House of Commons - Health

Select Committee on Health Fourth Report

FOURTH REPORT

The Health Committee has agreed to the following Report:—

PROVISION OF NHS MENTAL HEALTH SERVICES

1. Mental health services have traditionally been marginalised within the National Health Service, in much the same way as people with mental health problems have been marginalised within society. During the 1990s, both the previous and current administrations have sought to combat this tendency, with high profile announcements on the future of mental health policy[6] and the creation of specific grants to encourage the development of community-based services.[7] Much of the debate has focused on the policy of "care in the community" for people with mental health problems: the principle that, wherever possible, individuals should be cared for in their own homes, or in home-like surroundings, instead of in isolated asylums. While few have challenged this principle, there has been considerable debate as to whether the pendulum has swung too far: whether the hospital sector has been reduced too much with the consequence that patients have been left to fend for themselves in the community without adequate support. There are regular reports of extreme pressure on acute beds: the Mental Health Act Commission, for example, commented in its latest biennial report that its 1999 National Visit (a simultaneous inspection of 117 mental health units) demonstrated average bed occupancy of 99%.[8] Moreover occupancy in inner and outer London was 107% and 111% respectively, if patients on over-night leave were included in the figures.[9]

2. Our decision to launch an inquiry into mental health services stemmed from the strong impression we had received that patients often ended up in the wrong part of the mental healthcare system. We had seen at first hand in an earlier inquiry, for example, how many of the residents of a private secure unit in Yorkshire were young black men from London, isolated from their homes and communities.[10] We felt that this isolation would make it much harder for these young men to be re-integrated into mainstream services and back into their communities, however good the services they might be receiving in the secure unit might be. Similarly, in our constituencies many of us were aware of individuals in prisons who were ill enough to be transferred to secure mental health units, but for whom no place was available.

3. We wanted to investigate the extent to which there was a general problem with patients being in the wrong place, both in the sense of being remote from their homes and in the sense of having the wrong level of support and security, which could lead to appropriate therapy being compromised. Assuming there was a general problem, we particularly wanted to inquire into the part played by factors such as a lack of appropriate facilities at particular points in the system, inadequate links between the various parts of the mental health service, and the different routes by which patients entered the system, such as the criminal justice route. We also suspected that race and gender might play a part both in how and where patients access mental health services and in the appropriateness of the services provided. We therefore decided to undertake a wide-ranging inquiry, which would enable us to look both at the transition points in mental health services and at the ability of the various sectors of the mental health system to cope with the patients placed with them. It seemed to us that it would only be possible to make a sensible judgement on the correct balance between community and hospital-based provision, once we had established whether patients were currently appropriately placed in the system.

4. On 21 January 2000, we announced we would be undertaking an inquiry with the following terms of reference:

"To examine the provision of NHS mental health services for people, including children and adolescents, with mental illness or personality disorders, including consideration of the relationship with secure units, high secure hospitals and prisons. This will cover the following issues:

current Government definitions and categorisations of mental illness;
the ability of care in the community to care for people with acute mental illness;
the transition between the acute and secure mental health sectors;
the transition between adolescent and adult mental health services."

5. Between March and May this year, we took oral evidence from Department of Health officials, Mind, National Schizophrenia Fellowship, SANE, Young Minds, Breakthrough, FOOTPRINTS, Manic Depression Fellowship, Professor Genevra Richardson, Professor William Bingley, Newcastle City Health NHS Trust, Local Health Partnerships NHS Trust, the Association of Directors of Social Services, the College of Occupational Therapists, the British Psychological Society, the Royal College of Nursing, the Royal College of Psychiatrists, Mr. Mike Boyle of the Home Office Mental Health Unit, Rampton Hospital Authority, the Chief Inspector of Prisons and his Chief Medical Inspector, Women in Secure Hospitals (WISH), Mental Health Services of Salford NHS Trust, the Rt Hon Paul Boateng MP, Minister of State at the Home Office, John Hutton MP, Minister of State, Department of Health, and the Rt Hon Alan Milburn MP, Secretary of State for Health.

6. We also received around 80 written memoranda which were invaluable in our discussions. We are very grateful to all those who provided us with oral or written evidence.

7. In order to see for ourselves the challenges that mental health services are facing, we undertook a number of visits throughout England. We visited Ashworth Special Hospital, the Gardener Unit for adolescents in Manchester (part of Mental Health Services of Salford NHS Trust), Reaside Clinic medium secure unit in Birmingham (part of South Birmingham Mental Health NHS Trust), Northern Birmingham Mental Health NHS Trust, Broadmoor Special Hospital, Belmarsh Prison, Bracton Clinic medium secure unit (part of Oxleas NHS Trust), South West London and St. George's NHS Trust and Nafsiyat Inter-cultural Therapy Centre.

8. We were fortunate to receive initial briefing on mental health issues from the Sainsbury Centre for Mental Health, who hosted a very informative informal seminar for us before we started taking formal evidence. We are very grateful to those who participated, particularly Dr. Matt Muijen, Dr. Andrew McCulloch, Dr. Richard Ford, Dr. Diana Rose, and Erville Millar of the Sainsbury Centre, Professor William Bingley of the University of Central Lancashire, Professor Graham Thornicroft of the Institute of Psychiatry, Professor Tom Burns of St. George's Hospital Medical School and Professor Robert Bluglass of the University of Birmingham.

9. We have also benefited enormously from the expertise of our five specialist advisers: Professor Robert Bluglass CBE, Emeritus Professor of Forensic Psychiatry, University of Birmingham, Professor Tom Burns, Professor of Community Psychiatry at St. George's Hospital Medical School, Angela Greatley of the Working Together in London Initiative and the Kings Fund, Professor Ray Rowden, Visiting Professor, Nursing and Clinical Management at the University of York and Chris Vellenoweth, an independent adviser on health policy and former special projects manager, NHS Confederation.

How mental health services are delivered

10. Specialist mental health services are provided by the NHS in a range of settings. The backbone of the service is provided by the "general" mental health services: a combination of in-patient ("acute") beds and community-based services, usually delivered through geographically-based community mental health teams (CMHTs). In addition to CMHTs, local mental health trusts may also provide "assertive outreach" teams which have a much smaller case-load than their colleagues in CMHTs, and which aim to keep in touch with patients who would otherwise be hard to engage with services. Increasingly, trusts may also provide "home treatment" or "crisis services", which aim to care for individuals experiencing acute mental distress to enable them to remain in the community, usually at home, instead of becoming hospital in-patients. These services may be provided by dedicated home treatment teams (as is the case in Northern Birmingham Mental Health NHS Trust, for example), or by general CMHTs (as in South West London and St. George's NHS Trust), or by specialist crisis teams sometimes using dedicated crisis houses.

11. The NHS trusts providing general mental health services may often also have access to a locked ward, or intensive care ward, where patients who need a higher level of physical security, or greater staff input than is possible on acute wards, can be cared for. "Intensive care" wards aim to provide relatively short-term care, while "low security" or "high dependency" wards expect to provide for those who need longer-term care in a locked environment.[11] In practice both types of ward may be grouped under the general term "low security".

12. Mental health services are also provided with "medium" and "high" security, through the regional network of medium secure units and through the three high security Special Hospitals, Ashworth, Broadmoor and Rampton which are each managed separately as Special Health Authorities.[12] Patients being cared for in these settings should, in theory, require high levels of physical security, either for their own protection or that of others. Many of the patients in these units will have accessed the mental health system through initial contact with the criminal justice system. This may be through court diversion schemes, which aim to identify offenders who are mentally disordered and divert them wherever possible to hospital rather than to prison, through the use of a "hospital order" (section 37 of the Mental Health Act 1983) with or without an order restricting discharge (section 41). Alternatively, remand and sentenced prisoners may be transferred from prison to hospital, if they are found at a later date to be suffering from a mental disorder which makes hospital admission appropriate. Because of their links with the criminal justice system, these secure mental health services are known as the "forensic" services. However, it should be emphasised that it is the need for physical security, and not the nature or existence of a criminal conviction, which should determine whether patients are placed in medium or high security services.[13]

13. A substantial proportion of mental health services are also provided in primary care settings. Figures often quoted suggest that one in four GP consultations have a mental health element, whether a mental health problem alone or a mental health element within a broader range of difficulties, and that over 90% of patients with mental health problems are cared for within primary care.[14] Some of these consultations will be for people who have, or are developing, mental illness in the sense of having a classifiable mental disorder. Some will have personal or social difficulties often causing extreme distress, and others will have a range of less serious but still significant mental health problems.[15] Primary care thus provides a wide range of people with treatment, care and support as well as referral to specialist mental health services, and now directly cares for patients with psychotic disorders, depressive illnesses and anxiety disorders in a way that was unimaginable twenty years ago. The current emphasis on the role of primary care, and the development of Primary Care Groups and Primary Care Trusts, is likely to encourage this trend further. Primary care is increasingly providing a range of services beyond the traditional GP consultation and involving both a broader range of primary care professionals and, in some cases, staff from specialist services working within and alongside the primary care team.

The legal framework

14. The current legal framework governing mental health services is found in the Mental Health Act 1983 (the "1983 Act"). This Act sets out the criteria which must be met if mentally disordered individuals are to be detained for assessment and/or treatment, and includes a number of safeguards for detained individuals, including their right of access to reviews by hospital managers and Mental Health Review Tribunals, and the powers of the Mental Health Act Commission to visit them and check their welfare. It also makes provision for individuals to be diverted from the court system or from prison. With limited exceptions, such as section 117 of the Act (which gives detained patients the right to "aftercare" services once they are discharged), the 1983 Act is essentially concerned with compulsion, rather than with the way mental health services should be provided to those who need them. As the 1983 Act is essentially the consolidation of an earlier measure, the Mental Health Act 1959 and its amending statute, the Mental Health (Amendment) Act 1982, its philosophy is still based on the assumption that most treatment for mental disorder will be provided in hospitals.

15. The shape of mental health services has, however, changed radically since the passing of the 1959 and 1983 Acts. Although the policy of care in the community has been in existence since Enoch Powell forecast the end of the "water-tower" asylums in 1961,[16] the development of genuine community-based services was relatively slow until the early 1990s.[17] Despite the slow development of services, hospital beds have been drastically reduced from 129,000 in 1968 to 91,000 in 1978, 63,000 in 1988/89 and 36,000 in 1998/99.[18] More recently, the question has been raised as to whether the shift from hospital-based care to community-based care has gone too far, or whether the well-publicised problems of care in the community, such as the murder of Jonathan Zito by Christopher Clunis in 1993, are due to in-patient services being closed before adequate replacements were developed.

16. In 1995, concern about discharged patients "slipping through the net" of aftercare services led to the Mental Health (Patients in the Community) Act 1995 being passed. This Act amended the 1983 Act to create a new power of "aftercare under supervision": patients made subject to this new power could be discharged after detention in hospital but still be required to live in a certain place, allow access to certain professionals, and attend for medical treatment at specified times and places. The Act stopped short of requiring patients to accept treatment, but the hope was that if patients remained in touch with the system they would be more likely to continue taking treatment. This power has not been widely used: in its latest biennial report the Mental Health Act Commission states that 318 applications were made in England in 1997/8.[19]

Recent policy on "care in the community"

17. In 1996, the then Secretary of State for Health, Stephen Dorrell, made a major announcement on mental health services, emphasising the need for a "spectrum of care" for people with mental illness and arguing that the policy of care in the community had never meant the abandonment of all 24-hour residential care facilities.[20] In September 1997, after the change of government, Paul Boateng, then Parliamentary Under-Secretary of State at the Department of Health, announced the creation of an "Independent Reference Group" to consider proposals for the closure of the remaining long-stay psychiatric hospitals (the "water-tower" hospitals) in the light of the available support in the community.[21] The following July, the then Secretary of State for Health, Frank Dobson declared that care in the community had "failed".[22] Arguing that locking up patients in long-stay institutions was "harsh and harmful", Mr. Dobson described a "third way" for mental health, with more acute beds and more secure facilities, but also increased numbers of 24 hour crisis teams, hostels and supported accommodation, home treatment teams and assertive outreach teams. He also promised a "National Service Framework" providing guidance on the level and balance of mental health services, and a "root and branch" review of the 1983 Act.

18. Mr. Dobson's announcement was followed up in December 1998 with the publication of the strategy document Modernising mental health services, which developed the themes from the July announcement and promised £700 million extra for mental health services over the following three years. The promised National Service Framework was published in September 1999 and set out seven National Standards for working-age adults which are reproduced below:

Standard one: Health and social services should:

      •  promote mental health for all, working with individuals and communities
      •  combat discrimination against individuals and groups with mental health problems,
and promote their social inclusion.

Standard two: Any service user who contacts their primary health care team with a common mental health problem should:

      •  have their mental health needs identified and assessed
      •  be offered effective treatments, including referral to specialist services for further assessment, treatment and care if they require it.

Standard three: Any individual with a common mental health problem should:

      •  be able to make contact round the clock with the local services necessary to meet their needs and receive adequate care
      •  be able to use NHS Direct, as it develops, for first-level advice and referral on to specialist helplines or to local services.

Standard four: All mental health service users on the Care Programme Approach (CPA) should:

      •  receive care which optimises engagement, prevents or anticipates crisis, and reduces risk
      •  have a copy of a written care plan which
      —  includes the action to be taken in a crisis by service users, their carers, and their care co-ordinators
      —  advises the GP how they should respond if the service user needs additional help
      —  is regularly reviewed by the care co-ordinator
      •  be able to access services 24 hours a day, 365 days a year.

Standard five: Each service user who is assessed as requiring a period of care away from their home should have:

      •  timely access to an appropriate hospital bed or alternative bed or place, which is
      —  in the least restrictive environment consistent with the need to protect them and the public
      —  as close to home as possible
      •  a copy of a written after care plan agreed on discharge, which sets out the care and rehabilitation to be provided, identifies the care co-ordinator, and specifies the action
to be taken in a crisis.

Standard six: All individuals who provide regular and substantial care for a person on CPA should:

      •  have an assessment of their caring, physical and mental health needs, repeated on at least an annual basis
      •  have their own written care plan, which is given to them and implemented in discussion with them.

Standard seven: Local health and social care communities should prevent suicides by:

      •  promoting mental health for all, working with individuals and communities (standard one)
      •  delivering high quality primary mental health care (standard two)
      •  ensuring that anyone with a mental health problem can contact local services via the primary care team, a helpline or an A&E department (standard three)
      •  ensuring that individuals with severe and enduring mental illness have a care plan which meets their specific needs, including access to services round the clock (standard four)
      •  providing safe hospital accommodation for individuals who need it (standard five)
      •  enabling individuals caring for someone with severe mental illness to receive the support which they need to continue to care (standard six)

and in addition:

      •  supporting local prison staff in preventing suicides among prisoners
      •  ensuring that staff are competent to assess the risk of suicide among individuals at greatest risk
      •  developing local systems for suicide audit to learn lessons and take any necessary action.[23]

Possible legislative change

19. An Expert Committee, chaired by Professor Genevra Richardson of Queen Mary and Westfield College, University of London, was commissioned to carry out the review of the 1983 Act, with the explicit remit of advising on how the aim of introducing compulsory treatment for patients not formally detained in hospital could be implemented. The Expert Committee's report, Review of the Mental Health Act 1983, was published in November 1999, alongside the Green Paper, Reform of the Mental Health Act 1983: proposals for consultation.[24] We discuss the Expert Committee's recommendations and the Government's response in the Green Paper below (see paragraphs 105-151).

20. The strategy document Modernising mental health services also highlighted another area where the Government was considering possible legislative change: the issue of individuals who suffer from "severe personality disorder" and are considered to be dangerous to the public, but who cannot be detained under the 1983 Act because they are deemed "untreatable". The joint Department of Health/Home Office document, Managing dangerous people with severe personality disorder: proposals for policy development, published in July 1999, put forward two alternatives for change. The first proposed the development of existing systems within prisons and hospitals, including extending the use of discretionary life sentences to ensure that people convicted of serious crimes would not be released if considered still dangerous, and amending the 1983 Act in order to remove the "treatability" requirement for "dangerous severely personality disordered" (DSPD) people. The second proposed the construction of a whole new legal framework to allow DSPD individuals to be detained on the basis of their diagnosis and an assessment of the danger they presented to the public, and to be held in new facilities separate from both the prison and hospital systems. The responses to this consultation paper are currently being considered together with the responses to the more general Green Paper, Reform of the Mental Health Act 1983.

Prison health services

21. There have also been recent policy developments over prison health care. In March 1999, the Department of Health published The future organisation of prison health care, a report produced by a joint working group of the NHS Executive and the Prison Service in response to a proposal by Her Majesty's Chief Inspector of Prisons that responsibility for delivering health care should be shifted from the Prison Service to the NHS. This report acknowledged "weaknesses" in the current system of prison health care, leading to "less than optimal health care delivery" and considerable variation in the quality of services between prisons.[25] The Working Group recommended that funding and departmental accountabilities should remain the same: that is, prisons would continue to fund primary health care, while the NHS would remain responsible for secondary care services. However, there should be a formal partnership between the NHS and the Prison Service, with the aim both of ensuring that standards in prison health care centres matched those in the NHS and of avoiding the historic isolation of clinical staff working only in prisons. The cost of providing "in-reach" services, such as NHS community mental health services in prisons, which had in the past generally been funded by the Prison Service, should be met by the NHS. In order to develop this partnership, a prison health Policy Unit has been set up within the NHS Executive, and a Task Force has been appointed to help prisons and Health Authorities identify the health needs of prisoners in their area and to agree prison Health Improvement Programmes.[26]

Child and adolescent mental health services

22. In a previous inquiry we drew attention to the inadequacy of child and adolescent mental health services, both in terms of quality and in geographical spread.[27] We wanted to return to this area of service provision in this inquiry, focusing this time on the transition from adolescent to adult services as part of our overall analysis of the extent to which patients are receiving treatment in the appropriate place.

23. The structure of our Report is as follows. We begin with a short section on definitions of mental disorder, because we felt that the criteria used to define access to services for people suffering from mental disorder could constitute the first "hurdle" to patients ending up in the right part of the system. We then look at how users of the system, patients and carers, regard the services currently available, what they see as the main problems that need addressing and how they would prioritise improvements. The next two sections consider the changes taking place in the general mental health services, in particular the effects of the National Service Framework, and the proposals to overhaul the existing legislative framework to allow compulsory treatment to be given in the community as well as in hospital. The discussion of the legislative changes includes consideration of the proposals to create a specific legal framework for people with severe personality order who are deemed dangerous, and how these should fit in with the wider review of the Mental Health Act 1983. Finally, we look at how the transitions are managed between the general mental health services and other more specialised services: the child and adolescent services and the secure mental health services.

6 Eg HC Deb 20 February 19996 cols 175-177. Back

7 the Mental Illness Specific Grant which was later renamed the Mental Health Grant. Back

8 Mental Health Act Commission, Eighth Biennial Report 1997-1999, 1999, p118. Back

9 Ibid. Back

10 The regulation of private and other independent healthcare, Fifth Report of the Health Committee (HC 281, Session 1998-99). Back

11 Ev., p18. Back

12 "Medium Secure Units" were originally known as "Regional Secure Units", as when they were first developed in the 1970s the aim was to provide one unit per NHS Region. The development of more medium secure units, together with the merging of some NHS Regions, led to their change of name. Back

13 A more detailed account of the categories of mental health beds is given in the Department's memorandum, Ev., pp17-18. Back

14 QQ656-657. Back

15 This distinction between classifiable mental disorders and personal or social difficulties leading to mental distress is discussed in a recent British Medical Journal article: Middleton and Shaw, "Distinguishing mental illness in primary care: we need to separate proper syndromes from generalised distress", BMJ, 27 May 2000, pp1420-21. Back

16 Report of the Annual Conference of the National Association for Mental Health, 1961, pp4-10, cited in Kathleen Jones, Asylums and after, 1993. Back

17 All talk and no action", Health Service Journal, 1 February 1996, pp12-13. Back