Joan Ruddock
Mental health services in the NHS
Health Select Committee Report - Mental Health Services in the NHS
Mr. John Austin (Erith and Thamesmead): I am sorry that my hon. Friend the Member forMorley and Rothwell (Mr. Gunnell) has had to leave us, because he said that today's speechmay be his last contribution in the House. I hope that it is not. I knew the hon. Gentlemanbefore I became a Member. We all recognise the enormous contribution that he has made notonly in the House but for the benefit of the people of west Yorkshire, as my hon. Friend theMember for Wakefield (Mr. Hinchliffe) knows.
Mr. Hinchliffe: I am grateful to my hon. Friend for referring to our hon. Friend the Memberfor Morley and Rothwell. His contribution to the Committee's work was remarkable. He hashad a great deal of experience in health and social services matters. He chaired a socialservices committee and served on the Health Committee, and his contribution was positive inevery inquiry.
Mr. Austin: I welcome the way in which my hon. Friend the Member for Wakefieldintroduced the debate. I also thank the hon. Member for West Chelmsford (Mr. Burns) for hisbalanced and rounded speech, and for his concentration on the border issues of mental illhealth, especially stigma. Public safety issues are important, and no one wants tounderestimate the tragedy of homicides and suicides, but all members of the Committee shareconcern at the fact that media focus on such events prevents a rational discussion of issuessuch as the location of hostels for people who present no real risk to anyone in thecommunity. Those people are probably vulnerable individuals themselves. That focus alsomakes it more difficult to tackle the stigma problem.
The Committee is concluding its major inquiry on public health issues. The most importantdeterminants of health are economic, social and environmental. Access to employment,training, housing, security and social interaction are key elements for the promotion of goodhealth. Those who lack them are more likely to suffer physical and mental ill health. However, those who suffer mental ill health have more difficulty in accessing them. As the hon. Member for Runnymede and Weybridge (Mr. Hammond) and our report said, such people face difficulties in re-accessing the benefit system.
My hon. Friend the Member for Wakefield referred to unequal or inappropriate treatment ongrounds of race and ethnicity, and my hon. Friend the Member for Romford (Mrs. Gordon) referred to the same problem in terms of gender. Witness afterwitness gave evidence of the fact that health services, especially mental health services,suffer from institutional racism. As my hon. Friend the Member for Wakefield pointed out, patients from ethnic minorities tend to access services later than their white counterparts although they may be more severely ill. They are more likely to be detained than treated as informal patients, are over-represented in the secure system and are often provided with inappropriate or insensitive services. They are more likely to receive physical treatments, and less likely to be offered counselling and other non-physical treatments.
That is not news. Our inquiry has not suddenly uncovered that information, as it was welldocumented 10 or 15 years ago by people such as Roland Littlewood, Maurice Lipsedge andAggrey Burke. We met Roland Littlewood during the course of our inquiry when we visitedNAFSIYAT. Little seems to have changed for the better in terms of discrimination andinstitutional racism. I am glad that the Government have begun to consider the matter,especially in the wake of the McPherson inquiry.
Our inquiry found that many of the most appropriate services for ethnic minoritycommunities seemed to be provided by voluntary and community-based organisations. Myhon. Friend the Member for Romford pointed out the severe difficulty in continuity offunding. We made a firm recommendation on that, and I am pleased that the Governmenthave taken it on board in their response. I agree with her on gender issues, and ask whythere are so many women in special hospitals who even my right hon. Friend the Secretary ofState for Health admits should not be there. That is also recognised in the White Paper,which is pleasing. We have heard that the director of women's services at Broadmoorbelieves that 60 per cent. of the women in her care could be looked after in a less secureenvironment.
As my hon. Friend pointed out so vividly, women who are difficult to manage but are notdangerous are spiralled up the system because of a lack of segregated facilities in mediumsecure units. The choice appears to be between a mixed ward with male sexual abusers inmedium secure units, or transfer to a special maximum-security hospital. That cannot beappropriate or right. My hon. Friend also referred to the gender-blind approach of thesecurity directions on child visiting, following the Fallon inquiry into Ashworth. It wasclearly aimed at men, yet women at Rampton and Broadmoor are now restricted in seeingtheir own children, without any consideration being given to the therapeutic implications.That cannot be right, and I hope that it is being dealt with.
The Committee also considered issues relating to caring for people in the community. Therehave been some reports, including a study at York university, on the success of assertivecommunity treatment. They show that that form of treatment maintains contact with morepatients, cuts hospital admissions, and reduces time spent in hospital with no evidence ofclinical harm.
The Committee was impressed when it visited both north Birmingham and St. George'shospital in south-west London, where assertive outreach programmes are combined with theuse of the newer atypical anti-psychotic drugs, which were referred to earlier, as well as psycho-social interventions and home treatment. That combination is achieving real results. I welcome the commitment in the Government's recent White Paper to an additional 170 assertive outreach teams with 24-hours-a-day, seven-days-a-week access to services. I recognise that performance varies across the country, and that more research must be carried out into which forms of assertive outreach work.
Questions have also been raised as to whether community care has failed, or whether it hasgone too far. It was said earlier that, although care in the community has not failed, theabsence of such care has often failed vulnerable people. The late development of theappropriate care in the community packages has led, unfortunately, to the question beingraised as to whether the shift from hospital-based care to community-based care has gonetoo far, or whether tragic incidents such as the murder of Jonathan Zito in 1993 were theresult of the closure of in-patient units before the development of adequate communityprovision.
Those widespread concerns in the 1990s contributed to the passing of the Mental Health(Patients in the Community) Act 1995. That Act contained an element of compulsion since itcreated a new power of after-care and supervision. However, it stopped short of requiringpatients to accept treatment. In practice, the power of conditional discharge has not beenwidely used, perhaps because of the absence of community support facilities rather thanbecause of the absence of a power of compulsory treatment.
The passing of the recent human rights legislation will be an interesting challenge for themental health services. Last summer, before the implementation of the human rightslegislation, the Court of Appeal ruled that local councils should pay for after-care servicesfor some categories of long-term psychiatric patients. The human rights legislation could, incertain circumstances, require local councils and health authorities to meet the conditions ofmental health tribunal discharge orders.
Last year, a case was brought against a health authority by a woman who had been held indetention in hospital for more than a year after a mental health tribunal had directed herrelease because the health authority had failed to find a forensic psychiatrist to supervise herafter care. In a similar case in 1997, a patient with schizophrenia took the United Kingdom tothe European Court of Human Rights in Strasbourg. He had been detained for several yearsafter the release date ordered by the tribunal because the local authority could not find asuitable supervised hostel. The council was found to be in breach of the Europeanconvention on human rights for its failure to fulfil the tribunal's conditions within areasonable period.
Until recently, the only real remedy available to people was the long and arduous process oftaking the United Kingdom to court in Strasbourg. Their only other form of redress was byway of judicial review, but ultimately, in judicial review, the court could decide only whetherthe authority had acted reasonably and had little power other than that of being able toencourage the authorities to explore alternative solutions. Mental health tribunals do nothave the power to compel authorities to comply with the conditions of discharge.
Now that the human rights legislation has been incorporated into British law, any individualcan apply to the British courts. That will have an impact on mental health services and theirdelivery and will, in some cases, ensure that services are available to meet discharge criteriaand free up much needed in-patient beds. However, I fear that without additional resources,those authorities may end up having to rob Peter to pay Paul. The Government musttherefore be aware of the resource implications of providing an adequate care in thecommunity system.
When my right hon. Friend the Member for Holborn and St. Pancras (Mr. Dobson), theformer Secretary of State, said in 1997 that community care had failed, his choice of wordswas not helpful. However, he was not asking for a return to the old system, with thereintroduction of the water-tower asylums--or the bins, as they are more appropriately knownin the trade. He set up the independent reference group's review of community services andrecognised, as do the Government, that locking up patients in long-stay institutions is oftenharsh and harmful. He said that he was looking for a third way. That was perhaps the onlytime that the right hon. Member for St. Pancras and I looked for a third way; a way thatcomprised the provision of acute beds, more secure facilities, more 24-hour crisis teams,hostels--as the hon. Member for West Chelmsford said--supported accommodation, hometreatment teams and assertive outreach.
My hon. Friend the Member for Wakefield referred to the evidence that we received onpeople with dual diagnosis. That is of real concern to the Committee and I hope to all hon.Members present. My hon. Friend referred to people with a dual diagnosis of mental disorderand substance misuse or mental disorder and learning disability. Despite their differentcircumstances, both groups face the common problem of what is known as "pass theparcel"--it is someone else's problem. Young Minds told the inquiry that
"the division between drug and alcohol services and mental health services creates widespread problems throughout the mental health system". As the National Schizophrenia Fellowship put it: "they are deemed too 'mad' to go into an alcohol or drugs unit or too 'high' to go into a mental health service".
Turning Point gave us evidence that people with alcohol or drug and mental health problems also find it difficult to access primary care services so that their physical health needs are not addressed.
It is not an easy issue with simple solutions. One NHS trust put it bluntly when, referring tothe problem of patients with dual diagnosis on a general ward, it said: "you have people withother conditions who do not want young men out of their heads on wards." Those whomisuse drugs or alcohol also have a right to treatment. Since some may be the people forwhom compulsory treatment is considered, a human rights issue arises if they werepreviously denied access to appropriate services. Substance misuse is often implicated inacts of violence, both homicide and suicide.
Sitting suspended for a Division in the House.
On resuming--
Mr. Austin: I was referring to the problems faced by people with a dual diagnosis. TheHealth Committee received two studies, one from Maudsley, the other from Lewisham. Thefirst showed that 40 per cent. of alcohol-dependent patients had some form of mental illness,and the second that 58 per cent. of people accessing mental health services had a dualdiagnosis of substance misuse. Although the national service framework acknowledgesproblems of co-morbidity, it provides little guidance, which led the Committee to recommendthat the Department of Health should require joint working and co-ordination between mentalhealth and substance misuse agencies. It also recommended that working with people with adual diagnosis should be made a requirement within the remit of assertive outreach servicesand that the duty of partnership imposed on the NHS and local authorities under section 27of the Health Act 1999 should include substance misuse and housing services.
I want to say more about drug treatment. In delivering a unanimous, cross-party report, theCommittee called upon the National Institute for Clinical Excellence seriously to consider theoutcome of treatment from a user's perspective, including the benefits of making compliancewith drug treatment less onerous. Our report was published at the same time as thepublication of a survey by the Zito Trust, showing severe gaps and weaknesses in theprovision of services, with patients being denied access to the most effective treatment--21per cent. of United Kingdom health authorities restricted the use of atypical anti-psychoticdrugs that are known to have fewer side effects and result in better compliance.
Notwithstanding the outcome of the NICE investigation, I share Jayne Zito's concern thatpatients who are non-compliant, often because of the horrendous side effects of typicalmedicines, are denied access to atypical medicines, which, as Jayne Zito said, improvecompliance, lead to reintegration into society and can result in significant savings.
The Government believe that independent advocacy services are important--it is a subjectdear to the heart of my hon. Friend the Member for Wakefield--as shown in the White Paper,which was published before the passing of the Health and Social Care Bill. The White Paperrefers to the patient advisory liaison service as the gateway to specialist advocacy services.
The Minister knows the importance that hon. Members attach to the assurance that theadvocacy services should be independent, and be seen to be so. In view of the amendmentto the Health and Social Care Bill on the location and provision of advocacy services, whichthe Government accepted, the matter will have to be addressed before we consider a mentalhealth Bill.
Mr. Hammond: The hon. Gentleman is talking about the Health and Social Care Bill as if itwere a fait accompli. The Bill is still under consideration in the other place and, depending onthe timing of the dissolution of Parliament, may not make it to the statute book.
Mr. Austin: Whether or not the Bill reaches the statute book in this or a future Parliament, Ihope that the Minister will acknowledge the commitment to the important principles of independent and accessible advocacy services in the Health and Social Care Bill.
The hon. Member for Southend, West (Mr. Amess) drew an analogy between the PrisonService and mental health services in terms of community interest. That may be valid, butthere is a clear distinction: most of us know something about prisons, but few hon. Membershave a loved one, a friend or a relative, who has been in the nick. However, I suspect thatevery one of us has someone close to them with personal experience of the mental healthservices. It is not only our constituents who have such experience.
I have two prisons in one in my constituency, and there are prisons in the constituencies ofmy hon. Friend the Member for Wakefield, the hon. Member for West Chelmsford and the hon. Member for Isle of Wight (Dr Brand). Many people are in Belmarsh prison in my constituency because of the failure and inadequacy of the mental health services to address their needs.
I have been a critic for many years of the inadequacy of the psychiatric and forensic servicesin prisons, but the new regime at Belmarsh prison, which I visit frequently, is a beacon of light in the development of services, and the Committee was very positive about it.
The media have concentrated on the small number of difficult to manage patients but thatshould not divert us from the need to raise the standards of mental health services generally.The Government's NHS frameworks may need even more resources than they have alreadygenerously made available, but if they are implemented, we may at last see the tag "Cinderella service" removed from mental health.
