Westminster Hall
Tuesday 15 January 2008
[Mr. Bill Olner in the Chair]
Elderly Mentally Ill People
Motion made, and Question proposed, That the sitting be now adjourned.—[Liz Blackman.]
9.30 am
Dr. Vincent Cable (Twickenham) (LD): 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.
Bob Spink (Castle Point) (Con): 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.
Dr. Cable: 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.
Bob Spink: 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.
Dr. Cable: 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.
David Taylor (North-West Leicestershire) (Lab/Co-op): 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?
Dr. Cable:
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.
Jeremy Wright (Rugby and Kenilworth) (Con): 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.
Dr. Cable: 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;”
“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.”
“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.
Jeremy Wright:
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?
Dr. Cable: 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.
David Taylor: 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?
Dr. Cable: 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.
Susan Kramer (Richmond Park) (LD): 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.
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