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Dr. Cable: 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 providerthe South West London and St. Georges mental health NHS trustand 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 Ministers 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 lodgean admirable institution for the elderly mentally illshould 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 Ministers 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, Pauls 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 units 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 councils overview and scrutiny committee and from the carers and Members of Parliament.
Susan Kramer: 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.
Dr. Cable: 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 councils 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 Ministers 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.
Norman Lamb (North Norfolk) (LD): 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?
Dr. Cable: 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.
The Parliamentary Under-Secretary of State for Health (Mr. Ivan Lewis): 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.
Dr. Cable: I could not understand why it was possible to have a major consultationa valid, meaningful oneon 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 Ministers 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.
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 Alzheimers 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.
David Taylor: 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 Ministers 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 servicesthe infrastructure for supportfor 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 Librarys 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 timesa worthy ambitionthere 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 peoples 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.
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 differencewhen someone with a mental health problem is in an acute hospitalthere 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 acceptas I know he always doesthe 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.
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