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Community Care

Volume 234: debated on Friday 17 December 1993

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12.30 pm

Policies for the care of the mentally ill were far too restricted in the 1940s and the 1950s. Many people who should have been allowed to stay in the community were incarcerated in asylums. I believe that the pendulum has swung too far in the other direction. The entire basis of our policy is predicated on the assumption that the mentally ill are sufficiently mentally well to take rational decisions about their treatment. That paradox is compounded by the all-too-frequent reluctance of psychiatrists to section patients.

I shall refer to two letters that were sent to me by constituents. In one, a constituent said that her son had been released from prison where he spent four months as a result of violent behaviour. He was then sectioned by a judge to stay in Friern hospital for up to six months. Two days after he had arrived at Friern hospital, he telephoned his mother and said that he had been told words to the effect that he was well enough to leave. It was only as a result of the mother ringing up the hospital and imploring its staff to keep her son there that a meeting was arranged which she attended and it was agreed that he could stay in hospital somewhat longer.

That is an example of a judge sectioning someone to stay in hospital for up to six months and the hospital saying after two days, "You are well enough to leave". On closer examination, it was obvious that the boy was not well enough to leave and that he should stay in hospital.

A neighbour who lives just up the road from me in Hendon has had great problems with his sister. He wrote earlier this year that his sister had been arrested at the end of last year after a number of incidents. As a result, she was sectioned and taken into Napsbury hospital and detained for two weeks. She behaved herself in there, but refused any treatment and was released. The family was most concerned that that could happen and a meeting was arranged with her social worker. The other members of the family were invited to attend the meeting, which took place at Edgware general hospital. When they arrived, however, they were told that the sister and her husband had refused to attend. The meeting served only to convince my constituent that the social workers are just "not of this planet" and that the whole system needs reforming, for the main reason that, as he says,
"a human being is living a life of anguish and torment when there is a possibility that with treatment her condition could be improved."
As my constituent continues—and no one could disagree—he finds it
"incomprehensible that a person who is known to be mentally unbalanced is asked to decide if she wishes to receive treatment or not."

He ends the letter:
"We can only cling to the hope that the present law will be reformed sooner rather than later."

I shall give another example of the reluctance of psychiatrists to section patients who need treatment in mental homes but who may not be willing to take it. A constituent of mine is convinced that the most gentle right hon. colleague of ours, my right hon. Friend the Member for Brent, North (Sir R. Boyson), is trying to poison her. One weekend there were 19 messages on my answerphone saying, "Sir Roddy"—as she calls him—"is trying to get me." I can think of no Member of this House who is less likely to poison a constituent than my right hon. Friend the Member for Brent, North.

I can think of no reason why my right hon. Friend should decide to move to a west Hendon council estate to poison one of my constituents. However, that poor lady suffers from that particular delusion and nothing is being done to help her. I have written letters to doctors and others, but they have not been dealt with satisfactorily.

That example underlines my point that all too often when a psychiatrist has to decide whether to err on the side of individual freedom or sectioning a patient, he will nearly always say, "Let him stay in the community as that is his freedom and right." At the end of the day, that benefits no one.

I want to underline that point by referring to a case in respect of which I attended the funeral of a 24-year-old constituent last summer. There is nothing unusual in Members of Parliament attending the funerals of their constituents. However, this occasion was particularly poignant because it was the funeral of a 24-year-old schizophrenic who had been receiving care in the community and who had committed suicide.

That young man had once been a lively, artistic and friendly lad who had never played a mean trick on anyone. However, he is alive no more. The occasion was particularly poignant because that boy's mother had warned the psychiatrists for many years that they were not giving that boy the right kind of treatment.

I have a file that deals with that case. The first letter on the file dates back to 29 November 1989 when a meeting took place between the psychiatrists and the boy's mother. The psychiatrists wrote back saying:
"Following our last meeting with you and David and Diana, I thought that it would be helpful to clarify the agreements that we reached on that occasion. We are aware that you all feel that Mark is suffering from a mental illness sufficient to warrant his detention in hospital under the Mental Health Act since he is unwilling to come into hospital voluntarily and that so far on the occasions when he has been assessed by our crisis team, their assessments have not concurred with yours."
The mother battled on for another four years to try to secure the treatment that she felt was suitable and satisfactory for her son. The psychiatrists always said, "No, you don't understand. We are the experts. You are just the mother." However, at the end of the day, the mother understood her son better than they did. That poor boy finally committed suicide by jumping off a seven-storey building. It seems to me that we should listen more to the relatives on those occasions than we sometimes do.

When Ben Silcock was mauled by a lion, the problems of schizophrenics momentarily became headline news. However, I believe that there is little doubt that mental health has become the Cinderella of the health service. What is even worse is that the whole policy has become far too optimistic.

Care in the community sounds wonderful, but it ignores the wishes of relatives and basic reality. The reality is that many patients and schizophrenics refuse to take their medication when they are released from prison or hospital. Public opinion may concentrate on the 32 murders committed by schizophrenics who were enjoying care in the community. However, those deaths—all of which are regrettable and, more importantly, all of which were avoidable—are but the tip of a much larger iceberg.

Since I was first elected to the House, I have had several meetings with my local branch of the Schizophrenia Fellowship. The stories it tells are uniformly horrific. I will always remember a mother telling me that her daughter was sleeping on a park bench somewhere in London. She did not know which park and still less which bench. It is one of the ironies of care in the community that many of those who sleep rough in London are discharged mental patients.

Do we really enhance the quality of their lives by saying, "No, we will not give you care in an institution, but you can sleep rough on the embankment"?

One hears stories of a vicious circle—patients failing to take their medication and often becoming violent. All too often, those who are released into care in the community end up receiving institutional care in prison. They suffer unnecessarily; so, too, do their relatives, who feel powerless to influence psychiatrists and policy makers, and so, too do many innocent third parties.

On one occasion, I received a delegation from residents of a block of council flats in my constituency. I said, "What is your problem?" I wondered what Barnet council had done to annoy them. They said, "It's Mr. Campbell." I said, "What's Mr. Campbell done to annoy you?" They said, "Well, he was released from Napsbury." I said, "Yes, what else?" They said, "He has a hobby. It is to play his hi-fi system for 12 hours a day, starting at 8 pm and finishing at 8 am," rather like the sittings of the House this week, but it was quite unsocial for those who had to do a day's work after having their night disturbed by that gentleman.

The suicide case to which I referred is not isolated. Some of the others who attended that funeral told me that, in north-west London, five or six people who had received care in the community had committed suicide. The Boyd report said that, in one year, 107 discharged psychiatric patients had committed suicide. Each week, about three people die either by suicide or are murdered by schizophrenics because care in the community has failed them and failed the community.

It is not only in Britain that difficulty has been experienced in persuading schizophrenics to take their medication. In Canada, for example, social security benefits are now paid only to those who are still taking their medication. Although that policy was originally opposed on civil liberty grounds, it is seen to be effective and it could be tried here.

There needs to be a closer working relationship between psychiatrists and relatives. The mother of my deceased constituent said of the psychiatrist, "If only he had listened to me." Many of those whom I meet are critical of psychiatrists' attitudes to them, the parents, and those who know the victims of schizophrenia.

In London, patients have frequently been released, despite an adequate number of psychiatric beds elsewhere in London which could take them. Despite the reluctance of individuals to take drugs when they are released into the community, they are still released into the community. One cannot blame individuals for refusing to take medication —it is not particularly pleasant. When we were children, we were told that the nastiest medicine was the most effective, but that did not make us more willing to take it, whatever else our mothers might have said and however well they might have tried to sweeten the pill.

If a patient is told, "You can go into the community, but carry on taking the medicine," he must be tempted to say to himself, "They have said that I can go into the community, so I must now be all right; I do not need to take the medication." We then have the vicious circle of individuals refusing to take medication, becoming violent and then indulging in antisocial behaviour, ending with their being institutionalised, not in hospitals but in prisons.

We must remember the impact of the release of individuals not only on themselves but on others. We must consider the impact on relatives. They are frequently devastated when they see the poor quality of life that their loved ones have outside hospital. We must remember victims who are murdered, assaulted, attacked or raped when individuals are cared for in the community.

My right hon. Friend the Secretary of State for Health is widely recognised as a humane Minister and someone who is socially concerned. I should like to ask her and my hon. Friend the Minister who will reply to the debate to look again at the policy that has caused heartache to so many and to look again at the availability of psychiatric beds in London before deciding to close our other hospitals or to encourage psychiatrists to release people into the community.

We must also remember the potential victims and try to stop them becoming victims when people who should not be are released. Only a few thousand people need to he treated in institutions rather than in the community. It is not a major problem in terms of numbers, but it can be a major problem if one is the patient, the patient's relative or a potential victim of someone who is not taking his medication.

Individuals who suffer from mental illness are just as deserving of care in hospital as victims of other illnesses. In days gone by, there was no disgrace in being sent to a fever hospital because one suffered from fevers. Today, there should be no disgrace in being in an asylum if one suffers from an illness which needs to be treated there. It is much better that such individuals are treated in the appropriate place rather than sent into the community, where the care may well be inappropriate to their illness and may cause them to do things that they later regret, and which their relatives and their victims regret.

12.46 pm

I congratulate my hon. Friend the Member for Hendon, South (Mr. Marshall) on securing time today to debate the important topic of community care and the mentally ill. I think that my right hon. Friend the Member for Brent, North (Sir R. Boyson) will read the proceedings with some interest, if not some astonishment.

I know that my hon. Friend the Member for Hendon, South has close links with several voluntary organisations working in mental illness. He takes a keen interest in matters that affect mentally ill people. I pay tribute to his hard work on behalf of that vulnerable group in our society. I know that he is a keen supporter of the National Schizophrenia Fellowship. The NSF does much valuable work to promote the interests of people with schizophrenia. That is why we are supporting it to the tune of more than £170,000 this year.

My hon. Friend expressed several concerns about the provision of services. I am pleased to be able to respond and say how we are taking forward care in the community for the mentally ill. I begin by reminding the House of the size of the agenda before us. About one person in 10 suffers from some form of mental illness in the course of a year. Mental illness is as common as heart disease and three times more common as cancer. For example, about seven people per 1,000 of the population will suffer from schizophrenia at some point in their life. Currently, it affects an estimated quarter of a million people.

Our policy is to encourage the development of locally based health and social services to meet the needs of people of all ages who suffer from mental illness. The aim is to provide a range of services that are local, comprehensive and sensible. The principal components of such a service must be effective assessment of need, community mental health teams supporting mentally ill people in their home, effective links with primary care services, an adequate range of day care services, adequate short and long-term hospital provision and an adequate range of health authority and local authority respite services.

This policy can be delivered successfully only by health authorities and local authorities working together and in co-operation with the relevant voluntary organisations and the private sector to provide a multi-agency and multi-disciplinary range of services, treatment and care. There is no doubt that our policy of providing care in the community enjoys widespread support, which is borne out by public attitude surveys. However, I recognise and understand the concern about the level and range of services being provided. That is why we set up the mental health task force. Its remit is to help unlock resources from the old, long-stay institutions and to help build up a balanced range of local services, based on best practice. That should meet my hon. Friend's request about places being available before hospitals are closed.

My hon. Friend also referred to rough sleepers and mental illness. He is right that very often many people who sleep rough suffer from some degree of mental illness. However, surveys of such people show that they have never been in touch with the psychiatric services. They have not been under their care and then returned to the community. He also mentioned some suggestions on conditions for benefits based on the experience in Canada. I, too, have visited Canada and the United States to look at some of their schemes. The one that he highlighted would be a matter for my right hon. Friend the Secretary of State for Social Security, should it be decided that conditions be attached to benefit. I have no doubt that my right hon. Friend will see and hear what my hon. Friend has said.

We are taking several initiatives to help provide a better range of services and those include the mental illness specific grant and the care programme approach.

The grant is paid to local authorities to help bring about a significant improvement in the social care provided to people with mental illness. It has been widely welcomed by local authorities and has proved a great success, stimulating more than 800 projects and bringing help to about 64,000 people. Since we started the grant two years ago, we have increased it by 47 per cent. in real terms and this year it stands at £34·4 million, supporting total spending of £48·4 million.

We introduced the care programme approach in April 1991 and it is intended to cover all patients being considered for discharge from mental illness hospitals and all new patients accepted by the specialist psychiatric services. The needs of each patient for continuing health and social care and for accommodation should be systematically assessed and effective systems should be put in place to ensure that agreed health and, where necessary, social care services are provided to those patients who can be treated in the community. Explicit, individually tailored care programmes are drawn up and a key worker is identified to keep in close touch with the patient and to ensure that the agreed package of health and social care is being delivered.

We now intend to strengthen that system. In particular, we want to deal urgently with the problem presented by a very small number of patients who, as my hon. Friend said, slip through the net of community care. On 12 August, we announced a 10-point plan to reinforce the provision of community care for mentally ill people. That plan very much takes into account the sort of difficulties and the occasional tragic cases that my hon. Friend mentioned.

That comprehensive package of measures, reinforced by stronger legal powers, includes a new power of supervised discharge. That was discussed in depth in the report that we published of the Department of Health review of the legal powers and of the care of mentally ill people, on which we are consulting.

The idea is to provide a legislative framework to enable carers to give greater support to that small minority of especially vulnerable patients. Those are the people whose condition can deteriorate, especially if they fail to take their medication as my hon. Friend said, so that they present a risk either to themselves or to others. We want patients to be clear about what their treatment in the community involves and their care programmes will be carefully agreed with them before they are discharged. A failure to comply with the conditions would lead to an immediate review of the case and recall to hospital, if appropriate.

The other measures announced in our 10-point plan are intended to ensure that that happens. They include clarification of existing powers under the Mental Health Act 1983, attention to the special demands on the mental health services in London to which my hon. Friend referred, and a review of the clinical standards of care for people with schizophrenia. We shortly aim to issue new guidance on the discharge of psychiatric patients, and we are moving ahead with arrangements for a national conference to establish an agreed approach to the training of key workers.

The new version of the code of practice that has been approved by Parliament emphasises the criteria for admission to hospital under the Act. In addition, we are discussing with the Royal College of Psychiatrists a possible training pack for section 12 doctors who are approved under the 1983 Act as having special experience in the diagnosis or treatment of mental disorder. As part of that, we shall consider whether the material might be used for training social workers in their responsibilities under the Act.

I draw my hon. Friend's attention to the code of practice, which makes it clear that people can be taken to hospital for assessment should their health be at risk or if they are a potential safety risk to themselves or to anybody else. Perhaps that has not always been understood in the past, but it is made clear in the new code of practice and I hope that that will be helpful.

The best safeguards for patients and the public are still professional judgment, co-operation between services and a proper understanding of the powers that are available under the Act and the limits that it imposes. It is just over a year since the Government's public health strategy, "The Health of the Nation" was published. As the House knows, the White Paper set targets for improvements in health and reductions in morbidity. It is significant that mental illness, which has often received insufficient attention in the past, was chosen as one of the five key areas. Reducing suicide is the other side of the coin of improving the health and treatment of people with mental illness.

My hon. Friend spoke about a tragic case and I am determined to do everything possible to reduce the rate of suicide. As he knows, the targets in "The Health of the Nation" are for the overall rate of suicide and the specific rate in the case of people who have some form of mental illness.

We also seek to improve primary care for the mentally ill. General practitioners come into contact with, and are responsible for treating, the bulk of those with psychiatric disorders. My Department is funding the work of the senior mental health fellow in general practice so as to cascade knowledge and skills to GP tutors and course organisers, and it supports the "Defeat depression" campaign being run by the Royal College of Psychiatrists and the Royal College of General Practitioners.

Adequate resources are important and the Government are firmly committed to improving services for the mentally ill. That is demonstrated by the fact that, including secure provision, about £2 billion is being spent this year on mental illness. That figure, although impressive, does not tell the whole story, because it does not show the 37 per cent. increase in real-terms in gross expenditure on hospital and community health services since 1979, and a real terms increase of 86 per cent. in gross expenditure on local authority social services.

Those figures clearly demonstrate that the Government are committed to their policies for the mentally ill. However, the Government can provide only the framework and guidelines for policy. It is up to local health and social services departments to use and develop those as they assess and seek to meet local needs in mental health. I am grateful to my hon. Friend for initiating the debate and for the measured way in which he put his case.

I am grateful to the many people working in the professions and voluntary organisations, who do so much for mentally ill people. I am grateful also for the opportunity to respond to my hon. Friend. I share his determination that mentally ill people should receive the right blend of high-quality treatment and care.