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Elderly Mentally Ill People

Volume 470: debated on Tuesday 15 January 2008

Motion made, and Question proposed, That the sitting be now adjourned.—[Liz Blackman.]

I am grateful to have the opportunity to open this Adjournment debate. As is often the case, I sought it because of particular local circumstances, and I shall turn in due course to the institution about which I am worried, the St. John’s hospital centre for the elderly mentally ill with particularly challenging conditions. It is under threat, as are similar units in other parts of the country. As I have been fortunate enough to obtain a long debate, I shall also take the opportunity to make general arguments about how the NHS approaches elderly mental illness. I wish to express appreciation of the various charities involved—Age Concern, Help the Aged, the Alzheimer’s Society, Mind and the Royal College of Psychiatrists—all of which have done admirable work in the field. That work all points to similar conclusions.

I shall continue in this debate a line of argument that I developed in an Adjournment debate last April, which was also a long debate and gave me an opportunity to mention a problem affecting Twickenham in particular as well as the wider treatment of mental health. From that, Members can infer that mental health is probably the most important NHS issue in my corner of London.

I shall make some general arguments before proceeding to the particulars of my local community. We are dealing with a phenomenon on a massive scale. Crude figures suggest that about 3.5 million people are loosely defined under the general heading of having mental illness in old age. Of course, such big abstract figures mean little unless they are translated into the cases of individual human beings. Most of us have ageing parents, and several people in this room will know exactly what elderly mental illness means. My late mother, who died a couple of years ago, spent the last few months of her life not having the faintest idea who I was, talking nonsense in our conversations and, in her brief, fleeting moments of lucidity, expressing the wish to die. Those are all symptoms that many people encounter.

One in five people over 80 have senile dementia, and two in five have depressive illnesses. My mother had both, as many people do, although they are often not properly diagnosed. The numbers are enormous, and all the people involved in work and analysis on the matter are absolutely confident that they will increase to what one charity has called pandemic proportions. Some 600,000 to 700,000 people suffer from the particular condition called dementia, a word that is often used loosely to refer to any form of absent-mindedness and confusion but which actually has a specific clinical connotation. That is expected to double in the next 30 years. Depression among elderly people is much more widespread and will double by the middle of the century to something in the order of 5 million people. There will be a total mentally ill elderly population of about 7 million—an enormous number of people.

I congratulate the hon. Gentleman on securing this important debate. I believe that he is referring to the report and analysis produced by the UK inquiry into mental health and well-being in later life. No doubt he will give in some detail the figures involved, so I shall not do that. Age Concern supported that investigation and is deeply concerned about depression and mental well-being linked to the supply of decent-quality stoma and incontinence products to homes, which some people find a taboo issue that is difficult to talk about. Does he share my concern that the Government have taken their eye off the ball on that and, in seeking to save a little money, are putting pressure on elderly people that will cause depression and reduce the quality of their life as they get older? We should consider that carefully.

I have had correspondence on that from quite a few constituents. I must say that I have not seen the link with elderly mental illness. That might reflect the hon. Gentleman’s creativity in finding an opportunity to bring it into the discussion, or there may well be a genuine link that I have not seen, which I would fully acknowledge.

I have visited residential homes in my constituency where there were specific problems in that regard, which were clearly causing great depression to elderly people and making them not want to stay alive.

I thank the hon. Gentleman, and I appreciate his educating me on that point. I had not seen that link, which is clearly important.

There are several other examples of what the statistics mean in reality. One thing that particularly horrifies me is how elderly mental illness translates to high suicide rates among the old. Apparently, for women, over 75 is the age category with the highest suicide level, much higher than in other age groups. The situation is not very different for men. In turn, that often translates into stress and depressive illness for people who have to care for the elderly mentally ill in their own homes. The problems are not confined to the elderly mentally ill themselves.

I congratulate the hon. Gentleman on securing this debate, which is a successor to an excellent debate secured by the hon. Member for Rugby and Kenilworth (Jeremy Wright) a few months ago. As he says, dementia is sometimes considered synonymous with mental ill health among the elderly, but he has rightly widened the debate to include depression, anxiety, delirium, problems with drugs and alcohol and so on. We must transfer the care of mentally ill people in an older age group to general hospitals in many circumstances, as they are often left to vegetate in entirely inappropriate circumstances. Will the hon. Gentleman develop that point?

I shall. The hon. Gentleman is right that it is completely wrong that people vegetate in the community with unsatisfactory informal caring arrangements. Many people are simply never diagnosed, so hospital treatment is an improvement for them. However, it is often not general but specialist hospitals where the best treatment can be found.

I wish to explore the impact on the NHS of this massive pandemic, as it has been described. I was staggered by figures that emerged showing that, far from being on the periphery of the health service, the matter is at the centre of it. Some 40 per cent. of people who visit general practitioners are elderly people with some form of mental illness.

I, too, congratulate the hon. Gentleman on securing the debate.

On the burden on the national health service, does he agree that one problem that arises frequently is that older people who are admitted to hospital for a physical injury are then discovered also to have mental conditions. The physical injury, such as a broken hip resulting from a fall, often accelerates the mental condition that was previously undiagnosed.

The hon. Gentleman is absolutely right that mental illness comes to light as a result of examinations that take place. I am not a medic and do not understand the mechanism involved, but it also appears that after elderly people have had operations, many of them lapse into confusion as a consequence of the treatment. The problem is enlarged as a result of admission to hospital.

In terms of the burden on the NHS, about 40 per cent. of visits to GPs and 50 per cent. of all hospital beds are accounted for by elderly people who have some form of mental condition. Such people also account for 60 per cent. of all residential home places. So, about half of the health and social care economy is taken up by people who have some form of elderly mental illness. I have found it difficult to get my head around that.

Age Concern did an economic study on the overall impact of elderly mental illness and concluded that the total cost to the health and social care economy was greater than that of cancer, stroke and heart disease combined. When I saw that in print, I thought that it could not possibly be right and that somebody was doing some creative accounting. On reflection, however, it was clear why that is the case: those acute conditions may be deeply traumatic, but often involve only short, albeit expensive, stays in hospital, whereas elderly mentally ill people often need years of either care in residential homes or informal caring at home. Such care implies costs in relation to the loss of work opportunities and to carers and the NHS system. Thus, on reflection, figures that seemed staggeringly implausible appear to be right.

How has the NHS responded to that enormous challenge? There has clearly been a growth in awareness of the problem over time. I was first exposed to the problem four decades ago, when, as a student, I looked for work in the vacation and was directed to the local mental hospital to do some nursing. I was given a posting on the geriatric ward, and the experience has stayed with me ever since. I acquired, among many other things, a lifelong admiration for the professional nursing staff who were, under appallingly difficult conditions, giving dignity to people who had lost their mental, and often physical, faculties. They showed respect for and gave care and attention to people who could not reciprocate or express their appreciation. They soldiered on in difficult conditions and played an admirable role.

The extent to which the problem was swept under the carpet, in that generation, is striking. Even in that enlightened mental hospital, which was doing experimental work on psychotherapy and adventurous work with children, the ward was a forgotten corner of the hospital. When I had been there for a few weeks, I noticed that nobody ever visited the patients; their relatives had long since forgotten them and did not want to know anything about them.

As a society, we have become more aware, open and honest over the years about such conditions. It has therefore obtained much more attention within the health service, and rightly so. None the less, many charitable organisations that have looked at the treatment of elderly mental ill health have expressed considerable concern about the way in which it is being approached even now. Age Concern carried out the important study that the hon. Member for Castle Point (Bob Spink) mentioned, which explained the scale of the problem and concluded that 3.5 million people did not obtain satisfactory support and service. It also noted that half of the mentally ill elderly population was never properly diagnosed, so there were major failures within the system. Help the Aged conducted another inquiry and came up with the rather stark conclusion that age discrimination is explicit within the system, with over-65s being subject to a service regime different from that for under-65s.

The Royal College of Psychiatrists was even more harsh in its assessment of the way in which the system is dealing with the problem. Its review reached two conclusions:

“Older People’s mental health services, which have been among the most innovative, are being cynically dismantled;”

and

“There is clear age discrimination within Government health policy.”

I was slightly shocked to read that. When I became a Member, about 10 years ago, I introduced a ten-minute Bill on age discrimination in the NHS, which was then rampant and fairly explicit. It is clear that, with ministerial guidance, many aspects of age discrimination in the NHS have disappeared and that there is much better practice and awareness of the issue. However, leading charities are alleging that age discrimination continues on a systematic scale within the field of mental health.

There is a small beacon of hope among all that negative analysis. I look hopefully to the Minister because he made a speech last August that everyone in the field has hailed as a positive breakthrough in the Government’s approach on this issue. His speech has been widely and favourably quoted, and I shall pick out a few lines to demonstrate why it is a good framework for judging the way forward. He said:

“I am determined that this disease is brought out of the shadows…By concentrating on improving awareness, diagnosis and managing the disease, we will help transform the lives of those with dementia by improving their quality of life...This is an exciting opportunity to make sure the knowledge and expertise we now have about dementia care and treatment makes a difference to the lives of thousands of people throughout England.”

He concluded:

“By the summer of 2008, Ministers will announce a transformation plan to ensure dementia services are improved in all parts of the country.”

I think that everyone in the field drew a great deal of comfort and optimism from that positive and helpful statement. I hope that the test applied to my local facility will be whether it meets the strategic approach that the Minister helpfully set out in his August speech.

Our local circumstances are not unique to Twickenham. I discovered from the press cuttings that there are similar problems with the closure of specialist elderly mental health units around the country, including units in north Staffordshire, Truro, Sutton and Tolworth, in the constituency of my hon. Friend the Member for Kingston and Surbiton (Mr. Davey). Perhaps the closure that has attracted the most attention is one in Stroud, Gloucestershire, where the leading champion of the local community is a member of the Government, the Under-Secretary of State for Communities and Local Government, the hon. Member for Gloucester (Mr. Dhanda). He has led the organisation of a large petition and has spoken to Ministers about the issue, achieving some success in communicating the problems with the closure. So, our problem is not unique; indeed it is rather similar to the situation in Gloucester.

St. John’s hospital is a small facility in the middle of Twickenham. It was established in the mid-19th century by the Twining family. When Elizabeth Twining died, she said that it was

“forever thereafter to be used as and for the purpose of a hospital or dispensary”.

It had a somewhat mixed existence and, in 1995, a purpose-built, new facility was established to cater for the needs of people who are what I call band 1 elderly mentally ill: people with severe dementia and challenging behaviour. There are two wings to the small hospital: Cole Park lodge, which provided respite facilities, and Marble lodge, which provides extended care and initially had 18 beds. I shall talk about Marble lodge. I stress that the facility was newly launched just over a decade ago. Indeed, a key player in its establishment was my Conservative predecessor, Toby Jessel. His sister, Lady Panufnik, was the chairman of the League of Friends. In a bipartisan spirit, I was invited to play a role in support of the League of Friends. It has been seen ever since, by many psychiatrists, as one of the great successes of the local health service.

The unit has a different philosophy from that of many centres for the treatment of the elderly mentally ill. Its underlying philosophy is quality of life without medication. The significance of that is that most elderly mentally ill are, to put it crudely, stuffed to the eyeballs with drugs in order to calm their behaviour. Those of us who visit residential homes will see elderly people sitting around in a dazed state, often full of drugs that are used, in essence, to sedate them.

The hon. Gentleman may know that the all-party group on dementia, which I chair, will begin in the next month or so an inquiry into precisely the point that he raises about the use of neuroleptic or anti-psychotic drugs that are designed primarily for the treatment of schizophrenia, not dementia or other mental illnesses of the elderly. Does he agree that one of the most important issues to resolve is that drug prescriptions should be for the right drugs for the right period for the right conditions, and not simply to keep elderly mentally ill patients quiet for the benefit of staff and other residents?

That is exactly the point, but I would go beyond it. The philosophy that underlies the unit is not simply that of finding the right medication but that in many cases medication is actually unnecessary, and that, with sophisticated treatment, patients can be managed in a much more humane way and without extensive medication. The unit at St. John’s concentrates on two things: one is the built environment. That may sound rather fanciful, but enormous attention is paid to the design of the building, lighting and colours in order to introduce a calming environment.

Also, the unit is an oasis of peace. Instead of the noise that is frequently oppressive in many residential homes and general hospitals, great attention is paid to trying to keep patients calm at all times. Because the environment is carefully managed, patients are more easily managed. Even extreme conditions can be handled in a much more civilised and dignified way than is often the case when people are simply pumped with drugs.

I am grateful to the hon. Gentleman for giving way a second time. The Richmond and Twickenham primary care trust says that it will be able to halve the cost of St. John’s by privatising the service and contracting it out. How confident is he that the existing inspection arrangement will be able to detect a worsening in the quality of care in relation to the use of drugs? My own observations elsewhere in the country are that that type of approach is rather more common in privately run homes than in publicly run establishments. Is that a worry for him?

It is very worrying. The hon. Gentleman anticipates the key point that I shall shortly move on to, which is of concern to me and to my hon. Friend the Member for Richmond Park (Susan Kramer), who is also involved in this campaign. The simple point, as he said, is that of course one can halve the cost of treatment simply by sending patients off to an old folks’ home and pushing drugs into them. The fear is that that is what is envisaged.

I thank my colleague for giving way—he is being generous with his time—but I just want to pick up on that issue of cost. In one of the meetings that he and I had with the PCT, it became evident that the cost differential between a service contracted out to traditional care homes versus one in the NHS is partly caused by including in the NHS cost an allocation of a great deal of central overhead costs. I believe that my colleague would agree with that. However, if the service were tendered out to the private sector, that core overhead would not disappear. It would merely be reallocated to other programmes. In fact, it might even be that the service provided by the care homes would be more expensive in total to the NHS—the overhead costs would still be part of NHS costs—than continuing the service in its current structure. The accounting mechanism makes that apparent.

I thank my hon. Friend, who anticipates some of the points that I want to make in my concluding remarks. She is absolutely right: we are dealing with complex and often misleading systems of cost accounting in the NHS market, and the problem in this case arises from the fact that the costs are not merely irrational but completely opaque, because the NHS providers will not share with us how they have arrived at their cost assumptions.

Before I return to that point in my concluding remarks, may I add to one section of the narrative? Not merely is Marble lodge recognised as an enlightened institution, it was recognised as such in the local strategy for mental health that was developed as recently as 18 months ago. The local PCT, the local mental health provider—the South West London and St. George’s mental health NHS trust—and the local council embarked on a major strategic exercise involving a great deal of public consultation. It was an admirable, highly creditable NHS exercise designed to produce a strategy for mental health in the borough.

There were some controversial outcomes. Indeed, I raised the matter in Prime Minister’s Question Time with Mr. Blair when he was Prime Minister, but I am not here to deal with those controversies. What emerged from the strategy was that, whatever else had to change, Marble lodge—an admirable institution for the elderly mentally ill—should remain and, indeed, should be added to and strengthened.

That was where we were until a few months ago, when it gradually emerged, not through any formal announcement but through rumours and leaks from members of staff who were being encouraged to go elsewhere, that the PCT and the supplier of services, the mental health trust, had agreed that the facility should close. MPs and the council were not told. The information emerged from the system following an elaborate and very public public consultation that reached the opposite conclusion. I am bringing this to the Minister’s attention because of the unsatisfactory way in which that happened.

We became aware of the plans only because of the campaigning activities of an admirable individual, Mr. Paul Lamplugh, who is actually a constituent of my hon. Friend the Member for Richmond Park. The Minister may be aware of his name. His daughter, Suzy Lamplugh, disappeared 20 years ago, and, in their grief and distress, the family established a trust which later gave rise to the missing persons helpline. Its charitable work is acknowledged across the country. Unfortunately, Paul’s wife, Diana, who was the driving force behind that charitable work, had a major stroke in 2003 and lost much of her mind. She was recommended for treatment at Marble lodge and has been a patient there ever since. Paul Lamplugh sought to mobilise help from the two MPs for the borough and from councillors and others when he began to see what was happening.

My colleague and I have tried to construct exactly the logic that led to the decision to pull the plug on this admirable institution. It appears that two factors were involved. The first was that, as the hon. Member for North-West Leicestershire (David Taylor) said a few moments ago, the PCT spotted that the unit cost of treating people in Marble lodge was twice that of the typical cost of a residential home for the elderly, which would normally cost £600 or £650 a week. Marble lodge was said to be costing twice that. I do not criticise the PCT for picking up on that. It is, after all, its job to obtain value for money for the health service, and it has a good reputation for purchasing good quality care for residents, and for maintaining financial balance. I do not criticise it for looking at the problem.

What has also contributed to the problem, as my hon. Friend the Member for Richmond Park said, is that the provider has included costs that bear absolutely no relation to the real cost of providing the service. We cannot get to the bottom of this because the provider will not disclose the figures, but it seems to have incorporated administrative overheads from the headquarters in the costs. It also seems, as is often the case with large providers, that it is dominated by consultants and big hospitals with little interest in peripheral, albeit high quality, ancillary operations. It seems to be quite indifferent to the unit’s future. The problem is that the closure process is now well advanced. That is why I have brought the matter to a debate. The primary care trust has gone out to tender, despite protests from the council’s overview and scrutiny committee and from the carers and Members of Parliament.

Perhaps my hon. Friend would comment on the tender. From copies of the tender documents that we have seen, I think that he would agree that they do not even mention the highly challenging and severe nature of dementia in these patients, but in fact read as a standard tender for normal dementia cases.

My hon. Friend is right. That is one of the sources of the problem. As a result of the meeting that my hon. Friend and I had with the primary care trust, it has now been agreed that the carers should be represented in the tendering process. I acknowledge that, but none the less there appears to be no mechanism within the NHS for evaluating quality of care in relation to specialist services of this kind. How do we quantify the quality of life without medication? That is an important concept, but it is a nebulous one that does not have a figure attached to it and the accountants who are managing this process cannot get their heads round it or are fundamentally uninterested. How are these complex quality ideas to be built into the tendering process? That is a question for the Minister and for us locally and it is fundamental to the way in which this process comes out.

I am asking the Minister to look at this matter because the process is now well advanced. Tenders were sought in November and those are now being considered. There will be an assessment at the end of February. We are told that the unit will probably close in March. There has been no public consultation. We are told that, once the tender results have been announced, the council’s overview and scrutiny committee will be formally consulted. That is extremely perfunctory and very unsatisfactory and contrasts with the admirable public consultation on mental health 18 months ago. It is clear that the people in the primary care trust and the provider have determined that they want to shut this institution.

I want to make a specific request to the Minister. His own strategy will emerge in August in his strategy document. I would ask for this whole process, which is profoundly unsatisfactory, to be put on hold until there is an opportunity to test what is happening locally against the strategy that the Government are going to produce. I suspect that, having read the Minister’s speech in August, the Government have all the right ideas, are saying absolutely the right things and are setting exactly the right criteria. If that is so, we need to be able to judge what is happening locally against that strategy. I want some breathing space in order for that to happen.

I was struck by what my hon. Friend said about the absence of consultation and by his saying that it looks as if it will be only a formal consultation once we are presented with a fait accompli. Has he considered whether the way in which the bodies involved are proceeding meets with their statutory obligations on consultation with regard to a significant change in service provision?

I think that it probably does meet the statutory requirements and that is what is so worrying about it. It is so worrying because it is possible to meet the statutory requirements formally while wholly disregarding the spirit behind NHS consultation. I am sure that the people in the primary care trust, particularly, are well aware of their statutory requirements and will try to meet them. But it is possible to meet them while having minimal real consultation. That is the source of the problem.

I have a lot of sympathy with the case that the hon. Gentleman is making in a powerful and effective way, but I need to understand the question about consultation, because it is crucially important. Does he contend that every ward closure and every change of unit in the NHS throughout the country should be subject to extensive public consultation, as opposed to major reconfiguration of services locally? Is that now the policy of the Liberal Democrats? If that is so, they should say so up front in this Chamber.

This particular closure raises major issues. I am making a contrast. I was not directing criticism at the Minister; I was merely raising questions.

I could not understand why it was possible to have a major consultation—a valid, meaningful one—on mental health locally, which came to one conclusion less than a year ago, while the primary care trust and the health provider came to the opposite conclusion with minimal consultation a few months subsequent to that. There is clearly a mismatch, not just in the decisions but in the processes and in respect of engaging the public. That is what concerns me and why I am mentioning it to the Minister. It would be unrealistic to say that all closures must be stopped. Perhaps at the end of the day something has to happen here, but it is unsatisfactory that the process should be rushed through in this way without an attempt to test it against the criteria that the Minister will establish in a few months.

I am not making this a party political point at all. As I have mentioned, one of the Minister’s colleagues is fighting a similar battle in Gloucester. In other parts of the country a stay has been put on the closure of some specialist, high-quality institutions for the elderly mental ill as a result of the local authorities being forced to consider things again.

I ask the Minister to take a personal interest in this matter to help us have it properly considered. Perhaps in a year we will come to the same conclusion, but the process by which this is happening is fundamentally unsatisfactory and shows up flaws in the tendering process, in the way that costs are accounted for and in the way in which quality is measured. I hope that those broader lessons, as well as the narrower ones, will be learnt.

Absolutely.

I congratulate my hon. Friend the Member for Twickenham (Dr. Cable) on securing this debate and on raising again an issue of fundamental importance. He has a track record on this matter. He mentioned that he secured a ten-minute Bill right at the start of his time in this place, demonstrating a commitment to a Cinderella part of a Cinderella service that does not secure nearly enough attention from the public or from politicians of any party.

My hon. Friend presented a powerful case with regard to the facility in his area, Marble lodge, which serves his constituency and that of my hon. Friend the Member for Richmond Park (Susan Kramer). It is extraordinary that, having gone through a full consultation process just 18 months ago and reaching the conclusion that the facility should continue to play a valuable part in local health services, a completely contradictory decision was taken only a short period afterwards. There is, inevitably, concern that the decision was driven more by cost saving than by quality.

I pay tribute to the organisations that fight tirelessly to keep such issues in the public mind, including Age Concern, Help the Aged, the Alzheimer’s Society and Mind. They operate in a difficult area and are constantly in touch with the Minister, who has the same view about the role that they play. Their work is of fundamental importance in securing improvements to services that are so vital in a civilised society.

The hon. Gentleman mentioned a longish list of the organisations that are involved, one or two of which believe that there is significant age discrimination in the provision of mental health services, such that older people are not entitled to experience as wide a range of services as those in younger age groups. Does he believe that there is any meat in that allegation? Does he hope that the Minister will respond to that in winding up the debate?

I am grateful to the hon. Gentleman for raising that issue, which I was going to cover. I understand that there is clear evidence of discrimination, not because the Government want that, but because of the way in which the system has ended up operating in too many parts of the country. The Royal College of Psychiatrists has done a lot of work to highlight key concerns.

I acknowledge the Minister’s commitment to improving the quality of the service. My hon. Friend the Member for Twickenham referred to a speech that the Minister made last summer, and I acknowledge his role in seeking to improve service provision. I do not intend to make a knocking, party political contribution; I want to raise issues of genuine concern, which mirrors what my hon. Friend said. I hope that the Minister will accept my comments in that light.

I acknowledge that there have been significant improvements in funding. We supported the increased investment in the health service, which has clearly benefited mental health services in many parts of the country. None the less, increased investment in funding for mental health has lagged behind. I appreciate that it depends partly on how that is measured, but it has lagged behind investment in some other parts of the health service, and that should be acknowledged and addressed, particularly because, as my hon. Friend said, it is self-evidently a growing problem. It looks as though it will be the greatest challenge to face us in funding health care and social care.

The disparity in funding was highlighted in the autumn pre-Budget report; on the same page there was reference to a 4 per cent. increase in funding for the health service, but to an increase of only 1 per cent. for social care. Support services—the infrastructure for support—for elderly, mentally ill people depend not only on funding support within the health service, but on social care support. In many parts of the country, social care is drifting into a state of crisis. The Library’s helpful debate pack refers to a report about the situation in Lincolnshire, where social care is pretty dismal, and crisis management is ineffective in partnership with other organisations such as the NHS. We must never neglect the problems of social care within the health service.

As well as funding increases lagging behind other areas of the health service, the drift into deficit has had an impact on many organisations within the NHS where the political imperative is to get them out of deficit. The Select Committee on Health highlighted the extent to which mental health services around the country have been disproportionately affected by cutbacks.

My hon. Friend the Member for Richmond Park talked about distortions based on accounting principles, but I have been told by people working in the NHS that there is another distortion. With payment by results in the acute sector and the impact of targets to reduce waiting times—a worthy ambition—there is a tendency for money to be channelled disproportionately into acute treatment to meet the stringent waiting-time targets. Because payment by results does not operate within mental health, there is less money in the pot for primary care trusts to enter contractual arrangements with mental health trusts for the funding of mental health services, so PCTs ask the mental health trust to negotiate a reduction in the contract or in what it hopes to provide for mental health service funding. That seems to have happened in many parts of the country and, in turn, puts pressure on trusts’ mental health services.

I shall talk about the impact of the pressures on mental health services as a result of funding challenges. The Royal College of Psychiatrists provided a helpful briefing for the debate, and highlighted two issues. It said that old people’s mental health services are among the most innovative person-centred community services in the country. My hon. Friend the Member for Twickenham used the same terms as the Royal College of Psychiatrists when he referred to services being cynically dismantled. The RCP also raised concerns about age discrimination.

I shall deal first with the assertion that specialist services for elderly, mentally ill people are being cynically dismantled. The royal college said that primary care trusts throughout the country seem to be transferring the care of older people with mental health problems to general psychiatric services. Age Concern has also raised specific concerns about that. Part of the justification for transferring specialist services for elderly, mentally ill people to general psychiatric services is to end age discrimination by providing the same service for all ages. The paradox is that dismantling specialist services for elderly people increases age discrimination, as the services provided are not appropriate, suitable or sufficiently specialist for the particular needs of elderly people with mental health problems.

That can happen in a countrywide health service, and I am not blaming the Government for masterminding the drive to apply general psychiatric services to everyone, and thus being responsible for an increase in age discrimination, but I urge the Minister to address what seems to be happening, and the concerns of many specialists and charitable organisations in the field.

The Royal College of Psychiatrists fears that we will end up with a second-rate service for elderly people with mental health problems, that we will lose specialisms because we will not have people with training in that area of mental health and that the end result will be an inferior service for those with mental health problems in their older years. The royal college draws attention to the fact that the national service framework for mental health has introduced the targeted commission of new services. It refers specifically to early psychosis, assertive outreach, and crisis resolution home treatment teams and says that the £300 million investment in those new services broadly excludes older people, so again the services are discriminatory. I am sure that will be as much a concern for the Minister as it is for us. The RCP also says that the £1.65 billion cash increase for adult mental health services over four years excludes older people.

I am sure we all agree that access to services must be based on individual need, and not on the age that someone happens to be. There are some good, innovative pilots in the country. East Sussex has a particular commitment to ensure that services are suitable for each individual, and that must be the objective we all seek to achieve.

I want to comment briefly on the role of acute care, to which the hon. Member for Rugby and Kenilworth (Jeremy Wright) referred. He seems to have disappeared.

Thank you for your clarification, Mr. Olner.

People with severe mental health problems often end up in acute hospitals. An intervention at that opportune moment could significantly improve their care after they leave hospital. However, according to the report “Improving Services and Support for Older People with Mental Health Problems”, there is insufficient co-ordination between psychiatric services and acute hospitals. Many acute trusts have no real provision for psychiatric support, which means that at the moment an intervention could make a real difference—when someone with a mental health problem is in an acute hospital—there is insufficient input. The report said that there was poor screening, diagnosis and management of care. Its conclusion was that nobody, including commissioners, had that matter on their agenda. I would be grateful if the Minister could specifically comment on how we can ensure that there is better co-ordination between psychiatric services and the work of acute trusts. There needs to be a point at which we can ensure that someone who has had no contact with psychiatric services before going into an acute hospital has access to services when they leave. Better co-ordination between services would provide a great opportunity to improve care significantly for the individual, and would save costs for the NHS, because better support in the community will mean fewer emergency admissions to acute care.

I urge the Minister to accept—as I know he always does—the spirit in which these issues have been raised and to acknowledge that this is the greatest challenge facing us as a society. The figures for the costs and possible social implications to which my hon. Friend the Member for Twickenham referred are quite frightening. We need a national commitment from the Government to transform those services.

I join other hon. Members in congratulating the hon. Member for Twickenham (Dr. Cable) on securing this debate. As we have already heard, it runs on the back of the debate on 24 October 2007, which was secured by my hon. Friend the Member for Rugby and Kenilworth (Jeremy Wright). My hon. Friend has not vanished; he is acting as Whip on the Health and Social Care Bill Committee. I understand that he apologised before he left us.

We need to address this massively serious area of public health. I congratulate the hon. Member for Twickenham on raising not only the very important issue of his own constituency but also the excellent work that Age Concern and others have done in this field over recent months. I want to take this opportunity to praise Age Concern for its report and the work it has been doing. I know that the Minister has read the report, and I wonder whether he will respond to the 35 points that the organisation has raised in its summary and conclusion. Will the Minister let us know how many of those recommendations he will accept and how many he will reject?

I am conscious that this is not a bipartisan debate; it is too serious for that. I am also conscious that, on this issue, we are seeking guidance from the Minister about how he intends to take forward certain issues. I am sure that he will consider the constituency problems of the hon. Member for Twickenham, but there are other issues. Following the speech and the comments made by the Minister last summer, he built up expectation levels among those who care for older people with mental health problems. Some 3.4 million older people may be suffering from mental health disease. That means that about one fifth of the population is involved in caring for such people. That is a very large lobbying group. It is also a very vocal group, who will demand concrete proposals from the Minister to back up the comments that he made in the summer.

I will quickly comment on some of the interventions. My hon. Friend the Member for Castle Point (Bob Spink) raised a very important point, even though the hon. Member for Twickenham did not quite grasp what he was referring to. We all get correspondence about people who need specialist equipment, and this particular issue is very relevant to those who are looking after and caring for people with mental illness in their older age.

My hon. Friend the Member for Rugby and Kenilworth is a member of the all-party parliamentary group on dementia which, as I am sure the Minister knows, is about to take evidence on the usefulness of the medication that is being used in this area. From the evidence I have seen, I have grave concerns about it. A witness statement from the Age Concern report said:

“I went to my doctor and he suggested Prozac. I told him no medication, especially Prozac. He’s a nice enough guy usually, but when I said I just wanted to talk to someone, he totally patronised me.”

I partly understand where the GPs are coming from. Given the time scales within which they have to operate, it is very difficult to treat someone who comes in suffering from depression. I think that depression is the forgotten subject in this area and it needs to be highlighted. It is very difficult when someone says to the doctor, “I need some time to talk to you.” We need to find ways in which that person can get the help that they need, rather than offering them the simplistic solution of putting them on drugs, to which they will almost certainly become addicted in the short term. In the long term, the drugs could have an even more adverse effect on their health. I look forward to the conclusions of the report from the all-party parliamentary group on dementia.

On Christmas day, I had the honour of visiting my local acute hospital. I visited the 14 wards that were open and the accident and emergency department. On many of the medical wards, half the beds were empty. When I spoke to the sister in charge of the wards she said that wherever possible they had sent people home over Christmas. I think that we all understand that. I noticed that the vast majority of the people still in hospital were elderly and, clearly, in most cases, suffering from some degree of mental health problems. In many cases, people with mental health problems had gone home over Christmas because they had loved ones and carers to look after them. For those who did not go home, the lack of provision within the NHS is stark. All too many of our wards are full of people who should not be there, but in a specialist unit being cared for by experts.

The hon. Member for Twickenham alluded to the time, some 40 years ago, when he first went on to a ward to work. In 1973, just before I joined the armed forces, I spent a year working at my local hospital on the geriatric ward, as it was known then. That is not a derogatory term; it is exactly what it was. I, too, at such a young age was astounded by the dedication and professionalism of those who looked after the patients. As we have heard, people were often unable to thank them or give them the credit that they deserved. Today, we may change the terminology that we use, but having gone round the different facilities that look after those with mental health problems, particularly among the older generation, in my constituency, I pay tribute to those who specialise in this field, whether in the public or private sector. In my constituency, Robin Hood house specialises in patients with dementia.

There is an issue that we have not had an opportunity to discuss this morning, and perhaps the Minister will write to me if he does not have the relevant figures before him. Each time I visit the different facilities it has been put to me that the age profile of people suffering from dementia, and Alzheimer’s in particular, is lowering, so that people in their early 60s are suffering from dementia. I appreciate that dementia is a catch-all term and that there are many different areas, but clearly something is going on. Have the Government been looking into any research in that respect?

We have had discussions about whether consultation has been done correctly and not only in relation to the constituency of the hon. Member for Twickenham. He clearly touched a nerve with the Minister when he mentioned the word “consultation”. It is an emotive subject in the community. The Minister is right to say that if a small piece of the NHS, such as a ward, is being moved or small facilities are changing, there cannot be full consultation in the public arena. I think that we accept that. However, when facilities as specialist as those that we are talking about are in the same position, everyone would expect the public and those concerned, particularly the carers, to be involved in the consultation process.

As the Minister knows, I am quite critical of the way in which the consultation process has continued to be operated across the country. We do not want a consultation process to take place in which the public, the experts and the other people involved voice a view, which is then ignored, because that causes even more anxiety and concern. I know that the Minister is aware of that. In my constituency, there was a public consultation in which 86 per cent. of the consultees opposed the relevant closure, but that fact was ignored. That just causes more and more anxiety.

We are talking about the NHS, which is publicly funded by the taxpayer. It is right and proper that major changes in the infrastructure should go out to consultation and that the views expressed in that consultation should be properly listened to. It should not just be a listening exercise, after which those views are ignored. All too often we hear that the decision was made before the consultation process even started, which just causes more problems. The primary care trusts and the different relevant bodies should consider a much more open way of conducting the process early on, so that people have a better understanding of what is happening.

The figures used in today’s debate are quite shocking, but other figures, which have not been discussed, are also frightening and shocking. I passionately believe that depression among older people is one of the undiscussed, quiet areas that does not quite receive the publicity that it deserves—it is a major problem. According to figures produced by Age Concern in its report, one in four older people have symptoms of depression, but sadly only one third of those with depression ever seek medical advice or ever discuss it with their GP. Sadly, as we heard from witness statements in the report, even when they do discuss the matter with their GP, they do not receive the type of care that they deserve. That leads to a disproportionately higher suicide rate for older people. We should consider the figures in the report. It cannot be right that the older generation, who have done so much for us—the generations who follow them—have a disproportionately higher suicide rate because they are not receiving the help that they often need.

I fully understand, and I am sure that the whole House would understand, that people are often frightened of talking about the fact that they have depression or that they feel they have the early signs of Alzheimer’s or dementia. It is for us as a community to come up with ideas to assist them, so that there is no stigma in any shape or form should people feel that they have a problem or others feel that they are starting to have problems.

We have rightly praised Age Concern, Help the Aged, the Alzheimer’s Society and Mind, and there are many other groups—small and large groups in our constituencies that do so much work—which we will not have an opportunity to talk about today. However, I would like to talk in more depth about carers—the carers who do so much for their loved ones. They do so not for money and not because they have been asked to go along and help as a volunteer, but mostly because it is their loved ones who are suffering.

I, too, have family experience. By the time I was 15 or 16, my great-aunt, who was mostly responsible for bringing me up, had no idea who I was. She had no recollection at all of the wonderful life that she had lived in the 62 years before the most difficult stages of her Alzheimer’s. Sadly, she lived for nearly another 20 years. That sounds like a terrible thing to say, but she had no life. She destroyed my great-uncle’s life, but he would not let her go into a home—he would not let her be taken away. In those days, there was not much respite. There is some respite today, although there are great concerns that some respite care centres are closing as well. In my constituency, there are real problems in that respect.

Without those wonderful people, what would the state do? What would we be able to do without those generous, caring, loving people who look after their loved ones in such a way? So when they do seek help and a little respite care, it is very difficult for them to learn that units are possibly closing and that there is not the necessary back-up from acute services, which we heard about. More training is needed in the acute sector to help people with this type of medical condition when they arrive at acute facilities.

I praise the Government for the increased expenditure that is there today in the NHS. However, it is difficult for the public to understand when units are clearly closing or being reconfigured or care is being transferred to other service providers because of money. There must be a better way of sorting out the situation and funding services through the system. I accept that there is a conflict between the local government funding side and the NHS side of mental health provision, but we need much more joined-up thinking. Actually, what we need is not more joined-up thinking, but more joined-up action—action that the Minister promised. The talk has happened and perhaps the action will now start.

I congratulate the hon. Member for Twickenham (Dr. Cable) on securing the debate and on setting its tone. We have had a high-quality discussion, free of the usual party politics and, as the hon. Member for North Norfolk (Norman Lamb) said, we have been addressing one of the great public policy challenges that faces our society and all political parties and it is the responsibility of Government. May I also say to the hon. Member for Twickenham that the way he talked about his own experience with his mum was very moving? We should remember that the situation that we are discussing is reflected in an increasing number of families throughout the country. It does the body politic good that occasionally we talk in the language of our own families and life experiences, which shows that we are not as out of touch as sometimes politicians of all colours are accused of being.

As the hon. Member for North Norfolk said, this issue is one of the great challenges that our society faces. I refer to the fact that we live in a society in which people live longer and, in doing so, have increasingly complex conditions such as dementia. In his recent speech on the NHS, the Prime Minister said that demography was one of the top challenges facing the NHS. That is an important step forward because, often, the debate is solely about social care, but demography is every bit as important. As the hon. Gentleman for Hemel Hempstead (Mike Penning) said, if one goes to an acute hospital, one will see an incredibly high number of older people receiving care. That is a challenge for the social care system, but, equally, it is a challenge for the NHS and, arguably, for all public services. If the demography of our society is changing, the future development of all kinds of public policy will have to reflect it.

People’s expectations are very different now. The vast majority of people wish to remain in their own homes rather than enter institutionalised care. That does not mean that there is no need for specialist, high-quality residential nursing units—there is, and there always will be—but the reality is that the vast majority of people, given the choice, would wish to stay in their own homes. The baby boomer generation—I shall not fit any particular Member into any particular generation—have much higher expectations of care than our grandparents’ generation, both in terms of the quality of care and of the level of personalisation.

As I have said before, I intend to bring dementia out of the shadows. For too long, individual families have struggled and battled with dementia, but public policy has almost been in denial about it, instead focusing on the generic needs of older people without recognising that dementia brings with it particular issues. Anybody who has seen the powerful and shocking documentary in which Barbara Pointon allowed the filming of her husband Malcolm’s deterioration could not help but understand the power of the condition for the individual and the family member. I am delighted that I have got to know Barbara recently and that she is playing an active role in the development of our national dementia strategy, and in the Department’s work with carers.

I have also focused on making the case for putting the dignity of older people at the heart of our care services, and I shall continue to provide leadership on that. I do not believe that there are easy solutions or magic wands, or that we can run every hospital, GP surgery and social care service, but providing national leadership that says that dignity at all times must be at the heart of care for older people would begin to make a difference and to get the debate going in every care establishment up and down the country.

The hon. Member for Twickenham talked about a number of issues. He was on to something when he put dementia alongside cancer, stroke and heart disease as a condition that challenges the NHS. Dementia should be given a much higher status and reflect the priority that we give to it. He was good enough to say that practice on older people’s mental health has improved in the past 10 years, but we are beginning in deficit, because practice is nowhere near as good as it needs to be. However, he said that we have seen advances in the way in which care is provided in the past decade.

The hon. Gentleman raised the issue of Marble lodge in St. John’s hospital in his constituency. Quality of life without medication is the ethos of that institution, which provides a calming environment––as he said, an oasis of peace. Those are the qualities, characteristics and attributes that people with dementia and their families in every part of the country would want. However, I must tell him that I cannot instruct local NHS organisations how to do their business. He made a powerful case when he said changes should not be made in advance of the national dementia strategy, without, perhaps, all the evidence on the direction of policy. The people charged with making such difficult decisions—it is a difficult change to make—should consider whether it would be appropriate. I should also like to put on record that the national dementia strategy will be published in the autumn, but a consultation document will be presented in June and people will have the opportunity to comment before the final strategy is produced.

The hon. Gentleman may want to acknowledge that carers have been involved in the tendering process—they have had input and oversight. To say that there has been no engagement or consultation in the case he mentioned is not fair, because significant attempts to engage and consult were made. Indeed, the matter was originally referred to the overview and scrutiny committee of his local authority, which chose not to express any reservations about the change. It subsequently had second thoughts and raised its concerns, but to say that there was no consultation is not fair. The hon. Gentleman did not say that there was no consultation, but the hon. Member for Hemel Hempstead spoke of consultation in a derogatory way. Genuine attempts to engage on the issue were made, but because of the unique nature of the unit, there is a great deal of emotional attachment to it and a great belief that the clinical care it provides is of the highest possible standard. I would be happy to speak privately to the hon. Member for Twickenham about that particular situation.

The hon. Member for Rugby and Kenilworth (Jeremy Wright), who has left the Chamber, does an excellent job as the chairman of the all-party group on dementia, and the group makes an important contribution to the debate.

The hon. Member for North Norfolk made a constructive and helpful contribution, and I echo his tributes to Age Concern, Help the Aged, the Alzheimer’s Society, Action on Elder Abuse, Mind and, indeed, to carers organisations such as Carers UK, the Princess Royal Trust for Carers, Crossroads, Partners in Policymaking, and the Royal College of Psychiatrists. Those organisations frequently ensure that older people’s needs are placed far higher on the political agenda than they would be by constantly pressuring parliamentarians and using the media, and by championing the interests of older people and their families, so I pay tribute to them.

The hon. Gentleman talked about funding. We spend large amounts of money, in every community through the NHS and local government, both on social care and on mainstream well-being services through the benefits system, but that is not often not referred to in debates such as this. We spend money, for example, on the disability living allowance, the attendance allowance, housing, and, indeed, we spend money through excellent third and voluntary sector organisations. We need to get to a situation in which we have a joined-up, integrated approach to health and well-being in every local community that shifts us toward early intervention and prevention. We signed the “Putting People First” concordat before Christmas with local government and the NHS. I believe that in the next three years, a radical transformation of the social care system in partnership with the NHS, focused on a shift to early intervention and prevention, and on giving people maximum control and power through personal budgets, universal information and advice to people, including those who fund themselves, is massively important. It would begin to transform well-being services in every community in every part of the country.

Is the Minister indicating that he sees a need to integrate fully the funding that comes through the benefits system? For example, attendance allowance could be provided through the care system so that there is one mechanism for providing funding and support.

I am open to that view, but that is not what I am saying and it is not the Government’s position. As the hon. Gentleman knows, we are about to embark on a major, extensive public consultation that will lead to a Green Paper and scope out the scale of the challenge of the future funding of social care and the range of available options. I am not necessarily talking about the need to put all the investment into one organisational framework because, sometimes, tinkering with organisational structure is not the solution. I am saying that those resources should be considered, commissioned and spent in a holistic and integrated way in every community rather than being looked at separately. That is not quite the same as saying that they should all be brought within the same organisational framework. In our view there is not enough money in local communities to ensure that older people, disabled people, those with mental health problems and carers have a much better quality of life. I argue that it is not only about more money, although the demography means that over the next 10, 15 or 20 years we will need more resources just to keep up with demand, but that existing resources could be used in a far more integrated and sensible way.

That is why I ask the House to consider the “Putting People First” protocol. It will be followed in the next few days by a letter to every local authority. Local government has signed up with the Government to a radical shake-up of social care services, in partnership with the NHS, in every community over the next three years, beginning in April.

The hon. Member for North Norfolk made an important point in respect of acute hospitals, and the opportunity for older people who are admitted to them to have access specialist mental health services.

The hon. Member for Hemel Hempstead—I welcome his unusually non-political contribution—rightly spoke about the inappropriate medication of older people. He will therefore welcome the significant expansion of psychological therapies over the next three years. At primary care level, people will have far greater access to psychological therapy than ever. That will be as relevant to older people as to those of all other ages.

Like the hon. Gentleman, I spent Christmas day visiting the two acute hospitals in the vicinity of my constituency. I felt a sense of awe on meeting the staff, who were giving up their whole of their Christmas time to care for NHS patients in a sensitive and professional way. It demonstrates the power and the uniqueness of our national health service and the staff who work on the front line. Of course, we cannot walk away from the growing number of patients in acute hospitals that have dementia, and Lord Darzi’s next stage review of the NHS will give serious consideration to that factor.

I could speak about all that the Government have done on these issues over the past 10 years, but much of what we have done is already on the record. In 1999, we introduced an annual carers grant to every local authority, the right for carers to request flexible working and enhanced pension credits for carers—and we will be doing more. That is why the Prime Minister, my right hon. Friend the Secretary of State for Health and I spent several hours in Leeds last Friday talking directly to 70 or 80 carers about what they want from the new deal for carers that the Prime Minister will announce later this year. Rather than a new deal for carers being drawn up in offices in Westminster and Whitehall, it will be based on the real, everyday experiences of carers.

We will consider respite care, a subject raised by the hon. Member for North Norfolk. There should be greater recognition and valuing of the tremendous contribution made by carers. That contribution will grow with the ageing population. Indeed, people often miss the significant implication for families if ever more people are to stay in their own homes rather than going to institutions. Nor, as the Minister for Schools and Learners arrives for the next debate, should we forget the plight of young carers. Together we need to do a lot more as we face one of the new challenges to which society is waking up—that far too many children are spending too great a proportion of their lives caring, inappropriately in my view, for sick or dependent parents. As the hon. Gentleman said, we must address the needs of carers, and we will be doing so in our new deal for carers.

The year 2008 will be crucial in facing up in a radical way to the challenges of demographic change. We will produce a national dementia strategy, which will focus on raising awareness of the problem among professionals and citizens, so that we can identify the symptoms at an early stage; the earlier we intervene the better. Appropriate diagnosis and intervention are important. Too often, family members or the older people themselves approach a professional, describe symptoms and are told that they are not suffering from dementia or Alzheimer’s, and many are given an inappropriate diagnosis. That is bad, because the earlier we intervene in such circumstances, the better and more effective the treatment and support will be.

The final element of the national dementia strategy will be quality specialist care. I agree entirely with those who said that we need specialist expertise, staff training and, when appropriate, specialist services. Simply to say that all older people should receive the same service, as an expression of equality, is a mistake.

The national dementia strategy will be produced in the autumn and we will consult on it from June. It will be incredibly important, and I am delighted that the chief executive of the Alzheimer’s Society is playing a central role, with recognised leaders in social care and the NHS, in developing the strategy.

As I said, extensive consultation will take place this year on the future funding of the social care system, and we will produce a Green Paper later in the year. I want an all-party consensus for change on the funding of long-term care. I hope that politicians will resist the temptation to resort to petty politics. We all know that it is not easy to balance the respective responsibilities of the state and the citizen when considering the scale of demographic change and people’s rising expectations. Publication of the Green Paper will be incredibly important.

I will be extending my campaign to put dignity for older people at the heart of all care services. We want the subject to be debated on every hospital ward, in every residential and nursing home, and within all domiciliary services, voluntary organisations and local authorities. The question is how to improve dignity for older people in every care setting.

We will review the protection regulation system for vulnerable adults. We know that elder abuse is a growing concern. Twenty or 30 years ago, we were beginning to talk openly about the scale of child abuse. With elder abuse, public debate is arguably at a similar stage so we will review the protection regulations later this year.

In the spring, the Prime Minister will announce a new deal for carers. With a 10-year plan, we will seek to address the growing number of people who spend a significant proportion of their lives caring for older or disabled relatives; and we as a society and as a Government must do more to recognise, value and support their contribution.

Alongside that is the Darzi review of the NHS. Having rebuilt the foundations of the NHS during the past 10 years, the challenge now is to move to a world-class health service, with personalisation at its heart—one in which people are treated as people and not patients, because individuals and families have distinct needs. As the Prime Minister said recently, we need to harness all our expertise and technology and the most recent medical advances to shift towards early intervention and prevention, moving from a sickness health service to a well-being national health service.

The year 2008 is the time for us to consider all approaches to the needs of older people and disabled people, and for the Government to demonstrate their willingness to step up to the plate and tackle the issues head on. I believe that many of them require an all-party consensus, and we will be striving to achieve that whenever possible as those debate become more acute.