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Psycho-Geriatric Services (East Surrey)

Volume 974: debated on Monday 26 November 1979

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Motion made, and Question proposed, That this House do now adjourn.—[ Mr. Cope.]

12.8 am

I wish to raise on the Adjournment the question of the psycho-geriatric services in the East Surrey health district. I should begin by explaining that the East Surrey health district covers the southern part of my own constituency. It also serves the constituency of my hon. Friend the Member for Dorking (Mr. Wickenden) and that of my right hon. and learned Friend the Member for Surrey, East (Sir G. Howe). I know that they are equally concerned about the situation that I am about to outline.

The psycho-geriatric service to which I am referring is the in-patient facility at Netherne hospital, in my constituency. In Netherne there are now 15 wards in the psycho-geriatric area, accommodating 407 elderly patients. Three of the wards are allocated to patients from the London borough of Sutton, and beds in the remaining wards include those allotted to patients from outside the East Surrey health district, namely, from Crawley and Horsham.

In this short debate I shall refer only to the crisis over admissions that has arisen in the East Surrey health district. The best way to draw my hon. Friend the Minister's attention to this matter is to cite the cases and examples that have been brought to my notice.

The first arose when a man and his wife visited my weekend constituency surgery to tell me of their experience prior to the admission of the man's father to Netherne hospital. This elderly man, who was 81, had lived with the couple for 18 years, but last year he had become demented and developed into a serious case. Numerous doctors had recommended his admission to hospital as an urgent case, but because of the dire shortage of beds he could not be admitted.

The experience of the couple went from bad to worse. The old man was still very heavy and strong. He began undressing himself at will in front of their children, urinating in saucepans and creating havoc in his bed. The only way in which the couple could keep him in bed was to tie him to the bed with ropes, much to the surprise and alarm of the community nurse when she visited them. She persuaded them to untie him. They did so and the subsequent weekend he fell out of bed six times. On each occasion the ambulance service had to be summoned in order to lift him back into bed. Finally, he was admitted to Netherne hospital and was found to be suffering from bronchial pneumonia. I shall call him Mr. T.

The next case is that of Mrs. P. She is 89 and lives on her own. Some months ago it was adjuged necessary to admit her to Netherne hospital, but no bed could be found for her. After a period she locked herself in her flat and refused to admit the doctor, the psychiatric nurse, the social worker or relatives. Clearly she was adjudged a danger to herself as long as she remained in the flat alone. Eventually the community nurse gained admission but, to my knowledge, a bed has still not been found for that woman in Netherne hospital.

The third case is particularly serious. It concerns an old lady living by herself in a small flat in a block allocated to elderly people, some of whom are blind. This old lady, living alone, is doubly incontinent and has no awareness of what she is doing. She spends her whole day moving around her flat in the mess that she has created. She suffers from severe hallucinations, insisting that her husband is there in the flat. She carries on conversations with him, although he died nine years ago. When her sister was dying earlier this year she had no idea who the woman was.

She has been adjudged a danger to others in the block since she is likely to dry her sodden underwear over a naked gas flame. On occasions, she has been known to burn holes in them. On one occasion her son-in-law visited her and found all four gas taps turned on, all unlit. In consequence, he arranged to have the gas supply cut off. As a result, this old lady, Mrs. K., now lives in a totally unheated flat. Her son-in-law believes that their only hope for her to be granted a bed in Netherne hospital, after repeated refusals because one is not available, is that as a result of living in the unheated flat she might develop pneumonia and be taken into hospital for proper care.

Those are three cases that have been brought to my attention. Others have been brought to my attention by the authorities in Netherne hospital, who are only too aware of the problems of having to refuse beds to patients who are a danger to themselves and to those around them.

The fourth case concerns Mr. B., aged 70, who wanders around uncontrolled day and night. He has been known to try to light his open fire with a can of petrol and he regularly swallows his medication in one go. As in the other cases, he is incontinent.

I would hope that it is obvious that there is a dire need in the East Surrey health district arising from patients in this psycho-geriatric state which Netherne hospital finds itself unable to meet. I emphasise that I cast no aspersions on the hospital staff. Its consultant psychiatrists and all the medical and nursing staff I have met lean over backwards to provide the best service that they can and to take in as many cases as they can find room for. Considering the circumstances under which they work, their morale is high. However, that cannot get around the fact that the hospital has too few beds to take in elderly people who are in urgent need of admission. That arises in part from the difficulty of recruiting staff on the fringe of London, just one or two miles beyond the band where the London weighting for nursing staff applies. That means a difference of about £4 per week.

It also arises from the economies that the hospital has been forced to make following overspending on its nursing budget. The overspending resulted from the shortage of staff, as that entailed paying more than is desirable in overtime rates. Therefore, in the five-month period ending on 31 August, the nursing budget at Netherne was overspent by about £52,000. If underspending on the learner budget is taken into account, the figure comes down to just over £30,000.

Instructions were issued to eliminate the overspending figure. To achieve that, it was necessary to cut the number of nurses from October to the end of the current financial year by 15. Under that arrangement, psycho-geriatric nursing suffered a reduction in establishment of six nurses, at a time when existing staff were stretched to the utmost to cover the wards. Therefore, it was decided to close two wards—one of them a psycho-geriatric ward. That resulted in a loss of 15 beds for patients in my district. The price of that contraction in terms of suffering is all too clear from the tragic cases that I have cited.

I know that the hospital authorities are doing their utmost to squeeze in every case that they can, but it is the old story that one cannot put a quart into a pint pot.

The crisis over admissions has been building up over a number of years and is but one part of a situation that is becoming acute throughout Surrey. Part of the difficulty is lack of funding. As long ago as 1976, the area health authority raised with the then Secretary of State the utter inadequacy of resources allocated for nursing the mentally ill and the mentally handicapped in Surrey.

For historical reasons, a substantial number of psychiatric hospitals were built in the green fields south of London instead of within the capital, so that we have a concentration of such hospitals not found in many other parts of the country. That circumstance has never been adequately recognised by successive Governments.

When measured against national norms, Surrey is 1,150 nurses short in the mental handicap division and 620 short in the mental illness division, which relates directly to the local situation that I am raising.

The effects of inadequate funding are accentuated by the high cost of obtaining any sort of accommodation in Surrey, which is proving a strong deterrent to recruiting nurses from other parts of the country. The accommodation factor was identified as being particularly applicable in the East Surrey health district by the area nursing officer in an urgent report to the area health authority in the summer.

I have also seen evidence that the staffing levels accepted as adequate at Netherne are below those of most other psychiatric hospitals in the South-West Thames health region. That, of course, has an effect on the morale of staff and on further recruitment.

I have been shown comparative figures showing the ratio of nursing staff to the number of patients in psychiatric hospitals throughout the region, and they suggest that Netherne is near the bottom of the league. Given that such a high proportion of Netherne's patients are psycho-geriatrics with such high levels of dependence for feeding, dressing and dealing with incontinence, that helps further to explain the admission crisis that has arisen at the hospital.

I suggest to my hon. Friend the Minister that the lack of suitable hospital accommodation for psycho-geriatrics in advanced states of dementia has become more serious in the East Surrey health district than in most other parts of the country, that the number of beds in the hospital is utterly inadequate to meet the needs of the district, that this places an impossible burden on families forced to nurse demented relatives awaiting admission, that that amounts to positive cruelty to those living alone after their minds have gone, that it is high time that the funded staff establishment at Netherne be reviewed to bring it into line with the funded establishments at other psychiatric hospitals in the region, that if present staffing levels are to continue it will inevitably be necessary to review the hospital's role in providing beds for psycho-geriatric patients from Sutton—outside the health district—and that more thought must be given at the highest levels to ways of attracting more nursing staff to psychiatric and mental handicap hospitals throughout Surrey.

12.24 am

My hon. Friend the Member for Reigate (Mr. Gardiner) has eloquently described a number of shortcomings in services for the elderly severely mentally infirm in his constituency which rightly give cause for concern. He has substantiated his case with several worrying, moving stories. I shall attempt to deal with his points specifically, but it is first necessary to set them in context. This, as successive Administrations have acknowledged, is a Cinderella service, and its problems are being aggravated by the pressure of demographic change.

There are now about 8 million people aged 65 and over in Great Britain, nearly 15 per cent. of the total population. In 1946, there were less than 4½ million—10 per cent. of the population. More importantly, between now and the end of this century the number of people aged over 75 is expected to increase by nearly one-third, and those over 85 by nearly two-thirds. The estimated prevalence of dementia in these very elderly groups is high—13 per cent. for the 75-plus and 22 per cent. for the 80-plus. Research suggests that there are at present about 700,000 people in England suffering from some degree of dementia. Some 13,500 of these are estimated to be in hospital. If it is assumed that their hospital costs are proportional to numbers, this gives a revenue cost for hospital care of about £76 million. That is the size of the problem and it is a growing one.

Most elderly people with mental illness or infirmity are, of course, living in the community, and it is right that they should continue to do so for as long as possible. Where hospital admission becomes necessary, our policy is that they should be admitted in the first instance to an acute psychiatric unit in a general hospital for assessment, diagnosis and short-term treatment. Longer-term hospital care where needed should, in the new pattern of services, be provided mainly in relatively small, local hospitals serving their own communities. That is the policy. The reality is rather different and, as we have heard from my hon. Friend, we still have a long way to go. However, we are making progress.

In 1976 about 90 per cent. of all mental illness patients were in traditional psychiatric hospitals, but since the number of such residents reflects outmoded patterns of patient care this is not a very good indicator of current practice. Between 1974 and 1976 the percentage of admissions of patients with dementia to mental illness hospitals fell from 82 per cent. to 78 per cent. and that to general hospital units increased from 11 per cent. to 15 per cent. The number of patients aged 65 and over in mental illness hospitals and units is declining steadily. It fell by 17 per cent. between 1969 and 1977. At the same time, between 1972 and 1976 the number of those admitted to hospital with dementia increased by 11 per cent. and those discharged by 20 per cent. This reflects an increasingly active pattern of treatment—a move away from custodial care towards rehabilitation back in the community. We have also seen an important development in the day care of elderly mentally ill patients. Those aged 65 and over attending psychiatric day hospitals increased during this period by 28 per cent. The increasing use of community psychiatric nurses is also having an impact on services for the elderly mentally ill.

Nationally, we are taking steps to increase the availability of manpower—consultants, registrars, house officers and so on—to tackle the growing demand. We have heard in particular about the problem of shortage of nurses in my hon. Friend's constituency and I do not underestimate the seriousness of that problem. Nationally, however, there has been a steady increase in nursing staff in mental illness hospitals since 1969—in all some 38 per cent. We are now well ahead of the target set in the White Paper "Better Services for the Mentally Ill" of a nurse-patient ratio of 1:3. There was, in 1976, a ratio overall of 1 nurse to 1·76 patients. There are, of course, wide regional variations, with some places still well below target.

That is the national picture, and it sets our policies in context. I will now turn to the situation in East Surrey health district. Services for the elderly severely mentally infirm in this district are provided at Netheme hospital, which has about 1,000 beds, and houses for the most part long-stay mentally ill patients. Netherne also has an annexe a few miles away, Clerk's Croft, near Bletchingley, which provides about another 100 beds. It is at Netherne and Clerk's Croft where in-patient services for the elderly severely mentally infirm are provided. There are 15 wards at Netherne accommodating about 400 patients. Some patients suffering from dementia are also at Clerk's Croft, mainly the more ambulant and less dependent ones.

My hon. Friend has described in some detail the problems besetting Netherne at the moment. The health authority acknowledges that it has a long way to go before it has the pattern of service that I described earlier. This is the long-term problem. But it is aggravated at the moment by a shorter-term problem with which I shall deal first.

I do not think that I need to dwell on the financial difficulties that health authorities are facing this year and the reasons for them. They will be well known to my hon. Friend. The entire NHS is facing rising costs which are largely the result of the policies of our predecessors. They did not make adequate provision for these increases when they set health authorities' cash limits, and we have reluctantly had to conclude that we cannot do so this year either. If our public expenditure policy—and our wider economic policy—is to have any chance of success, health authorities must remain within their cash limits, which are an integral part of this policy. We have, therefore, said that no extra money can be made available this year, and most health authorities are having to make savings to remain within their cash limts. We have urged them to cut out the waste which inevitably occurs in any large organisation and to exploit to the full the scope for making better use of resources in fuel and energy, catering and domestic services, consumables, and administrative overheads. Unfortunately, some authorities, such as Surrey, have found that the necessary savings cannot be made by these means alone, and there have had to be some reductions in patient services. I am assured that the Surrey AHA gave very careful consideration to the economies that it needed to make, based on full reports from each health district, and that it has exhausted the potential for savings in the areas that I have described.

A quick look at the financial situation in the East Surrey district gives an idea of the order of the savings that have to be made. In 1978–79 the district overspent its budget by about £400,000, which has had to be carried forward to this year. On top of this, the budget for the current year was already overspent by £145,000 in August, and this included overspending of the nursing budget at Netherne to the tune of £30,000. As there is no spare money that can be diverted to the budget, the district has had to take steps to rectify this overspending. This has meant reducing by 15 the number of nurses at Netherne from October until the end of the financial year. Six of these 15 have come from the wards for the elderly severely mentally infirm. These wards were poorly staffed, and this further reduction made the burden on the remaining nurses too great.

To alleviate the burden a little and to maximise the use of skilled staff, two wards—one for the elderly severely mentally infirm—were closed and the patients moved into vacant beds in other wards. This, of course, has meant a reduction in the number of beds for the elderly severely mentally infirm at Netherne and has added to the waiting list. The position is, however, expected to improve at the end of this financial year, when it seems likely that the nursing budget will be back in balance. It will then be possible to increase the number of staff to the pre-October level, although restrictions on overtime may need to remain. The AHA very much hopes, therefore, that the present deficiencies in services for the elderly severely mentally infirm should be removed to a significant extent next year.

My hon. Friend has also referred to the recruitment difficulties at Netherne. This is, indeed, another of the hospital's problems. I am told that the difficulty here is mainly in recruiting learners, of whom there are at present only 82 in post, whereas the funded establishment is for 94. One of the reasons for this difficulty is, of course, the high cost of property in the area and the relatively low level of rented accommodation. There is accommodation for nurses at Netherne, but the district's financial position has prevented it from maintaining it at the standards it would like. Another factor special to Netherne is that the hospital falls just outside the area which attracts London weighting, whereas Cane Hill hospital, another mental illness hospital nearby, comes within the London weighting area. I am told that there is not the same difficulty in recruiting the more senior nurses, such as charge nurses and nursing officers, and this is probably due to the very good reputation which Netherne has gained in the recent past.

The health authority acknowledges that it has a long way to go before it is providing a satisfactory district-based community service as an alternative to institutional care. The development of a community-based service for the elderly severely mentally infirm is necessarily linked with the development of such a service for all mentally ill patients and the gradual movement away from total reliance on in-patient care at Netherne. The health authority has already made some progress in the development of community services. There is, for instance, a total of 150 day places for the mentally ill in the district which are also available to elderly severely mentally infirm, and these are not all concentrated at Netherne but are spread around the district—indeed, only 20 are at Netherne itself, with 60 in the grounds of Clerk's Croft, 40 at Reigate and another 30 at the industrial unit at Redhill. Day provision then is much more integrated into the community and accessible for clients than is in-patient provision. The district plans improvements to its day patient provision which will include both additional places and the replacement of existing facilities, in particular those at Clerk's Croft, by improved centres. The district also recognises the need for separate day centre provision for the elderly severely mentally infirm.

Coming back to Netherne, one of the district's priority objectives there is to increase the number of nurses. I have explained already that the severity of the present nursing shortage will be alleviated next year. There will still, however, be a significant shortage of nurses, not only in East Surrey district but throughout the area. The obstacle here of course is one of money. At its present level, the district's budget is committed fully to the maintenance of existing services. The only way it could significantly improve nurse staffing levels for services for the elderly severely mentally infirm would be to divert resources from other areas of patient care. As I have already explained, whilst there is no scope for improvement this year, next year's cash limits will put right the effects of this year's squeeze, and there will also be a small allowance for real growth. As the resources become available, modest improvements can be made.

One of the obstacles to a community service is the extent to which Netherne has responsibilities outside the district. Of the 400 patients there, about 90 come from the Sutton area, about 30 from around Horsham and Crawley, and about another 150 originally had their homes outside the district in places such as Epsom, Surbiton and Wimbledon—in other words, a minority. To be successful, a community service needs in-patient facilities near people's homes, otherwise patients lose contact with the community and cannot easily return to it. Furthermore, if reliance on institutional care is to be reduced, community services for patients coming to Netherne from outside the district will, of course, need to be provided in their own areas, and it is understandably difficult to get other authorities to take on a new responsibility for patients for whom they have not hitherto had to provide.

Looking ahead, there are other improvements included in the district's plans. It is hoped in the not too distant future to complete the transfer of wards for the elderly severely mentally infirm at Netherne to the ground floor. In the longer term, a later phase of the new district general hospital on which work has already started at Redhill will provide an acute psychiatric unit which will also cater for the elderly severely mentally infirm.

I realise that what I have been able to say to my hon. Friend tonight is not a complete answer to the problems he has described. However, I hope that I have been able to reassure him somewhat about the present temporary difficulties and that he can see now some grounds for optimism for the future.

Question put and agreed to.

Adjourned accordingly at twenty-two minutes to One o'clock.