the local situation remains. There is, therefore, need for a mechanism to promote projects which both the health and local authorities regard as of high priority but which central allocations are not sensitive enough to pick up.
We hope to publish before the end of February a paper for consultation on joint planning and joint financing for health and local authorities. It is intended in this coming financial year April 1976–77 to identify for each joint consultative committee the amount of money available to each area health authority. These specific sums of money will be used in financing either capital or revenue joint projects. But the money will be Health Service money and as such the responsibility of the area health authority and, where appropriate, the regional health authority.
We envisage starting off with a figure for all forms of collaboration of £8 million, building up over five years to a little short of £20 million. The total involved will be more than this, of course, since it is envisaged that the area health authority should normally at the maximum make a 60 per cent. contribution, and only in exceptional circumstances will the whole cost be met from NHS funds; and there would be need for a tapering of revenue support over a period of year so that the social services department eventually bears the full cost. This switch, of course, would have to be reflected in the annual rate support grant negotiations.
Some will advocate that the money should be earmarked and that the JCCs should be made executive bodies, but I do not believe that this is the right way forward at this stage, for that would merely create yet another tier of management in the health and personal social services. What is needed, however, in order to ensure the success of joint projects is a far greater degree of joint care planning between the area health authority and the local authority.
At present, the Health Service has established health care planning teams at district level, but with insufficient linkage with the local authority personal social services. We hope to take into account the strong criticisms that have been made by local authorities of a draft circular on health care planning so as to reflect particularly in these four main areas where 39 community care is so crucial—mental illness, mental handicap, geriatrics and disablement—a far greater degree of joint activity than has hitherto been envisaged
It may well be that in the present financial difficulty joint financing will have its biggest impact in revenue support. I should, however, stress that the criteria on which an area health authority will agree to use its money for joint financing will be that such a project is in the interests of the NHS as well as the social services, either allowing the Health Service to discharge more patients into the community or to ensure that more people in the community can stay there and not need admission to an NHS hospital.
Some local authorities may argue that the mere notification of the sum of money potentially available will give them insufficient leverage. I hope that this will not be the case—that the mutual self-interest of the two authorities will ensure that the money is used—and the Department will be monitoring the whole process and will certainly want to know why an area health authority has not used its allocation if that were to be so.
I believe that this financing could be a powerful catalyst for achieving some progress towards real community care and really successful joint planning. It could give the JCC machinery the stimulus which it badly needs. Another area in which we intend to stimulate joint planning is to allow—
§ Mr. Michael Alison (Barkston Ash)
Is this to be a net extra allocation of resources from central funds or a redistribution of planned expenditure with-in the district health service?
§ Dr. Owen
It will be a redistribution among existing levels which we shall be announcing in the Public Expenditure White Paper. It will be earmarked as an allocation identified for each area health authority to try to encourage the practical movement of the switch of resources from the hospital service into the community services.
I was saying that some local authorities will argue that they have insufficient leverage and that we shall be monitoring the process. A movement which I hope to stimulate is to allow land or property surplus to NHS requirements to be made 40 available to local authorities for personal social services purposes under specially favourable financial arrangements, subject only to the proviso that the use of the land or property by the local authority shall not be changed without the approval of the Secretary of State, or that if it ceases to be used for a social service purpose there will be a reversion of the land or property to the Secretary of State. Many local authorities that wish to use hospital land in their community are unable either to afford the capital amounts or to make satisfactory arrangements because of the present governmental restrictions that apply.
I am also prepared to discuss with health authorities the proposal that has been put forward by MIND in the past of safeguarding the priority that should be given to mental illness and to the mentally handicapped when land is released. Some hospitals hold large amounts of land, and at least a portion of the profit that is made from the sale of land could go back into mental illness or mental handicap. There are considerable problems, but unless we allow some leverage in the allocation of priorities against the ever-increasing demands of the acute sector I believe that history shows there is a danger that these services will miss out.
§ Mr. Patrick Jenkin (Wanstead and Woodford)
One of the last things I remember doing at the Treasury before I left in the beginning of 1974 was to approve in outline a scheme which was put forward by my right hon. Friend the Member for Leeds, North-East (Sir K. Joseph) for achieving exactly what the Minister has said about allowing some part of the profit on disposal to remain with health authorities. Will the hon. Gentleman tell the House whether his Government have decided to proceed with the scheme which my right hon. Friend proposed?
§ Dr. Owen
The right hon. Gentleman will realise that I did not respond to some of the remarks that were made by the hon. Member for Reading, South. I think he will agree that it is much better to keep party politics out of the matter. There has been no change of policy. The policy to which he refers is the sensible policy of allowing the allocation of land that is surplus to stay 41 with the regional health authority and not to go back into overall central allocation. That allows authorities some share of the land as well as providing a far greater devolution of authority. That is the praiseworthy policy which we are following. As I understand it, that is exactly what the right hon. Member for Leeds, North-East (Sir K. Joseph) outlined. It is important to remember when reallocating resources across the Health Service that we must be a little careful. Some wellfavoured regions may have a great deal of land from which they can make large profits from land sales. I would not be happy if such profits were retained within those regions. However, it is desirable to give some stimulus to the sensible use of land planning. If it is felt that it will all be done by central government there will be no stimulus for local authorities to act. I am thinking of extending this concept and I want to discuss the matter of sales with the health authorities.
I think that these arrangements will allow those concerned to establish a closer working relationship than at present exists, and with the least possible intervention. I believe that overall planning arrangements from central Government should be subject to consultation. There may well be changes in the light of our experience. They mark, I believe, a breakthrough in our whole attitude to health and social service planning, coming to grips with the central problem of how to persuade a local authority already under pressure from hard-pressed ratepayers to accept the financial burdens of the NHS, knowing that the service will be reducing its financial commitment in the long term with no compensatory transfer to the social services. They should also help hard-pressed doctors in the NHS who face the depressing prospect of having their hospital beds full of patients who could well be discharged into the community but who cannot be discharged because of the inadequacy of community facilities. In consequence, the highly desirable emphasis on active rehabilitation in hospital care is stultified. I stress that the figures I have given cover the whole range of personal social services, but I hope that they are material. There is nothing against area health authorities entering into joint financing projects on a much larger scale than the one I have envisaged.
42 Reference has been made to the situation that has arisen following the articles in the Daily Mirror about Birmingham. I pay tribute to those articles in that they raise yet again a picture of the sordid and unsuitable conditions in which many ex-mentally-ill patients are living when they have been discharged from hospital. This is a matter of great concern to all of us. For many of us such revelations are not new. Community-based services for the mentally ill have not kept pace with the ever-increasing demands that have been put upon them for many years. However, with a major national newspaper championing the cause, I believe that the sector will be given the priority which it certainly needs. I think that MIND is to launch very shortly a campaign entitled "Home from Hospital". I hope that we may be able to give some pump-priming in the form of financial assistance.
§ Mr. Eric Moonman (Basildon)
Following the reports in the Daily Mirror, will my hon. Friend tell the House whether he has taken any steps by circular or any other method to see whether authorities can engage in similar practices and what reports he has had?
§ Dr. Owen
I have asked for reports from the AHAs and the RHAs. I have said that I intend to go to Birmingham to discuss the matter with the area health authority and the local authority. I hope that the initiative we shall be taking on joint financing will be as helpful to them as anything else as it is capital and revenue. I do not think that there is only one health authority that is involved. It is a joint problem. It is a problem that falls on the social services. In many cases it falls on the housing departments. This is a particular problem where housing is separated from the social services and is under a different authority. I am ready to consider issuing a circular. We have concentrated on this problem but there are many others to be tackled. There is a lot to be said for leaving local people to try to determine the priorities in their own situation.
The conditions that exist for the mentally handicapped are often appalling and sordid. There is also much argument and debate about geriatrics. As my hon. Friend knows more than anyone else, some areas have particular deficiencies. 43 For example, there is the problem of discharging patients from psychiatric hospitals. Another problem might be a large geriatric hospital that faces great problems because it has been starved of resources over the years. There is a lot to be said for trying to see the situation in the round. The Hospital Advisory Service has reported on psychiatric hospitals, and future terms of reference must include consideration of the whole question of community services. I hope that it will be able to concentrate on the problems which have been outlined.
§ Dr. Vaughan
Before the Minister leaves this subject, will he comment on the possibility of a much greater use of voluntary organisations and a possible rôle shared between voluntary organisations and local authorities?
§ Dr. Owen
I think that we must make distinctions. More needs to be done for those patients who can never be discharged, but in developing new policies for the future there may be a situation in which it will be extremely unsatisfactory for patients who have been discharged not to receive adequate community facilities.
§ Mr. Wyn Roberts (Conway)
The hon. Gentleman has been talking about patients leaving hospital, but is he aware of the conditions of patients in certain mental hospitals, where I understand the feeding allowance per head is less than that enjoyed by other patients in other hospitals? Is he aware that this is causing quite a problem in many hospitals?
§ Dr. Owen
The hon. Gentleman makes the point that one can point to problem areas elsewhere. The late Dick Crossman did more than anyone to make massive changes when he resisted standard vetting of patients in psychiatric hospitals and sought to improve the conditions for mentally handicapped patients. When I go round the country visiting these establishments, I do not hear the kind of complaints one heard about food in psychiatric hospitals 10 years ago. Changes were also made by the right hon. Member for Leeds, North-East when he was Secretary of State for Social Services in terms of the priorities one should give to mental illness and mental 44 health. Of course, Ministers constantly face demands from other sectors for more money to meet various needs.
I believe that in the next few years we shall have to develop a "low-cost" mentality, a willingness to make and mend. This applies across the whole area of activity. It also means a readiness to harness voluntary effort with professional skills, a readiness to accept the attainable and not always to hold out for the desirable.
There are many schemes, despite their low cost, embodying what is recognised to be good—even best—practice. Some are obvious and involve adapting existing premises for use by the mentally ill as day centres or social clubs, for example, instead of costly new purpose built centres, as well as the sharing of facilities with other groups. If we could universalise existing best practice in caring for the mentally ill, we would be surprised how much could be done even in a time of economic restraint. Not everybody who leaves a psychiatric hospital needs special residential provision. The great majority of people can, and do, return to their own homes to live with their families. We must remember that over 90 per cent. of patients in hospital are there voluntarily. It is for those patients to decide whether they are ready to be discharged. It is not always the hospital that has that choice.
However, the demands placed on relatives can be considerable and should not be under-estimated. A very welcome development is the way in which the National Schizophrenia Fellowship has set up a series of local self-help groups for the relatives of people suffering from schizophrenia so that they can share their problems and pool their knowledge and experience of how best to solve them.
Community psychiatric nursing services can provide a valuable means of follow-up and care for discharged hospital patients, as has already been done in enabling those people to live in homes and to maintain contact with nurses. This is an old idea in the sense that such a system operated in Croydon as long ago as 1954, but there are many areas that do not operate that system. An increasing number of psychiatric hospitals has adopted the system. The nurse pays regular visits to the patient's home to ensure that prescribed treatment is being 45 carried out, to assess the patient's progress and to supervise general welfare. I am discussing with MIND ways in which we can stimulate volunteers to take responsibilities in this area, working in the way in which NACRO has done in the probation service. We are trying to overcome the problems faced by nurses and other workers who face heavy case loads.
A relatively inexpensive and successful approach to the problem of providing accommodation for the mentally ill who cannot manage entirely independently is the establishment of group homes. These are particularly suitable for people who have been in hospital for some time and have lost touch with relatives and friends. Ordinary houses and flats can be used for this purpose, and some local housing authorities are willing to make accommodation available for this purpose. A small group of residents—up to five or six—who may often have got to know one another in hospital, live together as a family and organise their own finances, with a worker or voluntary helper to check that all is going well. If there is difficulty or trouble, the group can fall back on a specialised professional worker. I believe that this is a form of help which has already been developed in many places with considerable success and to which we should give further consideration.
Boarding out is another comparatively low-cost means of providing mentally ill people with satisfactory accommodation and care outside hospitals. Some local authorities and voluntary organisations have already begun to develop schemes of this kind whereby mentally ill people are found foster homes in sympathetic households where they can live as one of the family with the help and support of other members.
Supervised lodging schemes provide similar accommodation, except that they allow for a more independent existence, often in sub-let bed-sitters, which some people prefer, but with a sympathetic landlady available to help if required. In both cases, although no capital cost is involved, considerable social work effort has to be invested particularly in the early stages either by the local authority social workers or by voluntary agencies. It 46 must be remembered that such workers are hard pressed in many other respects. The selection of boarders and landladies must be handled with a great deal of care and all concerned need to know that, if necessary, they can obtain skilled support and advice.
The full potential of many of the voluntary bodies involved in mental illness has not yet been realised. They must he encouraged to raise the scale of their effort to match the scale of what is needed. Statutory authorities can by their attitude have a crucial impact on the scale of voluntary effort. Local authorities can help by undertaking some pump-priming under the present legislation.
Central Government already provide funds for these purposes. Therefore, a little pump-priming money for a local campaign, using voluntary workers to find families or landladies willing to take mentally ill boarders, could be one initiative. An effort to organise volunteers with some basic training to befriend and support individuals or groups can relieve hard-pressed social service departments from at least some demands on their time.
I wish to stress the fact that these are all low cost factors. In the present financial climate we cannot avoid the fact that local authorities already shoulder heavy burdens. It is impossible for hon. Members on either side of the House to seek to put restraints on expenditure and at the same time to expect local authorities to provide all these services. Those authorities cannot do so, and they will become disillusioned and bitter if we lay on them statutory obligations which they cannot carry out.
That does not mean that we can give up the battle and say, "We cannot do better." We can, even while using exactly the same resources, do a great deal better than we have done before. We have become too accustomed to think that progress is measured only by the opening of new purpose-built centres, often built on too lavish a scale. I plead guilty on that score on behalf of central Government. We must recognise that many of the professionals in this area carry an appallingly heavy case load. Our society, and our newspapers in their comments, must recognise that it is no 47 good constantly bullying people about their mistakes. Of course mistakes are made, but they may be due to the fact that we have not been prepared to earmark sufficient resources.
It is no good willing the ends and failing to provide the means. There are whole areas of need in dealing with mental illness and the White Paper has not attempted to hide them. The mentally ill need a champion, and it is nice to see that role being taken by a Government Department. I do not believe there is one central answer. I am convinced that it will be solved only if the health and personal social services recognise in their approach to the mentally ill that they must plan together and see the problem as a unified whole.
§ Mr. Spriggs
On the question of the use of resources, is the Minister aware that I have a young constituent who has reached a high standard of academic education, that this young lady was discharged from Rainham hospital as cured and that when she attended several interviews to obtain employment she was not accepted—in other words, as soon as the prospective employer learned that she had been an in-patient at a mental health hospital, she was not considered. She had no chance of obtaining employment. Does the Minister realise that such young people have no opportunity to play a full part in society again?
§ Dr. Owen
I wish I could answer my hon. Friend on that point and assist him, but he is talking of discrimination against a patient who was mentally ill and it is a matter of attitude—an attitude that has existed for many decades. It will continue to exist until people accept that they themselves carry a high probability of being affected by mental illness. Mental illness is no respecter of persons. Indeed, there are Members of this House who have been acutely depressed, or who have suffered mental illness, or can expect to do so.
The only way in which we shall eradicate that type of discrimination in employment is to make people realise that mental illnes is part of the pattern of illness that affects the community as a whole and that one person who refuses to employ another might, in a few years' time, find himself or herself in exactly 48 the same position. The Government can persuade, Members of Parliament can sponsor and help the cause of the mentally ill in their constituencies and many do. That is a great tribute to the work of the all-party group which has all the time fought for a higher priority for, and a greater awareness of, the problems of the mentally ill.
I could have dealt with many other problems in this short debate. There is the worrying problem of the increasing trend of alcoholism, the minority problems of the homeless alchoholic and that of drugs. To some extent that is not as bad as some of us thought it would become five to 10 years ago. Still, it is devastating for a family to be affected by it.
My overall claim is this—that there is a need to try all of these solutions in the next few years, to exercise restraint, to start afresh, and above all to change attitudes. It is attitudes which must change, and it is this which is the key to most of the improvements in mental Illness. This will ensure that it gets a higher priority when it comes to the question of what can be afforded. This will ensure that people—because they realise that there is a sense of urgency—will be prepared to adapt themselves and to make do with that which is, perhaps, much less than perfect. There must also be the realisation that if something is not done, these mentally ill people suffer. It is in that spirit that we conduct this debate.
I have no immediate answers to the problem. I believe that we are agreed in our analysis that more of the mentally ill can be looked after in the community than hitherto. At the same time, let us not forget the realism in this White Paper about the necessity to keep open some of the long-stay psychiatric hospitals for well beyond 15 or 20 years. Again we have not faced up to that sufficiently in the past. We have believed that they would all be closed. Consequently, they have been starved of resources. There has not been enough recognition of the fact that many of the pioneering innovations in mental illness started in these psychiatric hospitals. There must be the acknowledgment that the movement out into the community could well hold the key to changes in the future.
§ 4.23 p.m.
§ Mrs. Lynda Chalker (Wallasey)
Although this is a short debate it is better that we should have it now than put off the date when we start to discuss this subject and change the attitudes towards this vital issue of mental health. I must declare my interest. As a Council member of HIND, I particularly welcome this debate. We hope that, as a result of it, people in the community will not just take note of what we say but will begin to perpetuate some of the work taking place only in tiny corners of the country for the benefit of discharged mental health patients.
There are many schemes, some of them mentioned by the Minister. The difficulty is that often there is total lack of flexibility in the approach to the problem in hand. Many different schemes are operating in only a few places. Had we asked the Minister to state how often boarding out took place and how many local authorities were truly trying to help with day care and so on, he would have been forced to say that there were only a few here and there. That is the tragedy of the situation.
We talk of switching resources, but I believe that a great deal more can be done within the community. I congratulate my branch of MIND in Wallasey, which has set up five new community homes, each with four or five patients, in the past financial year.
There is one situation which must be clarified before it clouds this debate. It has already been touched on in the speech of my hon. Friend the Member for Reading, South (Dr. Vaughan). It concerns the position about mental health abnormal offenders. On every occasion that there is something desperately wrong there is, quite rightly, a great public outcry in the newspapers. What the public must realise is that out of 197,000 admissions in 1973, less than 1 per cent, came from the criminal courts or penal establishments. Of all admissions only 14 per cent. were compulsory. Of that number only 11 per cent. came from the criminal courts, penal establishments or the police. Altogether, psychiatric cases account for fewer than ½ per cent. of the 736,860 non-motoring convictions in our courts. We must get this situation into perspective. Most mental patients are 50 passive. They are often silent, fearful and withdrawn. Some are severely handicapped. Rarely are they violent.
The Minister estimates that one-third to a half of our mentally ill adults could be re-located in the community if hostels were available. This is saying something about our mental hospital patients which most of the community fail to realise. They think that anyone coming out when the bell sounds at Moss Side is about to rape someone down the road. That is not true. We must put this into perpective. If we examine the recommendations of Butler we see that it was thought that 500 people in the special hospitals—usually those holding the worst offenders—ought not to be there.
We come to the thorny, vexed question of people leaving mental hospitals for the community. We in this House must realise that there should be two stages in this process. There are vast differences in types of mental illness and in the ability gradually to move from an enclosed society—and it is very enclosed—back into a much more cruel world than any of these people ever knew before they entered the hospital. We must remember that a large number of these people may have been in hospital for 10 years or more. Life outside has changed drastically in that time.
We must also realise that the responsible medical officers in the hospitals are cautious about releasing patients. We must work out a system under which the mental health review tribunals take more note of what the responsible medical officer is saying. The layman, the lawyer and the doctor together are not the only people with knowledge. When it is found that there is a problem over releases from a certain mental hospital, each case should be looked at to discover what can be learned from it as well as to see what can be done to safeguard the rights of the community. I do not say that the community should not come first and foremost. I say only that we should get the matter into the correct proportions.
What further action is needed? A week ago I was privileged to spend some time at Moss Side. Later I hope to see a number of other local hospitals. I welcome the attitude of the staff at all the mental hospitals I have visited. We 51 often fail to recognise that they care, not on a daily basis, like hon. Members, but year in and year out. We owe them a great debt of gratitude for the completely selfless way in which they look after in-patients.
Can we not set up a system whereby patients may either be released from a special hospital on parole over a time into the community but under strict supervision or else released into one of the local mental hospitals? Here we face a grave problem. In a number of recent cases when Moss Side and Park Lane have wished to release patients into a local mental hospital that hospital has refused, partly because there could not be an exchange on a one-to-one basis and partly because it did not want someone from Moss Side. I hope that the House will forgive me for using Merseyside examples but I know that area better than others. We have to get an understanding between the staffs of these hospitals. Mental health review tribunals, together with the responsible medical officer, have to recommend, as they could, that these people be discharged to a local hospital. It is a stage in the process of rehabilitation.
Surely this is what we must be aiming at, bearing in mind not only the cost of custodial or institutional care compared with the cost of community care but the right of such people to freedom after they are cured. I hope that the halfway house through the local mental hospital will be a necessary step in the process of release.
The advisory body suggested in Section 65 of the 1959 Act should be instituted. It is wrong that the decision whether restricted patients should be released should rest wholly on the Home Secretary. There is a place for the advisory body, as Butler suggested, and the Home Office could make this condition. I am also concerned that Section 65 patients should never be released into the community without pro-diving supervision for them. In some cases the supervision starts too late after discharge. I hope that, as a result of Dr. Acres' study and of other studies which are now taking place, we shall learn from previous discharges and experience.
I have already mentioned the question of patients having home leave before 52 final discharge. Such leave should be supervised. I have been interested to note recently the number of cases of voluntary supervision. The system works well, but there is doubt whether voluntary supervision is sufficient. The Cambridge Institute of Criminology's Report showed that there was a higher reconviction rate among voluntarily supervised patients than there was among compulsorily supervised patients.
There is, however, more than can be done. There are people who, with a little training, could help in the supervisory task. In the probation service there are people who assist probation officers. They are not fully trained probation officers. I see no reason why people who wish to help in the rehabilitation of mentally ill people should not be trained along similar lines to work with social workers or probation officers in the task of supervision and rehabilitation.
Within existing budgets, and without spending more money, we are supposed to be doing something about the training of social workers. I have been terrified by the reaction of some young social workers when faced with the potential care of former mental hospital patients. They do not know what to do. They are frightened, and this fear transmits itself quickly to the people supposedly in their care. There is no confidence and there is no shoulder for the patients to lean on. The whole system then begins to break down because the pressure builds up on the social worker, who already has a very heavy load. A slight diversion of resources from other worthwhile projects would perhaps ensure that there were sufficient people equipped in carrying out personal social services in each local authority to look after discharged patients when they returned to the community.
I turn to the aspect mentioned by my hon. Friend the Member for Reading, South and the Minister, namely, getting other people to help in the community. I have been staggered by the amount that is being done. At the last annual general meeting of the National Association for Mental Health there was reference to experiments taking place in the community where volunteers, under the guidance of specialist workers, and often with probation officers, were helping in their spare time with the boarding-out issue. They were going round and talking to 53 potential landladies and explaining the problem. I was pleased to see the Granada programme, which was televised in the North-West only, I believe, which explained some of the problems and successes. Such programmes might well allay the fears of people who perhaps would otherwise care for someone in the community but did not know how to go about it and were fearful of it.
A number of churches are beginning to run day centres for people who are totally listless and who otherwise would not know to acclimatise themselves to a fast-moving world on their return to the community. The tragedy is that the local authorities are cutting the grants of the voluntary agencies which are working at what is termed the sharp end so that they do not have the money to help them with the small expenditure that they undertake. The Minister should do something to help in this respect, because there is no provision in many areas apart from that afforded by the voluntary agencies.
The hostel situation all over the country is absolutely desperate. I have no hesitation in saying that the hostel situation for homeless former mental health patients is worse than that for any other group. Hon. Members opposite laughed when my hon. Friend the Member for Reading, South said that he had seen three deluded people between Horseferry Road and the House of Commons on his way here today. It is not a laughing matter, but society has turned its face away from it and has closed its ears to it.
I shall not ask the Minister to take on the responsibility for homelessness, but there is a total lack of co-ordination from the day when the application is made to a mental health review tribunal or the discharge is organised. It is always somebody else's responsibility. Whether we believe that we should persuade local authorities not to cut the grants of voluntary bodies which are doing useful work, or should divert resources, or set up more joint planning committees, the aim must be the same, namely, to allow people, after they have received treatment and have been rehabilitated, to return to the community to which they rightfully belong. We have no right to say that they shall not live free and normal lives, provided they are well enough to do so. The trouble is that, instead of helping them, society, in its prejudice, puts up 54 every bar that it can think of against them.
§ 4.38 p.m.
§ Mr. Eric Moonman (Basildon)
I am grateful that the Opposition have allocated part of this Supply Day to a subject that has been debated far too rarely in the House. I echo the hope of the Opposition that the Government will allocate time for a more far-reaching debate than is possible today.
It is about 10 years since the all-party committee on mental health was set up. Some of us on both sides of the House were anxious to ensure that there would be a continuing pressure group on the subject. In view of the poor attendance in the Chamber today, one might wonder whether we have succeeded or whether our work has been all that useful. I think that it has been useful, because to some extent the job of those who feel anxiously and deeply about the mentally sick and mentally handicapped is to give information, recognising that this will never be an attractive subject. It is an embarrassing subject.
Although there are many statistics—some have been given today—which show that this problem affects a large proportion of the community in the western world, when it strikes a family it is still treated as something which is very personal, which is perhaps right, and it is contained rather than discussed. Although the statistics put the bite on the subject and put pressure on the Minister, they also conceal the personal anxiety and harrowing experiences of those who need or must obtain mental treatment.
I am also troubled about the use to which statistics are put. We are inclined to think in terms of those who are in need of mental treatment. The statistics do not take account of the enormous responsibility that is suddenly thrust on a family, or on the employer or neighbours. Very rarely is mental illness successfully dealt with within the family. At some point it is necessary to call upon the resources of the wider community. We have heard that about 5 million people consult their doctor about mental illness, but that figure is nothing like the total of those who require assistance.
The question remains: does the plea from both sides of the House move the House or move and activate the nation? 55 One of the jobs that we must do, without in any way qualifying it, is to ensure that local authorities are fulfilling their responsibilities. Perhaps my hon. Friend the Minister, who has a different rôle, feels that he should be a little more judicious about the local authorities. I have no such discretion. Unless we ensure that every local authority is fully aware of what is expected of it, we shall not bring about improvements and there will be the dumping that we have seen in one or two areas.
I think that the hon. Member for Reading, South (Dr. Vaughan) was a little harsh about the White Paper. It does not attempt to lay down priorities. We must await the consultative document for that. Although the White Paper is overdue, it lays down a series of suggested practices and describes research and experiences in a way which is extremely helpful. At the very least it is a good teaching aid for those in the social services. The problem of resources, which affects the National Health Service as a whole, is nowhere more critical than in the mental health sector. It receives the lowest proportion of resources per patient. Any erosion due to inflation will therefore have a fundamental effect on already inadequate services.
My hon. Friend is wrong to say that there can be no special pleading. Deciding priorities is the Government's responsibility. As parliamentarians we do not have that responsibility. If others have the opportunity to serve in the Government, it will then be their responsibility. It is not fair for any Minister to say that a group of people cannot make a case for dealing with the issue with which they are concerned. If there is a priority to be related to other parts of the Service, it must be defined.
That, presumably, is what will be done in the consultative document. If we are to be criticised for making our case, it is the fault of the White Paper, because it does not indicate the Government's thinking on the priorities. The mental health service must have priority. The current information and advice and the experience of the last 10 years make that clear.
I wish to make a number of points, the first being about prevention. Many of the factors that lead to mental illness are 56 outside the control of society at large. We can begin to deal with such illness without any capital expenditure by looking more intelligently at the areas of stress. I am talking about the type of work performed in many of our factories, the type of houses that we continue to produce, town planning, and how we fail to understand some of the stresses within our communities.
Dealing with those matters would go a long way towards beating the problem before there was any need for expenditure on the mental health service. We may not always be able to alleviate stress, but we do not have to add to it. It is one of the follies of our contemporary society that we do so.
My second point concerns recognition of the illness. The White Paper says that general practitioners treat 90 per cent. of all diagnosed mental illness. This means that the GPs' rôle is extended. Training in recognition is needed, not only by those who will be coming into general practice in the next few years but by existing doctors—men of over 45—who may not have had the benefit of this sort of training and analysis. A training programme should be given priority to enable doctors to treat mental illness quickly and to recognise those cases requiring specialist psychiatric help.
The other group of key workers in recognising mental illness, especially in families with a number of problems, are the social workers, who are also responsible for the valuable work of rehabilitation after treatment. I regret that the morale of social workers is as low as I have ever known it, partly because of reorganisation and partly because, despite the greater efforts to talk about communication and co-ordination, they have not been implemented in an intelligent way. My hon. Friend needs to keep a close watch on the way in which the new authorities use social work staff, so that their specialist skills are not lost behind desks or buried in local government bureaucracy.
Thirdly, in the White Paper and elsewhere there is evidence of the importance of volunteers, and not only because the Health Service does not have the resources for all the staff it needs. Even if we had all the resources needed, there would still be a valuable rôle for the volunteers. There is always room for 57 the little extra, the acts of individual kindness which are a spontaneous expression of the community's concern and a continuing link with the world outside the hospital. I welcome the steps to integrate voluntary work with the official services, which will make the volunteers' work more effective and more satisfying, which is equally important.
I was disappointed that the White Paper made little reference to the 1959 Mental Health Act. One of my hon. Friends asked whose responsibility the Act was. It does not matter. The important thing is that the Act was a reflection of the mood of the period, but that was a long time ago. We might not have a new Act until 20 years after the passage of that Act. We should distinguish between what was in that Act and what we need. It was a revolutionary Act, but after 16 years of operation its shortcomings are apparent. It has not triggered off a positive response from the community, because its provisions have left too many loopholes for local authorities to opt out of their responsibilities. This is an underlying theme of the discussions.
There is still considerable anxiety about the area in which mental health and criminal responsibility overlap. The whole procedure relating to compulsory admissions, renewals of committal orders and the rights of patients in relation to mental health review tribunals all give rise to great concern. Liaison between the Home Office and medical staff in these matters is not always as it should be.
Fourthly, the gaps in the Health Service reflect the attitudes of local authorities that have made little or no contribution to helping with their own case loads. To that extent they cheat. Their passing on work to another authority is a macabre joke. There is disgust in London and elsewhere at the way in which some local authorities pass on their problem families and other cases to other authorities, which is totally wrong. What happened in the West Midlands is not unique. Other authorities, too, are dumping their psychiatric patients.
I have questioned the Minister on this subject before and I was not entirely satisfied with his response. I can understand that he does not wish to engage in one particular inquiry—there are many other problems—but we have evidence of dump- 58 ing without adequate back-up, and we ought to be aware that it could happen elsewhere. Indeed, to judge from the evidence I have, it has already happened elsewhere. It is extremely important that we discover the extent of this problem, and to do so needs only a simple circular asking what facilities and back-ups exist. This is in line with the White Paper.
The situation in Birmingham is not unique. It has started to happen elsewhere. Dumping is monstrous at any time, and where there are not sufficient provisions of community services, it means that local authorities have failed to fulfil their responsibilities.
Co-ordination is a utility word that we all enjoy using. It has become part of the contemporary language in industry, the social services and elsewhere. Professor Evans of the King Edward Fund has started an important project to make the word meaningful. I am sure that my hon. Friend is aware of the work and will continue to give attention to it. Professor Evans says "Do not talk about coordination or failures and breakdowns between different levels of staff. What does it mean?"
We have often seen, for instance, after inquiries into battered baby cases, that we are dealing with the situation too late. Professor Evans found that one problem in connection with mentally handicapped people—and this could apply equally to the mentally sick—was a failure of communication. There was an absence of uniformity in the completeness of case records, with two groups of people talking about different types of records. One group had well-prepared, fully documented case records of a family and the other group was talking about something quite different. They were not talking the same language and did not have information relating to each other.
Another example was the inability of providers and parents to see eye to eye on the requirements of the mentally handicapped and their families. There were great gaps of understanding about what should be done. Providers of services have different perceptions of their own rôles and those of their colleagues. One of the case workers' most common complaints was that they did not know what they were doing in relation to people in other departments. Practitioners fail 59 to see themselves as co-ordinators. There is a tremendous job to be done in communications and supervisory training for the social services.
I have argued this before and I will continue to do so. I am not sure that those who take the decisions fully understand that this is basically a management problem—an element that has always seemed to be lacking from the Civil Service. We shall never make the breakthrough in care and supervision of care unless we have people talking meaningful language about some of these problems of communication and co-ordination. If we fail the question of whether we should allocate a larger budget becomes much less meaningful.
I am a little unhappy about the Minister's saying that we need a low-cost mentality. It is a dangerous phrase which he might regret. I can see it being brought up at a future General Election. I think he means—and this has not been rejected by the Opposition—that we should not just go for the major items, the conventional purpose-built accommodation, but should also make use of existing buildings.
He is quite right, but that should not be a short cut and there are many local authorities that will go along with the Minister's words in that way. Those of us on the all-party committee found that the low-cost mentality had been in existence for far too long. The evidence that has been given about less food being provided in mental hospitals than in ordinary hospitals is a terrible reflection and indictment of us all. What a terrible approach to this problem!
We must ensure that the low-cost mentality means getting value for money, but we must also make sure that everything else is right. It means an intelligent understanding of the services putting the maximum pressure on local authorities, closing loopholes and continuing to educate this House. We must have another debate. It is absurd that we should have to rattle off our speeches in three hours. We are grateful to the Opposition, but it should not have been left to them to give up their Supply time.
I wonder whether we have our priorities right. I do not wish to offend hon Members on the Scottish National Party 60 Bench, but I cannot understand why we spread ourselves for a week on problems north of the border when this problem affects us far more deeply in the long term than does anything in the short term. Education involves not just local authorities. It starts here. If we do not have the information, we shall not be able to win the batle for the mentally sick.
§ 4.56 p.m.
§ Mr. Cecil Parkinson (Hertfordshire, South)
I congratulate the hon. Member for Basildon (Mr. Moonman) on his powerful and well-informed speech. Those of us who take an interest in this subject know how hard he works to ensure that the House and the country is better informed about the problems of the mentally ill and the mentally handicapped.
In discussing this subject and bombarding the Minister with complaints, grievances and grouses, we should set the scene a little more clearly. For most people in mental hospitals or sub-normality hospitals, the standard of care and facilities is an infinite improvement on what was available a few years ago. I have five large hospitals in my constituency and anyone who goes to hospitals can see the difference between an upgraded ward and an old ward. The upgraded wards are in the majority now. Hospitals have left very few wards in their previous condition, and we should realise that a great deal is being done. We shall dismay and discourage hard-working hospital staffs if we do not pay tribute to that fact. There are now better facilities and better ways of giving a better life to people who have had very low expectations in the past.
There is agreement on all sides with the policy of moving people from hospitals into the community and building up community facilities. One rarely hears a case being made against it, but although the policy is unexceptionable in theory, it is not working in practice. In one hospital in my constituency, there are 200 patients who are capable of being discharged and are regarded as being reasonably self-supporting, but they have nowhere to go, and this is very depressing for the staffs of the hospitals who work very hard to get the patients to a level where they are capable of going into the world and making a stab at providing 61 for themselves. The patients' expectations are aroused and then destroyed when they are told that there is nowhere for them to go. They have to stay in places which staff have been training them to be capable of leaving, and this situation has a devastating effect on both staff and patients.
A subnormality hospital in my constituency has a children's ward with 200 beds. Of those, 120 are occupied by people who, by no stretch of the imagination, are children. Some of them are in their thirties. But there is no room in the main hospital because, thanks to the upgrading of the wards, there has been a reduction in the number of available beds. Therefore, although in theory there are 200 places for children—indeed, there is a need for 200 places for children—only 80 beds are available.
It is almost impossible to get a severely disturbed child into hospital for a week or two to give the parents and family a chance to reorient themselves. A great deal of horse trading goes on between hospitals to find beds in holiday homes, to which children from one hospital can go for a week or a fortnight so that others may be transferred for a change. An unbelievable waste of doctors' and staff time is involved. That is happening all the time.
In my constituency there is a chronic shortage of secure places. In virtually every hospital there are patients who, doctors frankly admit, should be in secure hospitals, but there are no places available. Therefore, they must stay in general mental hospitals, and the staff have to divert a great deal of additional time and resources to lookin1g after them.
We have heard about the article in the Daily Mirror. It is not news to anyone who takes an interest in this area that patients are being discharged into the community and that the community consists of dosshouses, rooming houses, or any place where a patient can find a bed. Week in, week out, one reads in the Press of patients who are sent to prison by the courts because there is nowhere else for them. They should be in hospital, but no hospital wants to know. Therefore, magistrates, to their fury, week after week are remanding people into prison. The prison service is being used to prop up the mental health service.
62 All these points are evidence that our policy is faulty, that it is not working as well as it should be working, and that it has been too clear-cut in its concept. The idea of being either in hospital or in the community is not good enough.
The one thing that the White Paper did, if it did anything, was to settle that argument. It clearly stated that existing institutions will be in use for a long time. It stated that there was no prospect of local authorities making provision on the scale required in the immediate future. The White Paper has, in effect, said that we accept the long-term objective of getting many more of the mentally ill into the community, of treating them as far as possible in the community, and of keeping them with their families, but that we also accept that it is a pipe dream.
I agree, with the Minister that a note of reality and frankness distinguished this White Paper from others. A lot of the cant and hypocritical chat of the last few years was dispelled by the White Paper. It is clear that we shall have to use existing facilities, that we shall not get this clear-cut division between the community and hospital, that we shall have to make do, and that we shall have to be more imaginative and flexible.
The Minister was generous to local authorities when he said that we should not criticise them. The duty to provide facilities has been placed firmly on local authorities. The facilities are not being provided on the scale required. Therefore, where else can the blame be put?
I often feel that local authorities simply do not face the scale of the problem. We all know of the token show hostel around which anybody who wants to see what the borough or town is doing for the mentally ill can be taken. But when somebody says, "That is lovely; that is a beautiful hostel; another 20 and we shall be on the way to dealing with the problem", the chairman of the local housing authority virtually keels over. As far as he is concerned that borough or town has made its contribution and can show it to the world. The implication is, "Nobody can accuse this borough of not making provision, because there is something to show." However, local authorities still have no grasp of the sheer size of the problem.
63 I referred earlier to a hospital with 200 patients ready for discharge. The borough from which it draws its patients has provided only eight places and, as far as I know, has no plans to provide any more. It needs to provide 25 times that number of places, but it has no plans to do so. Indeed, it is feeling quite pleased about what it has already done. This is a criticism of the Department, because it has not yet convinced local authorities that the problems of the mentally ill and handicapped are not matters for token gestures. Local authorities have the duty of making suitable provision.
I suggest that local authorities are slow, and are likely to be slower, in providing suitable facilities because, when a patient is in hosital, he is the taxpayers' problem. He is not the local authority's problem. The taxpayer is paying the bill. I suggest that a local authority which has 200 patients capable of being discharged into its area should be charged by the Health Service for the cost of maintaining those patients for which it is not prepared to provide. I think that there would be a spectacular increase not only in provision, but in interest by local authorities if that suggestion were put into operation. I cannot think of any other way of encouraging local authorities to grasp this nettle. It is wrong that a local authority should be free of all expense and duty to patients in hospitals. There is an incentive for local authorities not to make provision because, if they do not, the taxpayer will continue to pay.
Another problem concerns the failure of the follow-up services. I should declare to the House that I am setting up a policy group on behalf of the Conservative Party to look into this area of health care and I have had a number of letters about it. An elderly lady wrote to me saying:I hope when you look at this idea of discharging everybody into the community you will remember the case of my sister who is 63 years of age and 5 ft 2 in. tall and not well and has a husband who is 6 ft. 3 in. tall, is a tremendous handful, and when he is discharged from hospital, as far as she and the public are concerned, she is the community.We may feel that we are being more humane to patients by discharging them into the community, but often we are just landing them back with families who 64 are ill prepared and ill supported to deal with the problem. We are not solving the problem. We are simply hiding it.
The Birmingham exposé clearly showed that many people who are theoretically discharged from hospital go straight into not very good facilities—dosshouses and secondary hotels—and that they can become the subject of exploitation. I do not want to minimise the contribution which the private sector can make. The Minister was right to point out that the small boarding house with a friendly landlady who takes an interest is much better than many of the other facilities which are available.
I suggest that the Department should look at the licensing rules again. I appreciate that a discharged mental patient is not a mental patient any longer or he should not have been discharged. However, there should be legislation to enable the Department to supervise the working of private homes. I am sure that those who want to make provision for profit would accept having to conform to certain minimum standards. It is important that this House sets those standards as quickly as possible.
Housing is the critical area time after time, and I was delighted to hear what the Minister said about the possibility of using land or the proceeds of the sale of land. There are five large hospitals in my area, and the one thing that distinguishes them all is that they have huge areas of land. This is because the prewar approach to mental patients was almost literally to put them out to grass. There is a lot of land in almost every hospital, several of which are on the fringes of towns, and that land could easily be made available for joint development with the local authority and the Department. This would dramatically reduce the unit costs of housing.
There are two final matters with which I propose to deal. The first is the special problem of children and adolescents. I mentioned earlier the problem that there are so many people in the subnormal category that hospitals are totally gummed up and have no leeway when it comes to the provision of beds. If a family is under tremendous pressure with a severely disturbed child, very often if the child can be taken away from the family for a month that gives the 65 family a break and gives the doctors an opportunity to treat the child. The child can then be reintroduced to the family, and in that way we can save the family tremendous wear and tear and give all concerned a chance.
There is a chronic lack of facilities for mentally handicapped children. My policy committee will, as a matter of urgency, be looking at the whole matter of the special problems of children and adolescents, because it is absurd to say that as soon as a child is 19 he ceases to be a child, that many of the facilities that had previously been made available are no longer to be provided, and that he is virtually on his own. Many parents dread the growing up of their disturbed and handicapped children.
My last point concerns the shortage of secure places. It has been interesting listening to this afternoon's debate. Nearly every speaker has touched on the problem of the shortage of secure places. Everybody feels that patients should not be discharged from the Broadmoors and the Ramptons. Everybody feels that there should be other units for the mentally handicapped, but everybody equally feels that they should not be accommodated anywhere near their own constituencies. In my area two of my hospitals are being examined as possible sites for a secure ward of 30 people, and already the cries are going up of rape and murder.
The truth of the matter is that many people who ought now to be in secure hospitals are in general mental hospitals, and the creation of a secure unit would ensure that the public are better protected, not that they would be worse off. Proper facilities would be available, and proper staffing ratios would be provided. It is incumbent upon us as Members of Parliament not to fall for the easy line of scaring the life out of our constituents at the prospect of such a unit but of reminding them that the danger exists now. The 30 people to be housed in the unit will not be created when the unit is built. They are alive now and living somewhere, and, by implication, they are in less secure premises.
A great deal needs to be done here, and not least is the job of engaging the public's attention and of persuading the community that this is a problem which we must all make a contribution towards 66 solving. I thought that we were on our way here, but if one looks at the national societies one sees that almost invariably they are composed to a large extent of parents and relatives and that the general public are active in only a marginal way
Only last weekend one of my local newspapers refused to print a picture that was taken at a Christmas party for mentally handicapped children. The photograph was of two charming little girls, with the chairman of the council and myself. The newspaper refused to print it, on the ground that it did not like printing pictures of handicapped people because readers found it disturbing. It seems a straw in the wind. There is a big job to be done in persuading the public that they must get involved in a community problem, and I hope that in having this debate the House in its small way is making a contribution towards that exercise.
§ 5.15 p.m.
§ Mrs. Margaret Bain (Dunbartonshire, East)
I, too, am delighted at this opportunity to discuss the great problem of mental illness. I have a few brief points to make to the Minister and I am glad to see the Under-Secretary of State for Scotland here because he and I recognise that there are different aspects of administration pertaining to the Scottish situation.
In terms of hospitals for the mentally ill, it is disturbing that only 5 per cent. of mental illness hospitals have reached the staffing ratios recommended by the Department. This is a cause for great concern amongst many people, including the nursing profession. As other hon. Members have said, members of that profession are dedicated people, and they are concerned that they are not able to use their abilities and capabilities to the full to deal with the problems because there are not enough staff to help throughout the day and night.
Equally, people are concerned about the ratio between qualified and unqualified nurses in mental hospitals because this is still only 55 to 45 and, as far as they are concerned, that is not good enough. Union representatives have put it to me strongly that they are not deprecating the use of unqualified staff in the hospitals, because they value their work, 67 but they would like to see an improvement in standards by the attraction of more qualified nurses.
In my area, both COHSE and NUPE have raised this matter with me. I could not agree with the Minister when he said that we should not attack local boards because in my area there are cut-backs in the staffing ratio at a major mental hospital. No vacancies are being notified to get qualified staff into that hospital. This is causing concern not only to the nurses but to the local community because standards at the hospital will be reduced.
There is also the feeling that the security aspects will be neglected. Many hon. Members have referred to security aspects being neglected if there is a reduction in staff, and it is only natural that local communities feel slightly upset at such a prospect. It seems logical to me that, at a time of high unemployment, the Government should start a recruiting campaign to attract people into the nursing profession and make sure that they are highly qualified.
There is a need to bring the problem of mental illness and its treatment to the notice of the community, because only in this way shall we get the change of attitude to which the Minister referred. There are still people who have fears and suspicions about the mentally ill. By hospitalising people all the time we endorse those fears, because people believe that those suffering from mental illness should be locked away.
The problem is acute in Scotland. The Scottish Society for the Mentally Handicapped, when dealing with the problem of community services, said:Many children are placed in hospital unnecessarily, due to lack of community services, In Scotland 11.4 per 10,000 children are in mental deficiency hospitals: in England and Wales only 7.5.That same organisation said that there is a need for hostel accommodation, and the Government in their memorandum of 1972 said that there was a need for 2,500 hostel places in the community. So far, only about 500 places have been provided in Scotland, and we must bear in mind all the time that it is 50 per cent. cheaper to have hostel places and community services than to provide institutionalised care.
68 There are 64 local authority centres in Scotland for the mentally ill and handicapped. Stephen Jackson and Margaret Struthers produced an interesting report which said:Of the supervisors of the centres, only seven considered the buildings adequate—and they went on to talk about various problems that they found.
There has been report after report on the problems of mental illness and mentally handicapped people, yet although they are read they are seldom acted upon. I hope that this White Paper, which has recognised many of these problems—public ignorance, general neglect, the failure to initiate real planning or to provide training facilities and so on—will be implemented and not allowed to gather dust on the shelves. In a time of economic recession we all know the problems, but let us not make it the mentally handicapped, the mentally ill and the most vulnerable sections of the community who suffer.
§ 5.21 p.m.
§ Mr. Ronald Atkins (Preston, North)
What concerns me most, especially in this time of financial stringency, is the low priority given to the mental health services. Fewer crumbs come from a smaller cake. I wish that I had been reassured by the Minister's speech that he intends to raise this priority. I do not think that there will be any fundamental improvement without a greater proportion of the funds of the National Health Service going into mental care.
The Minister has said that some help will come from the Department for social service and community work and from local government for local government work. But there is a need for an improvement in the attitude towards the priority of these services. Just as in education, money will be found for the gifted children while the mentally handicapped children go without, so in the health services the mental patient is placed at the end of the queue. This is probably because there is nothing glamorous about mental wards. No one could make a romantic film or television series about mental medicine as one can about an emergency ward or a maternity ward or a ward in a general hospital. That shows the weakness of the position of 69 the service, which depends on a fundamental change in the attitude of the public.
The public and therefore their public representatives often turn their backs on mental illness as something sordid, frightening or incurable and best left to itself. The consequences of this neglect will be more evident as the proportion of mental illness increases progressively with the increasing complexity of our civilisation and the change in the social age structure, which will also increase the incidence of mental illness. Money spent on mental health now will save expenditure and distress in future.
Treatment of the mentally sick in the past has ranged from flogging to exorcism, from the padded cell to the straitjacket. The weakness in our case is that some people today would still favour this kind of treatment. Some mental treatment today is no great advance on the old methods. Drugs are used as a kind of chemical straitjacket because scarcity of staff and resources prevents the individual and personal treatment that the staff would like to give.
Drugs are frequently given to control the patient, although the effects of some are irreversible. Once started, they will have to be given to a patient all his life and frequently cause the patient to deteriorate physically and mentally because of various side effects. Many mental patients are very intelligent and are aware of this. It must affect them mentally to know that their treatment is doomed to a sort of holding exercise. These drugs are sometimes given without conclusive tests in the diagnosis of the complaint—again through lack of facilities. That is even more disgusting, but we should not blame the staff, who are tremendously under strength and lack the vital resources. Some wards in mental institutions have become clinical dosshouses or even medical prisons.
Is this the most economical way of running the mental health service—to incarcerate a large proportion of the patients for most of their lives? Such a system wastes a great deal of money through the failure to spend more money on fewer patients in order to cure or understand them and more effectively to help others suffering from the same disease. A great deal of money also 70 is wasted through failure to provide accommodation and care in the community for patients who otherwise are forced to live, and, without cure or understanding, to die, in hospitals.
Local authorities should be informed of their responsibilities and forced to provide the badly needed accommodation and community care. Like other hon. Members, I disagree with the Minister's suggestion that local authorities are doing enough. They are certainly not doing enough. It is true that they need more resources and more Government help, but they do not work as hard as they should for the mentally ill. I know of several patients in my constituency who have attempted suicide or gone into the local mental hospital for treatment and who have left without this accommodation being provided or with conflict remaining in the family or unemployment difficulties increasing. In those circumstances, it is not long before they go back to hospital after a temporary stay in the community. Without this provision by the local community the ex-hospital patient cannot fit in. He finds the adaptation even more difficult than does the ex-convict.
Sometimes mental patients return to an environment even less favourable than that which triggered off their complaint. Overcrowding in the home is one of the more obvious causes. I can understand the difficulties of local 'authorities when councillors are approached by more articulate people. When there is a difficult housing problem, patients who cannot plead for themselves, even if represented by social workers, are forgotten. There is a tendency for hard-pressed local authorities to make excuses for dealing with people who are already on their lists. I can understand the difficulty, but that just makes Government help all the more necessary.
Much has been said about the need for a new attitude to mental health in the community, and indeed in this House and among local public representatives. Especially do we need to impress on the public the need for a greatly improved budget for the mental health services. In a community that is generally unsympathetic to the needs of the mentally sick and the mentally handicapped, it behoves the Members of this House 71 to espouse the cause of the least articulate and least vociferous of all patients.
§ 5.30 p.m.
§ Mrs. Jill Knight (Birmingham, Edgbaston)
In what is intended to be a very brief speech I shall touch on three areas of concern. The first is an area of great public concern, the second an area of wider professional concern, and the third is causing a good deal of localised concern.
My hon. Friend the Member for Wallasey (Mrs. Chalker) dwelt particularly on the fact that relatively few patients—I think she said a tiny minority—from mental hospitals committed crimes when released. She added that it was most unfortunate that great anxiety was felt, because the minority involved was so very small. Nevertheless, it is most important to recognise that when instances come to public notice of dangerous people getting outs of mental hospitals and murdering or injuring others, incalculable harm is done to the cause in which all of us here are so very involved—that of giving real care to mental patients.
It does not help to pretend that these cases are not important. My hon. Friend the Member for Reading, South (Dr. Vaughan) spoke particularly of the case of Ian Dunlop. I remind the House that his own defence counsel said after four appalling attacks on young boys while on leave from Broadmoor, that letting him out of hospital was like letting a mad dog loose and expecting it not to bite. Then there was the case of Thomas Pankhurst who was freed from Broadmoor having murdered his wife and five children in 1971. There was the case of Peter David Mackay who was twice released from a mental hospital and who killed three old people. Brian Knight was released from Broadmoor and then stabbed a flat mate to death. Terence Iliffe was released from Broadmoor having been committed there for attacking his third wife. He subsequently dumped the body of his fourth wife in the family deep freeze only 15 days after marrying her.
All those cases have come up only in the last few months, and it is a matter of great public anxiety that such dangerous people should be released into the community. The fact that they are released and then murder or harm their 72 fellow citizens creates enormous difficulties for all relationships between the public and mental patients. It is important that that should be recognised
Next, there is the area of professional concern. Here the subject of secure units arises. Very often the people who leave or release themselves from mental hospitals for an afternoon or an evening do not make the headlines, because they are not so much the murderers as perhaps the rapists.
In Birmingham recently a known rapist simply walked out of St. Margaret's Mental Hospital in Great Barr and went for a drink. He followed that by raping a 13-year-old girl. Ever since 1968 I have repeatedly raised in the House the need for secure accommodation within some of our mental hospitals. The 1959 Act, although a very enlightened Act, made it possible henceforth for cases such as that to happen, because it meant that there were no longer secure units in mental hospitals. Most of the patients can be trusted—one would wish them to be so trusted—but a minority cannot be trusted to behave properly when they walk out, as they are able to do.
It is now recognised that there is an unanswerable case for secure units. Ever since the Butler Committee reported, we have had evidence and acceptance of this need for regional secure units, and there are now plans for them. But the problem worrying RHAs, AHAs and administrators is from where the money is to come to build and run such units. There has been no public statement so far that any money is to be made available.
Is it the Minister's intention that the running costs of these units will have to be found by the reallocation of existing funds? Hard-up AHAs feel that they cannot find the money. There is an indication that there may be some delaying tactics here. I read recently that even when everything is clear to go ahead, it will be five years at least before these secure units are ready. Will the Minister confirm whether that is correct? There is great urgency about this matter. Innocent people will be the victims if we still have to wait another five, six, seven or more years for secure units.
Mental hospitals nowadays often resist taking patients because they cannot keep them secure. I do not know how many 73 patients there are in general hospitals who ought to be in mental hospitals, but I know that there are some. In the Birmingham area alone, I am told, because the authorities are so nervous about their lack of ability to keep certain patients secure, such people are often not accepted and they have to go into ordinary hospitals. The professions are asking for a clear statement by the Minister on how it is intended to finance secure units and how these units are rated against other priorities.
My third and last area of concern is the local after-care units. The spotlight of publicity beamed upon Birmingham is not altogether justified, because there are other parts of Great Britain where the problem is as severe as it is in Birmingham, but certainly it is true that a scandal of major proportions has blown up about the care of mental patients released from hospital.
About 8,000 patients have been readmitted to the community in Birmingham. It is reckoned that the figure is about 2,500 per year, but the local authority provides beds for only 130, a very tiny number. Up to 2,000 ex-mental patients live in 200 lodging houses in Birmingham, and they are often left to wander the streets during the day.
The scandal has arisen for various reasons. One is that the standard of care has been very low in two lodging houses run by a housing association. There is an argument about whether the grants by the local authority to that housing association were made in such a way as not to be available when the housing association needed the funds.
The Salvation Army in Birmingham states that 30 per cent. of the men using its hostels are ex-psychiatric patients. I do not think that there has ever been any suggestion that the Salvation Army has not looked after them well. The House will recognise the sterling and wonderful service given by the Salvation Army to the community in so many ways.
It is reported that the Minister has said that £20 million is to be made available. The Birmingham spokesmen have said that they hope for £1 million of that. I do not know whether it is accurate, but it has been reported. It may just be wishful thinking. Has any sum been mentioned? If it has, is it intended that 74 that sum should come from the area health authorities? Which of the two priorities—after-care units or secure units—does the Minister regard as more important?
It is also reported that the Minister will shortly visit Birmingham. He will be very welcome and given every help that we or anyone else in Birmingham can give him. We all recognise the problems. This is not a party political matter, but it is giving rise to great anxiety. If the Minister will answer those questions Birmingham and I will be most grateful
§ 5.40 p.m.
§ Mrs. Millie Miller (Ilford, North)
There has been a great deal of agreement on both sides of the House about this topic. As Chairman of the Labour Campaign for Mental Health, I am deeply concerned about many of the issues that have arisen in the debate, and about many others that have not.
I start by referring to the opening speech by the hon. Member for Reading, South (Dr. Vaughan). He referred to the part that trade unions and trade unionists might play in helping in this field and in dealing with the effects of mental illness. I should like to refer him to an example which has been going on in Bristol since 1960—an organisation called the Bristol Industrial Training Organisation. It is providing and has provided over the last 15 years work to the value of about £1 million.
The trade unions that have involved themselves directly and personally and in helping in the raising of funds with this organisation have been the local branch of the Transport and General Workers' Union and NATSOPA. Both unions have chosen to publicise the needs of people in their local area and to make this the campaign that they are supporting.
Over the years, this organisation has provided not only work and occupation for people recovering from mental illness but a hostel, which has 100 places for full board. It has also had the use of local authority housing to provide extra accommodation for those with whom it is working. That is a worthwhile example not just of what is being done but of how much more might be done were other large industrial groups to feel that they wanted to commit themselves to this type of work.
75 A number of hon. Members have commended the Minister on the White Paper and a number have complained that it looks too far into the future. There was a brief letter in Saturday's issue of The Times. It is probably one of the shortest that The Times has ever printed It said,Sir. If Concorde, why not pay beds?My question would be: if Concorde, why not help for those who are worst off in our society? Why not extra consideration? Why not the special treatment that the Minister would deny those who are mentally sick or mentally handicapped? I am sure that if most hon. Members had the opportunity to choose priorities, they might well decide on that kind of help rather than the type that will slowly beggar the country, for every time we sell a Concorde, we lose many millions of pounds.
I want to mention in particular the problems of children. I commend to those hon. Members who have spoken about children and mental health a small book published by the Council for Children's Welfare as part of its evidence to the Court Committee on child health. It is entitled "No Childhood." It reveals a tragic situation for children who are mentally or physically handicapped in some way, but who are treated as if they were ill.
Often, as the book's title says, they have no childhood because they remain incarcerated in a hospital setting for all their childhood years, for all the period when for other children there is freedom to expand their experience and freedom to learn with a large number of teachers to help them. All kinds of opportunities that able-bodied and mentally capable children can take are utterly denied to the many children who remain permanently institutionalised.
The tragedy is that many of them are not ill. Although many of them have mental handicaps, they still have abilities. They certainly still have the ability to enjoy the company of a variety of people, the ability to enjoy taking part in art activities, or of being part of a musical setting. All these are possible for them, yet, because of the lack of facilities in so many of the big institutions, they do not have the opportunities. It is a great 76 tragedy that we who spend so much time in the House talking about education, who last Session spent so many hours on the Children's Act and on the needs of children being taken into the care of local authorities and foster homes and so on, do not manage to find a little time to think of these other children whose only home is the hospital.
The Minister has said that we ought to call on the services of the voluntary organisations. I heartily endorse that, because I know from my experience as a member of various local authorities that there are many people only too willing and anxious to help if they know what the needs are. When we call on these people to help, we should ask them to help with the education needs of these young children, in the same way as nowadays people often go into schools to help youngsters who do not get enough backing from their homes to help with the development of their reading.
There is a great deal that local authorities can do. I do not accept what the Minister said about being sorry for the local authorities because of their difficulties, because the financial difficulties have developed very quickly in the last two years. Many of the years since the introduction of the 1959 Act were golden years for local authorities when they were encouraged to spend. In spite of that, we have heard statistics today to show that when they had the opportunity to choose, many authorities did not choose the most disadvantaged and often the most handicapped in our society on whom to spend ratepayers' money.
However, some authorities have given fine examples. I should like to mention in particular the type of work that is done in training volunteers so that they can make a better contribution to the work that they have chosen to do. There is a great opportunity for councils of social service, for example, to take on this work and to give those who are dedicated and want to be dedicated to a cause the right guidance about how to use their abilities.
One of the problems is that the White Paper talks about the care of the mentally ill when we have not even entered into some aspects of the care of mental illness. I want to mention one tragic case which occurred recently in my constituency.
77 Because of a tragic bereavement, a woman became completely mentally unbalanced. Her husband took care of her as best he could for 24 hours a day for a week. Then, unable to carry on, he took her to the local mental hospital and she was admitted. No one told him that, as a voluntary patient, she would be free to leave. Within hours of her admission to the hospital she had left. She went into the grounds, which are huge, wearing only a nightdress. Eventually her husband found her drowned in a stream running through the grounds. He assured me that no one had ever told him when she was being admitted that she would be free to go. Had he known, he would never have allowed her to go.
If this can happen in any of our mental institutions, it is certainly one aspect of the care of the mentally ill that ought to be taken up and dealt with without any delays before further tragedies occur, not to the public outside, but to patients who, in all good faith, are taken into these institutions to be cared for.
Many of the problems in our society arise in families with a history of mental illness. How many of the babies who have been battered or stolen from prams have been the victims of those who are not themselves fully capable of making mature judgments? This, too, is a area in which one should not be too hasty about pushing people out of hospital and back into the community, unless there is absolute certainty that they are capable of complete rehabilitation and that young children or adults will not be their victims later on.
To the extent that there will not be unlimited means, either in the local authorities or in the National Health Service, to provide for mental patients the kind of attention we should like them to have, a great deal more must be done in intertwining the training of nurses and social workers. As somebody who has had a good deal of experience in social work, I am far from happy about the type of social work training given today. I am far from happy about the freemasonry being developed in the social work profession, which is demanding higher and higher qualifications and spending more and more of the produc- 78 tive life of the social worker on training of various kinds when the great need is for them to be out in the field with families and patients who need them so badly. There is a need for nurses who have been trained primarily in the medical field to understand more about the ways of dealing with their patients from the social work angle.
One of the aspects of joint financing that might be of great value would be for the hospital services and the local authority services, together with the Central Council for Education and Training in Social Work, to see what kind of curriculum they can prepare to ensure that both sides of the fence get experience to help in dealing with the many tragic cases that come into their line of duty. I agree that this is not a romantic subject, but I feel very sad that the White Paper is so forlorn about the hopes of interesting the public in this topic. Paragraph 2.26 states:Whether much can usefully be done to influence public attitudes directly is uncertain.I am surprised that the Government take this line.
The Government have not felt unable to influence public opinion about other aspects of their activities, such as influencing the public to accept the £6 pay norm, or the idea of our entry into Europe. If the Government were sufficiently confident of their propaganda abilities in those respects, surely they could try a bit harder to get the public to understand the requirements and to accept the contribution that needs to be made in this. The Government should also show that they appreciate the voluntary work by not bearing down too heavily, as they now are, on the finances of the voluntary organisations.
§ 5.54 p.m.
§ Mr. Charles Irving (Cheltenham)
I have listened to the speeches from both sides of the House in this debate with growing anxiety. The one figure which depressed me most was that mentioned by my hon. Friend the Member for Reading, South (Dr. Vaughan) who referred to the 32,000 patients who have spent over 20 years in mental hospitals. Those who have been involved, through social service and other local authority work, are fully aware that a very large number of those patients would have no need at 79 all to be in hospital if the community would provide them with somewhere to go. It seems to me that there has been no real sense of urgency in providing facilities for out -patient treatment of mental illness. I propose to say more about that in a moment.
Additionally, the local authorities must surely through their social services provide, and I hope speedily, more small units to take care of a substantial number of the 32,000 who could well return to live in the community. I was at Stoke Park Hospital near Bristol this weekend, and the consultant psychiatrist told me that out of his 1,500 mentally handicapped children and adults, at least one-third could safely return to the community provided they had somewhere to go and there were supportive facilities of a minimum nature.
Let us examine briefly the cost of our negligence in this respect and our failure to tackle this problem energetically and imaginatively. At Stoke Park the cost of hospitalisation is at the moment about £74 per patient per week. Multiply that by 500 patients who could return to the community, and we have in this group alone a cost of £37,000 per week. If this were equated to what it would cost to provide a simple hostel or home facilities, there must surely be a very substantial saving in cost which could be equalised between the health service and the social services. I should have thought it was well worth while considering this aspect.
In the South-West there are one or two authorities which have provided surplus police houses or hostel accommodation of one kind or another, mainly managed by the National Association for Mental Health. Splendidly backed up by voluntary care and affection, these former patients have returned to a happy life at minimum cost. If the will were there, our mental illness hospitals could be greatly relieved of overcrowding and would at least have beds available for those who seriously require the care and affection of the dedicated staff in those hospitals to restore them to health.
Over the years I have visited many mental hospitals, and I am astonished at how cheerful the staff remain, often in depressingly sub-standard conditions. The 80 pressures that they are under and the situations with which they have to deal are sufficient to turn them from the profession into patients. But they carry on and hope that one day, one or other of the successive Governments who have failed realistically to assist will tackle as a matter of urgency this totally unacceptable, disgraceful and nationally scandalous situation of which we are all aware.
I took the opportunity of reading an incredible document produced by the Department of Health and Social Security in 1971. I then examined various papers concerning this problem and sadly came to the conclusion that the words of wisdom set out as a pattern were nothing more than pie in the sky. I only hope that the consultative arrangements to which the Minister referred will not be yet again another bit of pie in the sky. In being critical I accept that certain improvements have taken place, but there seems to be a continuing argument between the health authorities and the social services as to whose is the responsibility and whose budget shall be tapped for real improvement. I therefore urgently hope that the Minister will feel able to bring the parties together, and, if they cannot decide, decide for them.
Additionally I should like to see an instruction issued to local authorities that in all housing schemes some accommodation must be specifically earmarked for ex-hospital patients. Experience has proved that with care, such schemes work extremely satisfactorily. I think I am not far out in saying that at present there are only about 200 such homes throughout the country. These provide for just over 2,000 people, and it is pitiful when one relates it to the fact that there are about 180,000 patients who leave mental hospitals each year over and above those who could leave but cannot.
Community care, as one could describe the social services rôle and that of the local authority—I happen to be chairman of a social services committee—is not simply a matter of providing accommodation and occasional support. One has to tackle the lack of purpose in life, the loneliness, the inability to earn a living. Therefore, in view of the nation's restricted resources, we must turn even more to the voluntary movement and seek its continued help and co-operation in 81 providing day centres and clubs and a range of employment from sheltered to open.
Perhaps we could encourage the Government to ensure that the Housing Corporation, now one of the main motivators of rented accommodation, put a requirement or condition on local housing associations that they provide a small percentage of their accommodation specifically for ex-patients. I am chairman of a housing association, and we are at present progressing a scheme which will provide 142 bungalow-type houses, and the design will be in the shape of nine courtyards making an attractive site, but specifically included in this development will be units of accommodation for the elderly, the disabled and the ex-hospital patient. With that mix, with young and old families as well, it is hoped that they will merge into the outside community life and become a part of it. We are encouraged to do that because of the success we have seen in the Gloucestershire area.
Finally, I refer to the tragedy of the discharge of mentally disordered homeless people, people who, because of an uncaring community, are likely to find themselves alternating between lodging house and prison or, perhaps even worse, roughing it in derelict houses. One can only imagine the misery of all this. We greatly miss the reception centres, which were closed prematurely because, according to the thinking at that time, the Welfare State would provide. The Welfare State has failed miserably in that respect.
We are all aware, I hope, that about 3,000 people are sent to prison every year for drunkenness or for inability to pay fines. But about 300 people go to prison for sleeping rough or begging, and the point I make is that many of these people are in urgent need of psychiatric or hospital treatment, but the breakdown comes with inadequate resources for aftercare.
Recently, I believe, the Howard League disclosed in a paper that two-thirds of those convicted of petty offences in the South-East were either disordered or maladjusted, 38 per cent. being homeless and 24 per cent. unable to settle. Prison is known to be useless as a deterrent to people who have known no other home 82 for years. These people must not be overlooked in our assessment of accommodation and support needed in the community for the mentally disordered. Our penal institutions are a highly expensive way of providing a roof for people who should not be there at all.
We must more adequately support the National Association for Mental Health. We must take steps to insist that the bickering between the Health Service and the social services shall cease. We must insist on local authorities and housing associations playing their part by a firm allocation of accommodation, and we must ensure that the voluntary workers who are such a credit to the nation receive more help in their efforts to deal with this depressing and heartbreaking problem. What has been achieved so far has been but snail-pace progress over the past 10 years, and, to judge from what the Minister said this afternoon, I suspect that it will be much the same in the next 10 years.
§ Mr. Deputy Speaker (Mr. Oscar Murton)
I remind the House that there are still four right hon. and hon. Members desirous of taking part in the debate, and there remain only 25 minutes or so for them.
§ 6.3 p.m.
§ Mr. Tom Litterick (Birmingham, Selly Oak)
I shall do my best to be brief, Mr. Deputy Speaker. We are talking here about a group of people who are casualties, but it is a group that is growing rapidly, even more rapidly than the elderly, as a proportion of the total population. We are considering a phenomenon of human damage created by the process of change.
We constantly tell ourselves that change becomes more rapid each year and each decade, without recognising explicitly enough that the very process of change brings with it stresses which turn people into mental patients, and the rate of growth of this sector of the population throughout the developed world, whatever be the social or economic system, is indication enough that every legislative assembly in the developed world should give this problem priority not only in the present but for the future.
As I understood him, the Minister was saying, in his own way, that the mentally ill were likely to include any one of us, 83 and probably a significant minority of hon. Members, within the foreseeable future. But the mentally ill do not have a voting strength. They are not a pressure group. They do not lobby. They cannot do what even the physically disabled have been able to do. They cannot come and beat on our door saying "Look at us. We are disfranchised, we are underprivileged". Since they cannot do that, others have to speak for them, but, unfortunately, the political process being what it is, there are no votes in saying "Let us have lots of money to take care of the mentally ill".
The expression "mentally ill" is itself a polite phrase. We all know that it is not the kind of phrase commonly applied to people who are mentally ill. Perhaps it is a sign of progress that we have heard only one speech this afternoon in which the traditional primitive attitude to the mentally ill, regarding them as dangerous and violent, was emphasised. As I say, perhaps that is a sign that society is coming round to a more civilised view of mental illness.
The profession itself, however, is divided on the meaning of mental illness. I speak as a layman, but, as I see it, the medical profession is not yet sure whether to treat mental illness as an aberration from some sort of norm which in itself is impossible to define, or—as I suggested at the outset—as a consequence of a society, which asks the impossible of people, with the result, in my belief, that the orthodox approach of psychiatry, that is, to get people to adjust to things as they are, may in effect mean no more than asking the impossible of people who have been so damaged by the status quo that they can never properly adjust to it or ever be what we should call sane. Perhaps the descendants of Wilhelm Reich may prevail in society in the end, but that day seems a long way off yet.
What is true—several hon. Members have emphasised this—is that there has been a catalogue of errors of omission by us collectively as a society. We have not been ignorant of what is going on. There was the sensational report in 1971 of the goings-on in certain establishments on the Kent coast, at Ramsgate, Broad-stairs and Margate, similar to the scandal revealed recently in Trafalgar Road, 84 Moseley, in my constituency. But nothing was done, either by the Kent County Council or, sadly, by the House of Commons, because it has been convenient not to do anything about it. It is an embarrassing subject, and, as I said, the mentally ill have no votes. But, unwittingly, we have created a new class of Mr. Bumbles who have discovered that there is money to be made out of sick people in a certain category—the mentally ill—that one can set up rackets which can be highly lucrative, that one can dip one's spoon into the public trough and help oneself liberally, under the guise of being benevolent.
I do not suggest that all those who are involved in the running of such establishments as the now notorious institution in Trafalgar Road, Moseley, are of a like character. However, the present situation is one which creates circumstances in which such people can thrive. They know that so far we have not evinced enough anxiety about the mentally ill to ensure that such people are subject to close scrutiny.
The individual who runs an establishment in Trafalgar Road has two institutions. He calls one institution Whipp Enterprises. That is his property speculation company. The other institution he calls Dawn Trust. He uses the first for his commercial advantage and the second to obtain public money. When members of the Community Health Council seek to visit his establishment he gets them out by saying "This belongs to Whipp Enterprises". When he wants public money it is not Whipp Enterprises but Dawn Trust.
This man has currently asked for no less than £100,000 of public money. I am happy to tell the House that he has not obtained it as he is unwilling or unable to fulfil the 19 conditions which the local authority is attempting to extract from him by way of agreement.
He is not effectively spending the money which he has already been given on the people who are in his institution. It is obvious that the clothing allowance that he has received is not being spent on the patients. It is obvious that the money he is given to buy food for them is not being spent in that way, as he owes the local authority a great deal of money for lunches consumed by his people when they go to the local authority day centre. He is using the problem that now exists 85 as a cover for money-making. At the same time he is posing as a public benefactor. It is Mr. Bumble all over again.
Authors have scandalised Victorian England but maybe we need another Dickens to write about the present situation. The public need to be galvanised into an awareness that vultures are around and that mental illness needs to be considered in a different light. I am not one to suggest habitually setting up committees. The Curtis Committee was set up some years ago to investigate the circumstances of boarded-out children. Although Birmingham has been highlighted recently, the present difficulties exist not only in Birmingham but in urban areas throughout the country. It seems that we are not fully aware of the extent of the problem.
When my hon. Friend visits Birmingham—I am happy to know that he will be doing so—I hope he will use his visit as a platform. I know that he is passionately concerned for the interests of these defenceless people, but I suggest, with the deepest respect, that he directs his words to the general public.
As a councillor I have been involved in establishing half-way houses in various housing estates. I am aware of the difficulties and the attitudes that are prompted by establishing such places. No matter what social class is involved, the attitude is equally primitive. People do not want the mentally ill in their streets. They dredge up dark stories about what mentally ill people are supposed to do. There is phenomenal and abysmal ignorance.
I hope that when my hon. Friend visits Birmingham he will talk about these matters. If I may say so, for a Minister he has unusual qualifications to do so. By public activity we might encourage a new, healthier and saner attitude to this form of illness.
§ 6.15 p.m.
§ Mr. Graham Page (Crosby)
I am not acquainted with the sort of establishment which the hon. Member for Birmingham, Selly Oak (Mr. Litterick) has described, where profit is made out of the misfortune of the mentally ill. I know about the voluntary work that is done for the mentally sick. The Minister of State rightly mentioned the great aid which the voluntary organisations can give. I think that 86 almost every contributor this debate has mentioned it. However, we can reach saturation point.
In one small community in my constituency—namely, Magull—there is the now well-known Moss Side special hospital which receives the mentally ill when they have gone through the courts. Next door to Moss Side is being built the new Broadmoor. In addition, there are seven large homes for epileptics and the usual old people's home. The point has been reached at which the League of Friends of Moss Side is wondering how it can assist. One reaches the point at which it is difficult to find more and more voluntary help. That is especially so when there is considerable concern about discharges from the special hospitals.
My hon. Friend the Member for Wallasey (Mrs. Chalker) says that we must keep matters in perspective. She said that it is a very small percentage of the mentally sick who go through the courts and who are sent to security hospitals. She said that it is only a small percentage of those who are sent to such hospitals who are discharged and who commit further crimes. Yes, we must keep these matters in perspective and we can produce overall figures for the nation, but when we start to consider the figures of one small town in my constituency the situation is very worrying. My hon. Friend the Member for Birmingham, Edgbaston (Mrs. Knight) has demonstrated the public concern that now exists about those who have been discharged and who have committed further crimes. They may be a small percentage but they produce an extremely serious situation.
I express my great gratitude to the Minister for the sympathetic and informative answers which he produces to my queries. As my constituency includes Moss Side hospital, I receive many letters from patients asking for a transfer to an ordinary mental hospital. They ask to be discharged and they ask for a Mental Health Review Tribunal. When I read the pathetic cases of those who were put in Moss Side many years ago for what seems a comparatively small offence, I am faced with a difficulty. Should I press for a tribunal? If I do, what responsibility do I bear if the tribunal allows a dangerous criminal to be released?
87 There is deep concern about these matters in my area, but the concern about people escaping is misplaced. There is concern about whether applications for discharge are being properly considered. There is concern about the discharge criteria. The public should be assured about the criteria that are applied. There is concern about the tribunals. They are composed of worthy people, but the public wonder whether they are the right people to judge such matters. Should there be an advisory body set up by statute? Should such a body operate between advice on discharge and actual discharge?
What evidence do the tribunals hear and what weight do they give to it? It is suspected that a medical officer's opinion is not always given its full weight by the tribunal. It is suspected that the nurses, the people who really know about the patients and who know far more than the medical officer, do not have much weight placed on their evidence by the tribunals.
Then there is the question whether the tribunals consider what is to happen to the patient if he is discharged. Do they consider whether a half-way house is available? I know only too well that time and time again I have received requests from Moss Side patients to be discharged or to be transferred to an ordinary mental hospital, only to be told that it is impossible to find a place for them.
If there is no half-way house, should they be given home leave and, it so, what are their home conditions? Is that aspect considered by the tribunal? Does the tribunal consider what supervision is to be carried out when somebody is discharged and when it is well known that he or she has committed offences in the past? How is the tribunal to be satisfied that offences will not be committed again in future?
All those matters cause public concern. Therefore, I believe that the time has come for the system to be reexamined. I ask the Minister to set up an interdepartmental inquiry—interdepartmental because the Department of Health and Social Security and the Home Office are deeply concerned about these matters—under an eminent person outside those Departments, and to ensure that the 88 evidence is taken in private. I do not ask for a public inquiry because people would not then let their hair down—and that applies particularly to the medical and nursing personnel—when giving their evidence. Therefore, I seek a private inquiry, the report of which could eventually be made public so that the public will see that these matters are being taken seriously.
The public take this matter seriously, as I and other hon. Members know from our postbags and from discussions with constituents. The time has come to reexamine the system to see whether the tribunal has the correct constitution and applies the right criteria in considering the after-care of patients. Such an exercise should reassure the public that the system is correct—and, if not, that it will be improved.
§ 6.23 p.m.
§ Dr. Reginald Bennett (Fareham)
As my right hon. and hon. Friends know, before I began occupying myself in this institution, I used to work in other institutions such as those we are discussing. Therefore, with full knowledge of the huge burden of custodial care that weighs down the health Votes, I am fully aware that the scale of burden has prevented any dramatic improvements, even, perhaps, in terms of discharging some of the 32,000 people who have been in institutions for over 20 years. Those patients can loosely be referred to as burnt-out schizophrenics from way back and they are now leading an inoffensive and probably harmless existence. But the problem is that there is no home for them.
Nevertheless, to my certain knowledge, even since I left those other institutions some valuable reforms have taken place and indeed there has been a revolution in the type of work undertaken, and even in the buildings. The hospital on the borders of my constituency where I worked for a while consisted of tunnel-shaped wards dating from the Crimean War. That hospital has been transformed.
Could the Minister give me some information about security and high security developments at the Knowle Hospital, to which I understand a high security wing is being transferred? I have heard of this project, but I have no direct knowledge of it. I received my information 89 from a bunch of what might be called local vigilantes. Perhaps we could be told the Government's intentions?
I can vouch for the capacity of that hospital to preserve security. There never was a more secure building. When I was in the Navy, we used to transfer Service personnel to that hospital because it was more secure than our own security arrangements. It may sound a little like the "Gulag Archipelago", but it is a most secure institution.
We all know that there is great public alarm about the discharge of more or less violent patients from institutions. Some patients are extremely dangerous and have committed crimes. On the other hand, there are other patients who have not committed crimes but who are thought to be dangerous to themselves, if not to other people.
I appreciate the problems of doctors who have to decide whether such people are fit to be discharged, because I undertook that task when I worked in those institutions. Doctors are under relentless pressure about whether to discharge patients. I would be told that it was a mistake to compel some of them to remain inside because "They were at least as sane as I". There is no question of doctors taking a dictatorial attitude in these matters. No doctor ever wishes to keep anybody in an institution if it is unnecessary to do so. It is decided to detain people in such places only if they are considered to be a danger if allowed outside. But at present some doctors are being blamed for letting people out when they should not have been discharged.
In cases that do not involve high security patients or quasi-criminal considerations, there may be some way in which perhaps the ordinary mental hospital doctor could be backed by a lay authority to whom he could refer when in doubt. If the decision were made to discharge somebody considered to be unsuitable for his freedom, that lay authority could take the blame rather than the odium falling upon the doctor. It may be unfair that an overworked junior hospital doctor should be expected to take the blame.
§ 6.28 p.m.
§ Mr. Michael Shersby (Uxbridge)
A number of hon. Members have expressed concern about the availability of hostel accommodation for patients discharged by the hospital authorities or patients who have discharged themselves. I wish to express concern about a slightly different subject—namely, the number of patients and ex-patients still disturbed and suffering from mental illness in one degree or another who have been discharged or who have discharged themselves into the community and who are now wandering about rootless, friendless and without the care and accommodation they need. I am referring to accommodation of a residential and institutional character.
I question whether local authorities are able to provide the kind of accommodation needed by patients when they have been discharged from hospital. I listened with great interest to the speech of my hon. Friend the Member for Cheltenham (Mr. Irving), who dealt so ably with that point. I believe that there is something fundamentally wrong with the way in which the mentally ill are treated and with the facilities available to them under the National Health Service.
My interest stems from the problems of two families in my constituency. Both have mentally ill sons who are now middle aged and who are proving to be an increasing source of worry to their parents. There is a great danger that both men may find themselves discharged into the community without the care they need once their parents have passed away. In addition to specialised hostel accommodation, there is still a need for longterm residential institutional care for those for whom hostel accommodation would not be a satisfactory alternative. I hope that later in the debate we shall hear more about this problem.
This afternoon I was visited by a constituent who has a mentally ill son, a man who has spent a number of years in Broadmoor, but who has now been discharged. He is living part of the time with his parents and spends most of the time wandering about rootless in the community. He has committed a number of petty crimes and has gone from court 91 to court. He has been admitted to hospital for short periods of 72 hours for assessment and has then been discharged. He continues to wander about the community getting into more and more trouble.
For that man the National Health Service appears to have broken down. For his parents a serious problem exists. They are getting older. They will not be able to care for their son for many more years. They cannot see how his future is to be secured. That is a dreadful thing. It is terrible that someone so clearly in need of long-stay residential accommodation should be wandering about the community and gradually sinking into petty crime in this way.
All is not well with the provision for the mentally ill in our community. This debate has clearly illustrated that many hon. Members share my view. I hope that we shall hear something from the Minister to assure us that the future is brighter.
§ 6.31 p.m.
§ Mr. Michael Alison (Barkston Ash)
This has been an all too brief but nevertheless wide-ranging debate on the subject of mental illness. It is the first that we have had this Session. The fact that the Opposition have raised the matter so early is an indication of the clear priority we give in our thinking about social policy to the provision for this much-neglected, long-suffering and severely afflicted section of the community. It is also a reflection of the priority in terms of real expenditure which my right hon. Friend the Member for Leeds, North-East (Sir K. Joseph) accorded to this subject when he was Secretary of State in the last Conservative Government. He deliberately made what I hope and believe was an irreversible shift in the priorities we give to the needs of the mentally handicapped and the mentally ill. That was one of the most marked features of his administration at the Department of Health.
I very much hope that the Government will match the priority we have given in expenditure and in the timing of this debate by providing Government time for a full-dress, full-day debate on the White Paper on mental illness. It is not enough 92 to fit this subject into a half-day debate on Opposition initiative in Opposition time. I hope that this is the forerunner of a full-scale debate.
In the few minutes I have, I want to deal mainly with the dangerous mentally disordered offender. This is an area in which there is real, noticeable and widespread public disquiet. It is not simply a disquiet voiced by particular pressure groups but that which arises from genuine concern in the community at large. In the past three years there have been three dreadful cases of most serious crimes, including repeated murder and sexual assaults on children committed by dangerous mentally disordered offenders either while on conditional discharge or on parole from hospital.
I refer in these three cases to that of Graham Young the poisoner, whose case came up in 1972, Terence Iliffe, who murdered his fourth wife, whose case arose in 1974, and Ian Jack Dunlop, the sexual offender, whose case arose last year. His is an appalling record of no fewer than 34 cases of homosexual assault on small boys.
Governments of both parties have reacted promptly to these tragic and disturbing cases. The last Conservative Government set up the Aarvold Committee and the Butler Committee. It is the lot of this Government to implement the far-reaching proposals and findings in the definitive final Butler Report, in which there were no fewer than 140 recommendations. I hope that the Minister will be able to give us some reassurances about the Butler Report.
I fully accept the Butler findings thatthere is no way which would be acceptable in a civilised society by which the public can be absolutely assured that no one released from an institution will ever commit a violent offence subsequently.I accept that that is a common starting point. However, I believe there is clearly more that should and could be done to make the existing system of scrutiny and evaluation of particular cases and of conditional discharge procedures more foolproof and watertight.
I refer to what seems to be a startling loophole in the procedures under the Mental Health Act 1959. Section 66(2) of the Act sets out certain conditions for 93 what is known as the conditional discharge procedure for a dangerous mentally disordered offender. I will enumerate these conditions in outline. First, the patient is normally required to live at a particular, known and registered address. Second, he has to be under supervision there. Third, he must have there, in addition, the support of a social worker or probation officer. Finally, he has to attend from time to time at a psychiatric outpatient clinic. The House will note that these are four specific conditions for aftercare surveillance of the seriously disordered mental offender if he is to be discharged.
The House may not know that in the case of Dunlop, the sexual offender, a conditional discharge order had specifically not been made because these conditions of surveillance could not be arranged. Here I refer to a letter which the Under-Secretary of State for the Home Department sent to my hon. Friend the Member for Abingdon (Mr. Neave) on 9th January. In the letter the hon. Lady said:there was some delay in making satisfactory after care arrangements and final authority for discharge from hospital had not been given at the time of Mr. Dunlop's arrest for his recent offences.Because the four basic minimum conditions of surveillance were not available he had not been made subject to a conditional discharge order. No doubt the problem was a shortage of resources—either finding suitable external accommodation in the community or finding suitable social workers to supervise him.
The staggering and deeply disturbing fact is that by Section 65 of the Mental Health Act the Home Secretary can nevertheless authorise short weekend leaves—even extended leaves—away from hospital on a parole basis. The paradox is that this short-term parole leave—which is meant to be in preparation for conditional discharge—does not render the person liable to these four crucial surveillance conditions. The period on parole or leave is entirely unsupervised.
It happened in the case of Ian Jack Dunlop that the Home Office authorised him to be away for six weeks with apparently no surveillance conditions whatever. It is no part of the duty of a hospital to apply such surveillance in a leave period. Dunlop committed offences at 94 Poole in Dorset, Oxford and Blackpool whilst on parole leave. On none of those occasions was it required or could it be so required that the hospital should exercise surveillance over him. How can the hospital do that when the patient is allowed by Home Office authority to be wandering round the country without surveillance.
The Sunday Express, in a leading article last Sunday, made a severe judgment on the doctor concerned, Dr. David Duncan, at the Fair Mile Hospital, Wallingford, for having done nothing about Dunlop and allowing him out. But the responsibility is not Dr. Duncan's; it is entirely that of the Home Office. It was Dr. Duncan's recommendation—and this is an area in which no one can be certain—that the man seemed to be making good progress. The hospital reported to the Home Office about the circumstances in which Dunlop was once or twice apparently absent without leave. It reported to the Home Office about the family with which Dunlop was allowed to stay, which included four young boys. The probation officer suggested that the family might be the early warning system to see whether there would be any regression in Dunlop.
The Home Office knew all about the matter, yet Dunlop was allowed out on the authority of the Home Office without the imposition of any of the conditions of surveillance which usually and properly apply to cases of conditional discharge. That is what Section 65 allows one to do. It is unacceptable that loopholes of this sort should exist. It is essential that henceforth preparation for conditional discharge involving parole leave should be subject to exactly the same degree of surveillance, oversight and reporting back as cases of conditional discharge entail.
The administration of the interaction between Section 65 and Section 66 is entirely a Home Office responsibility, and no blame really attaches to the Fair Mile Hospital for the way in which the Dunlop case tragically transpired. I hope that the Home Office will without hesitation accept full responsibility.
Through the kindness of Sir John Hedges, Chairman of the Berkshire Health Authority, I have read carefully that authority's report into what happened at the hospital in Dunlop's case. 95 There is no doubt that the doctor's advice and recommendation to the Home Office fell within that category to which Lord Butler referred when he spoke of the impossibility of being certain in these cases. However, having made its recommendations, it is unacceptable that the Home Office should have allowed Dunlop to wander round the country without making a serious attempt to keep an eye on him, as it would have been bound to do if it thought that he was subject to a conditional discharge order.
§ Mr. Litterick
Is the hon. Gentleman aware that he has spent 13 minutes of a 15-minute speech emphasising a minuscule and unrepresentative aspect of a huge problem which exercises the House? Hon. Members on both sides of the House will deplore the hon. Gentleman's emphasis as distorting the nature of the problem and influencing the public mind in a regressive way with reference to the cause of mental illness.
§ Mr. Alison
At the outset of my speech I made an appeal for a proper, full debate in Government time on the White Paper. Meanwhile, a critical case has thrown up a serious loophole in the arrangements for administering the discharge of dangerous mentally ill patients. I make no apology for focusing attention on what must be a major Government responsibility.
Whatever we do, not least in dealing with the problem of surveillance of patients on parole under Section 65, we must face the fact that more resources are required in this sector of public expenditure. They are necessary for the implementation of the two most important recommendations of the Butler Committee—the setting up of the extended advisory Board—and I hope that the Under-Secretary of State will be able to give us some information on how the Board's enlargement is progressing—and for the establishment of the extra 2,000 recommended secure places in regional hospital establishments outside the special hospitals. The Government have accepted responsibility for funding 1,000 of those places. I hope that the Under-Secretary will tell us how the provision of them is proceeding and when we may expect them to be fully established.
96 The question of the progress made in providing secure regional places is of critical importance to the morale of and treatment given in the special hospitals. There has recently been a Hospital Advisory Service visit to Broadmoor. From what I hear, the report made as a result of the visit is very disturbing, but whatever may or may not be said in it—it has not been published, so I cannot speak with authority—it is clear that Broadmoor is overcrowded and until secure places in regional hospitals are provided to which patients who are getting better can be transferred there is no possibility of introducing a proper programme for progressive patient care and rehabilitation in the overcrowded special hospitals.
The suggested balance of expenditure in the next few years—£8 million a year on personal social services for the mental health aspect and £30 million a year on the hospital side—is inadequate in present circumstances. I do not call for greater overall public expenditure. It is simply a question of shifting the priorities. Let me give the Under-Secretary of State a few ideas about where he might obtain extra money.
It is a priority that provision should be made for the mentally ill. It is not nearly such a high priority that we should be spending £3 million a year on setting up and financing the Equal Opportunities Commission. Important though that is, it must give way in the order of priorities to the needs of the mentally ill. We should not be setting up the Police Complaints Board, which will cost, in my view, at least £1 million a year. We should not be phasing out the extra revenue which accrues to the National Health Service through the finances of the private patient.
Leaving aside the relatively small amount which we had to cut from public expenditure in our last year of office, which the present Government have not restored, the last Tory Government made massive increases in expenditure on resources for the mentally ill. One could now go through the list of departmental expenditures—whether it be on general environmental improvements, airport development, road expenditure, car parking developments or prison projects—and suggest ways in which millions of pounds 97 could be reallocated without making any net increase in public expenditure, and yet finance is the crucial priority of provision for long-stay mentally ill patients in hospital and the need to make community provision for them.
I hope that the Under-Secretary of State will show a proper sense of priorities in his attitude to the recommendations of the Butlers Committee, with special reference to the loophole which I have mentioned and the longer-term programme for financing these vital services.
§ 6.48 p.m.
§ The Under-Secretary of State for Health and Social Security (Mr. Michael Meacher)
This has been a low-key debate, but it has been strongly characterised by the sincere and determined demands made on both sides of the House for an improvement in services for the mentally ill and full implementation of the White Paper.
The debate has focused largely on the recent Press reports alleging that many former mental health patients in Birmingham are living in sordid accommodation and that some of them are being exploited by unscrupulous landlords. We have written detailed letters to the West Midlands Regional Health Authority and the Social Services Department and have asked for their detailed comments. My hon. Friend the Member for Basildon (Mr. Moonman) asked that the Government should issue more general guidance. We are awaiting answers to our letters and, in the light of the situation which they reveal, we shall consider what further action needs to be taken. It is, however, right that we should examine the general structure of supervision, because I agree with hon. Members that this problem is by no means confined to Birmingham.
The arrangements for the registration and inspection by local authorities of homes and hostels for the mentally disordered fall under Section 19 of the Mental Health Act 1959. But these apply only to homes and hostels whose "sole or main purpose" is the provision of accommodation for the mentally ill or mentally handicapped.
The legislation does not lay down specific criteria for registration. It is left to local authorities to determine, in the light of local needs and circumstances, 98 what standards must be met. They are simply required to satisfy themselves of the fitness of managers and premises and that it is proposed to conduct the home in such a way as to provide the services and facilities that would normally be required in such a home.
Of course, not all mentally ill or mentally handicapped people go to registered hostels or homes when they leave hospital. Many return to their own homes. Many, either because they choose to do so or because accommodation for people with a history of mental disorder is not necessarily easy to come by in the area, find accommodation in private lodging houses, or hostels, which are not registrable as homes for the mentally disordered, as it is claimed that this is not the sole or main purpose. It is this kind of unregistered accommodation which has been the subject of recent Press attacks. It has been argued in the Press that more of them should be registered.
There are undoubtedly very difficult problems about that, not least the question of how to differentiate between such an establishment and an ordinary private hotel. I can give the assurance which the House has asked for—that my Department is considering the whole subject of the registration and inspection of voluntary and private homes of all types, including those catering for the mentally disordered. If the conditions in some of the unregistered establishments have been accurately reported in the Press, there is a strong case for supervision.
But we must realise that the local authorities, in the absence of better alternative provision, might be reluctant, even if they had the power, strictly to enforce the registration of private and voluntary establishments in many borderline cases. The consequences would simply be that the establishments might be closed down, or they might be forced to put up their charges beyond what the residents could afford to pay, leaving them with no better alternative accommodation.
The issue is, therefore, inseparable from the amount of local authority residential accommodation that exists for the mentally ill. It is undeniable that this falls very far short of what is needed. The total number of places made available by local authorities for homes and 99 hostels for the mentally ill, including those run by voluntary organisations or registered private establishments, at 31st March 1975 was only 4,496.
I should add at once that this was an increase of no less than 24 per cent. on the position just one year previously. But I must also say that this is a sharp increase on a low base and one that has hitherto grown slowly over the last decade and a half. In 1963 the total number of persons resident in local authority homes and hostels for the mentally ill was less than 1,200, and by 1975 it had risen to only about 4,500.
Even the present total of about 4,500 places must be set in context against the extent of unmet need. There can be no definitive measure of this, but if a target for local authority residential provision for the mentally ill of 20 to 30 places per 100,000 population is accepted, there is a national requirement which may be estimated at some 12,000 places. Against this it can be seen that our national performance has been to move from a level of provision in 1963 of about one-tenth to a level now of only about one-third. On that trend it would take us three or four decades even to reach this fairly modest target of national provision.
But even within the meagre existing totality of community provision for the mentally ill there are great local variations. Birmingham Social Services Department was recently reported to be providing only 120 places in hostels for the discharged mentally handicapped and only 15 places for the mentally ill. There is no reason to suppose that this is such an isolated and unrepresentative example, for when Christian Action carried out a survey in 1971 of psychiatric after-care hostels for the mentally it found that against a national average background of five places per 100,000 population, some very few authorities such as Cardiff, Sunderland, Newcastle and Lewisham had achieved a ratio of 20 or more places.
I mention those authorities deliberately. But many more authorities—which I could name—had built none at all up to that date. The picture has certainly changed since then, which is why it is, perhaps, improper to mention them, but it remains true that big and seemingly 100 unwarranted variations exist between localities, and that only in a few areas can community care for the mentally ill yet be regarded as adequate or even nearly so. According to the latest figures, for 1973–74, the average number of places for all authorities is only 10 per 100,000 population—less than half of what we might regard as a proper national average target.
Therefore, there can be no question but that this is a main area of social policy which has been starved for a long time, where the nation is faced with significant extra costs if the indictments now being made are to be overcome. I regret that the hon. Member for Barkston Ash (Mr. Alison) suggested that we had not made considerable efforts to re-order our priorities. As he has introduced that tone, it is not unreasonable to ask him how it is possible for his party realistically to ask for major increases in provision for the mentally ill while his leader is recommending a significant reducton in public expenditure and an increase in, or maintenance of, the level of defence expenditure. It cannot be done.
Perhaps in the long term the new pattern of services will not in itself be more expensive to run than the present one, because the cost of district services will be offset by the phasing out of mental illness hospitals and there will be substantially less in-patient accommodation But in the short term the cost of the change is bound to be considerable because of the major capital investment involved and because for a number of years the new services will have to operate side by side with those of the mental hospitals.
Altogether the White Paper estimated that a capital programme of about £30 million a year on health services and £8 million a year on social services for the mentally ill, over 20–30 years, would be needed to provide all the new facilities required. That is a total of around £1 billion over a quarter of century at constant 1975 prices.
But if that remains our longer-term objective, what of the Government's short-term strategy during a period of no growth in overall resources? My hon. Friend the Member for Preston, North (Mr. Atkins) wished to see an increase in the funds allocated to the National Health Service so that more would be 101 spent on the mentally ill. But the Government have already injected nearly £750 million of extra funds into the National Health Service so that its share of the GNP is now greater than ever before. As to local expenditure, we have modified the rate support grant formula by attaching four new weights to the needs element to assist areas with an above-average number of disadvantaged families. To promote real joint planning and financing between the health and social services we shall soon be issuing an important consultative document to clarify the options and priorities for the next few years.
The hon. Lady the Member for Birmingham, Edgbaston (Mrs. Knight) asked from where the money was coming for the regional secure units. To meet the Butler Committee's recommendation of secure units for violent patients in the NHS regions we are making available special revenue funds in addition to the capital programme already agreed. For the immediate future of community care in present economic circumstances we are examining how to provide increased facilities at lower cost. I wish to pay particular tribute to the work of the Psychiatric Rehabilitation Unit in East London and the Industrial Therapy Organisation in Bristol.
Under the Housing Act 1974, which, for the first time, made local authorities and housing associations eligible for grants and subsidies for building homes and hostels for single persons, as opposed to families, we have paved the way for giving special aid to former psychiatric patients who might otherwise find themselves in situations reminiscent of the recent Birmingham reports. This new financial provision has also enabled voluntary bodies, like MIND and the Guideposts Trust, to show the way forward in community care by buying up houses and adapting them as group homes manned by voluntary workers at much lower cost than the full-scale supervised hostels.
I hope that the hon. Member for Reading, South (Dr. Vaughan), who asked whether we were making full use of voluntary workers, will feel reassured that we are doing just that. I would also lay stress on one further important initiative that we are taking and the con- 102 sequences of which could be far-reaching. Although the Mental Health Act 1959 was welcomed at the time as a beacon, some people now feel that some aspects of its working may need reconsideration. Some hon. Members have referred to this in the debate, particularly the right hon. Member for Crosby (Mr. Page).
We have therefore instituted a review, which is now being undertaken by an interdepartmental steering committee. The review is taking account of comments made by various bodies on the working of the Act, including the Butler Committee, the Royal College of Psychiatrists, MIND and social work organisations. A document will be issued as soon as possible as a result of this work. The document will cover such aspects of the Act as compulsory admission and continued detention, the function and powers of mental health review tribunals and issues such as the protection of the rights of patients and staff.
The hon. Lady the Member for Dunbartonshire, East (Mrs. Bain) made particular reference to staff and fears that had been aroused about cuts in the number of staff. She also made a number of comments about the situation in Scotland, and I shall ask my hon. Friend the Under-Secretary of State for Scotland to reply to her on those matters.
Another issue at which the Government are looking concerns the discharge of compulsorily detained patients, recent cases of which have attracted considerable publicity. These procedures were strengthened in 1972 to provide safeguards for the public following the case of Graham Young and were revised again in 1973 following the recommendations of the Aarvold Committee. They have since been thoroughly re-examined by the Butler Committee which has proposed certain other safeguards. The Committee found that existing discharge procedure for Section 65 patients had been largely successful, but to improve the protection of the public, it recommended that procedures instituted in 1973 for the special assessment of certain Section 65 patients should be modified and extended to cover all restricted patients in special hospitals.
We share the Committee's view that there should be a substantial expansion of existing arrangements for submitting proposals for the discharge or transfer of these patients to the scrutiny of an 103 independent advisory body and, as we have already announced, the Home Office intends to introduce wider procedures along these lines as soon as possible, and this is the reason an enlarged advisory board will be required. Its constitution and functions are now being worked out.
The hon. Member for Barkston Ash made considerable reference to the Dunlop case. He seemed to spend a disproportionate amount of his speech on this single issue which, perhaps, does not deserve the degree of attention that he gave it. I think that he was wrong to suggest that there is an inconsistency between Section 65 and Section 66 and that Section 65 is inappropriate in permitting parole without conditional discharge.
Dunlop had not been discharged when he committed this further crime. It is at the discretion of the Home Secretary and the responsible medical officer what conditions should be imposed on temporary leave for Section 65 patients. In May 1973 the patient was transferred from Broadmoor to Fairmile Hospital and the consultant at the hospital was authorised by the then Home Secretary to allow Dunlop day parole and weekend leave provided that he was satisfied that there was no risk in so doing.
Clearly the Fairmile doctor did not feel any serious cause for anxiety or think that it was necessary to impose conditions on Dunlop once he was out of the hospital. The Berkshire AHA inquiry recommended some supervision for patients working outside the hospital or on leave. There is already power to do this if those concerned believe it to be necessary. The Home Office will consider whether responsible medical officers should be given advice on this matter.
Nobody with a strong social conscience can believe that the present provision is adequate to meet the unmet need. Following our essential strategy, we have outlined in the White Paper the Government's proposals for joint health authority and social services financing, together with an extension of low-cost residential and day care, making a much fuller use of voluntary resources. This represents a realistic and forceful commitment to maintaining the momentum and quality of care for the mentally ill in economic 104 conditions almost universally recognised as unprecedented since the war.
Our commitment is clear and, having set our hands to it, we intend to see it through.