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Mr. Paul Burstow (Sutton and Cheam) (LD): I am grateful for the opportunity to initiate this debate regarding the future of personality disorder services provided by the Henderson hospital in my constituency. Last week, I brought a delegation made up of clinicians and my hon. Friend the Member for Carshalton and Wallington (Tom Brake) to see the Minister about the decision to close the Henderson in March. I hope that my hon. Friend will be able to catch your eye during the debate, Mr. Cummings.
My message today is simple: unless the Minister acts, the NHS is in danger of sleepwalking into the closure of this nationally and internationally renowned service. The diagnosis of personality disorder covers conditions and disorders that arise from severe emotional distress and inner chaos, most often as a result of trauma, childhood abuse or neglect, to the extent that such people are unable to manage life. As a result, they may suffer from depression, psychosis, have suicidal urges, harm themselves and others, have eating disorders, misuse drugs or alcohol, or be involved in crime.
The Henderson is a unique service because it is a self-governing community. The residents take responsibility for running the service, from cooking, cleaning, ordering food and gardening to selecting new residents, running meetings, supporting peers through crises and liaising with staff. Residents are not prescribed psychiatric medication, as the aim is to work through the underlying issues causing their problems. The Henderson is a 24/7 community in which the range of activities includes intensive group psychotherapy, sociotherapy, psychodrama and art therapy. It is completely unlike any traditional psychiatric hospital.
Prospective residents are offered support to prepare them for admission from an outreach team, which also offers post-discharge support. The Henderson allows its residents to work through complex and extremely painful issues such as childhood sexual abuse, which would be dangerous to explore in a non-residential setting when there is a risk of self-harm, violence or dissociation after discussing such difficult matters.
The Henderson is 60 years old. It has a long history of research and expertise in treating personality disorder in this country. The hospital is a unique national training resource, offering clinical placements, workshops and conferences for a wide range of staff working in both the health service and the criminal justice system.
In 1997, the Hendersons funding was secured by the national specialist commissioning advisory group in recognition of the fact that the then internal market had caused a dramatic fall in referrals. At the same time, convinced by the research evidence, NSCAG asked the Henderson to establish two other services in the north of England. Sadly, with the prospect of devolution of funding to primary care trusts, one of those services, Webb house in Crewe, has closed because of commissioning problems and the other, Main house in Birmingham, is also under threat. As last weeks deputation to the Minister explained, the Henderson is not a local service; it is a national service receiving referrals from places ranging from Lands End to Northern Ireland to John oGroats. I have already sent the Minister in a letter some figures that confirm that.
Last year, funding was devolved from NSCAG to PCTs. Unfortunately, in the devolving of those funds, the money from NSCAG was divided up between PCTs on the basis of population, rather than usage. Before the change in funding, the Henderson had a six-month waiting list. The transfer of funds to PCTs saw a fall in funded referrals from an average annual referral rate of 220 cases before the devolution of budgets to PCTs to just 33 since April 2007 to date. Such a dramatic fall can be accounted for, just as it was the last time round, only by the change in commissioning arrangements. Psychiatrists surveyed by the Henderson report that the uncertainty about the Hendersons future, the bureaucracy involved in applying for funding and the lack of PCT funding are preventing them from referring suitable patients. Clearly, the funding system, not clinical need, is driving the Henderson to the edge of extinction.
Lynne Jones (Birmingham, Selly Oak) (Lab): I am glad that the hon. Gentleman mentioned Main house. It is not in my constituency, but I have visited it, and it provides valuable services. It would be a tragedy if both the Henderson and Main house were lost, and I look forward to hearing the Ministers reply to the important points that the hon. Gentleman is making.
Mr. Burstow: I am grateful for that and for the hon. Ladys support. The debate is interesting because, although it is for only half an hour, my hon. Friend the Member for Carshalton and Wallington, and the hon. Members for Birmingham, Selly Oak (Lynne Jones) and for Wimbledon (Stephen Hammond) are here. Many hon. Members are interested in securing the future of specialist services, not only at the Henderson, but those provided on the same model in other parts of the country, including Birmingham.
The Carter review recommended that the way in which to deal with the problem of commissioning highly specialist services effectively was that primary care trusts should share risk to support the provision of equitable access to highly specialised services. However, frankly, the review recognised that PCTs are ill-equipped to commission such services. As I understand it, the Government took the Carter review on board when they published Health reform in England in 2006, and provided for special arrangements to be made to safeguard services such as the personality disorder therapeutic community at the Henderson. Why has that approach not been followed? The Minister will surely agree that it is incongruous that there is great need for a service but, because the funding is lacking, the service is closed because of a lack of use. That clearly does not make sense.
Closing the Henderson is not consistent with Government policy. In 2003, the National Institute for Mental Health in England published its policy implementation guidance for the development of services for people with personality disorder. The document states:
Patients with severe personality disorder can benefit from intensive residential treatment, and there are currently five specialist residential units which are run as therapeutic communities, and take referrals from across the country.
It goes on to name services that are based on the Henderson model: Main house, Webb house, the Cassel, and Francis Dixon lodge. Since the report was
written, PCT disinvestment has changed the picture dramatically: Webb house has closed; Francis Dixon lodge now takes day patients only; the Henderson is scheduled to close in March; and the Cassel and Main house are under threat.
Stephen Hammond (Wimbledon) (Con): I represent a constituency next door to the hon. Gentleman. This is an important debate and I am pleased to say that he has made his point not only for his constituency in south-west London, but for the situation nationally.
A constituent of mine, the consultant psychiatrist John Stevens, wrote to me today to make the point that one of the other failures of Government policy is that, as a direct consequence of the closure of the Henderson, people with disorders that are treated at the Henderson could find themselves in prison. The prison population is likely to increase as a direct consequence of the closure.
Mr. Burstow: The hon. Gentleman is right. That point was made during the deputation last week, and I shall underscore it later with some of the research evidence that underpins the model used at the Henderson and the other facilities that I mentioned.
Given the policy context provided by the national institute, how does the Minister justify a situation whereby five residential services for complex personality disorder from around the country are gradually being lost because of piecemeal decisions made by individual PCTs? Does he accept the national institutes view that therapeutic community models, such as the Henderson and Main house, are an essential part of the services for the treatment of severe personality disorder? Will he concede that to close the Henderson would be to exclude the most complex cases of personality disorder from the most appropriate treatment and that that would be against the guidance of the national institute and, therefore, contrary to Government policy?
The Minister rightly asked about the evidence base when we met last week. There is a strong evidence base for the approach I described. In 1995, the Henderson carried out a peer reviewed study that compared patients treated for a minimum of three months with patients who were refused funding for their treatment. The two groups did not differ in their demographic or clinical features on referral. In total, fewer than one in five of the treated sample were either convicted or re-admitted to hospital after one year of discharge, compared with more than half of the non-funded group. In short, those who participate in the Henderson therapeutic community are less dependent on psychiatric services and less likely to enter the criminal justice system after leaving treatment.
Research also shows that, in the year before admission to Henderson, a cohort of 24 patients used a total of £335,196 worth of psychiatric and prison services. In the first post-discharge year, no patients spent time in prison or a secure psychiatric unit. The total cost of the latter services was only £31,390, which represents a huge saving to the public purse and a huge benefit to the individuals who received the service.
What is the way forward? I believe that the Minister will tell us that the answer lies with the merger of the
Henderson with the Cassel. I do not believe that that is the way forward. That option is all about short-term fixes to get two hard-pressed mental health trusts out of a financial jam. Merger would not meet the need: some people with personality disorder who go to the Henderson could never be referred to a new service at the Cassel because of the latters families unit. Merger would provide cover for the closure of the Henderson, a cut in residential places and the loss of critical expertise. In the end, the service that would emerge from a merger process would be smaller and even more vulnerable to the vagaries of local commissioning.
Frankly, it is unfair to leave South West London and St. Georges mental health trust to sort out a national issue. A halt is required to give opportunity and space for the proper consideration of the alternative options. That is about having either national or regional specialist commissioning of a network of therapeutic communities. I hope that the Minister will give serious consideration to that proposal because his Department alone could bring all the agencies, local commissioners, the host organisations that provide the services and the national specialist commissioning group around the table. If that does not happen, we would have to ask what will happen to the people who do not go to the Henderson in future.
The loss of the service would leave some of the most marginalised and stigmatised people in our society at risk. Instead of being treated, those people are likely to become the victims of revolving door admissions to inappropriate acute mental health services. They are likely to be medicated but not treated, and, worse still, they could wind up in prison or even committing suicide. They deserve betterI hope we can achieve that.
Tom Brake (Carshalton and Wallington) (LD): I congratulate my hon. Friend the Member for Sutton and Cheam (Mr. Burstow) on securing the debate. I shall make no apologies if I go over the same ground that he covered or that was covered in the meeting that the Minister kindly arranged last week.
As hon. Members heard, the Henderson is a last resort for many of its patients. Many of those will have exhausted mainstream treatment and care including psychiatric medication and imprisonment and sectioning under mental health legislation. I should like to tell Members two personal stories that give insight to the Hendersons healing role.
Fifty-three-year-old Veritee was a resident at the Henderson in 1975. She describes herself at the time as desperate, chaotic and homeless. She had multiple problems, including drug use. Various in-patient psychiatric treatments were tried unsuccessfully. She was told that nothing could help her, until she was referred to the Henderson. She described it as a total success and has since gone on to work with young people and to found a charity for post-natal illness.
Emma experienced self-harm, suicidal thoughts and an eating disorder. She was not helped by cognitive
behavioural therapy, transactional analysis or anti-depressants. She turned her life around at the Henderson hospital. Ten years on, she is a senior academic who has a family of her own.
I am fortunate to have a trusted, experienced member of staff who was helped by her stay at the Hendersonindeed, she prepared my speech. The treatment that Veritee, Emma, and my member of staff received at the Henderson was not out of line with Government policy; on the contrary, it was very much in line with what was set out in Who Pays? Establishing the Responsible Commissioner, which recommends residential psycho-therapeutic services for severe cases.
The responsibility for funding such services is clear: it should be commissioned by specialist, national services. We should not lose the service simply because of a lack of specialist commissioning. Are commissioners in a position to ignore Government policy on specialist national services for personality disorder, and as a result to exclude the patients who can benefit from such expert input? It seems that the South West London and St. Georges trust was wrongly advised not to apply for national commissioning, but its position has changed. The Henderson is now putting together an application with the Cassel and Main house to provide a national network of services. A less satisfactory option, to which my hon. Friend referred, would be a merger, but there are significant issues on whether the commissioners would support such a service and because of the number of beds that would be available. Clearly, the preferred option is specialist commissioning for the full network of residential communities.
gives you control over your own therapy youre not just strapped to a bed and given drugs.
Residents value the feedback from their peers, who have had similar experiences to them. They also value the 24/7 nature of the Henderson, as residents support each other to deal with their feelings after difficult therapy groups without resorting to destructive behaviour and they are helped to manage their symptoms in their daily lives outside of groups.
I will conclude by asking the Minister whether, in the light of the facts presented here by my hon. Friend, myself and other Members through their interventions and also through the reports of the personal experiences of those who have benefited from the Henderson, he will support the application for the network of residential services from the Henderson, Main house and the Cassel for funding from the specialist commissioning groups?
The Parliamentary Under-Secretary of State for Health (Mr. Ivan Lewis):
First, I congratulate the hon. Members for Sutton and Cheam (Mr. Burstow) and for Carshalton and Wallington (Tom Brake) on securing this important adjournment debate. I also congratulate the hon. Member for Wimbledon (Stephen Hammond) and my hon. Friend the Member for Birmingham, Selly Oak (Lynne Jones) on attending the debate. They wanted to make the case for the importance of
specialist services for people with personality disorders, although I do not think that the importance of those services is the subject of this debate, which is about the nature of those services going forward.
I acknowledge the specialist expertise, the commitment, professionalism and indeed the ethos of the Henderson hospital; the passion and support for its service is because people genuinely and strongly believe that it makes a tremendous difference to peoples lives. There are many individual examples of people who feel that, as a consequence of the treatment they received at Henderson, their life chances are very different from what they might have been. There is thus no dispute about the specialist nature of Henderson; nor about the fact that it enjoys widespread support and that, for many people over a number of years, it has provided an incredibly important experience and, in some ways, a very different therapeutic experience from other mental health services, which one could describe as more mainstream, more conventional or more traditional.
However, in the context of a debate such as this one, we must acknowledge that there have been changes in mental health care, just as when one looks at various physical conditions such as cancer or heart disease one can see that, thankfully, we do not provide the same care as we did 60 years ago. There has been massive and rapid reform and change in the way that we treat a variety of conditions. Indeed, however much we still have to do, mental health services in the UK are much better than they were 10, 15, 20 or 30 years ago, although they are nowhere near as good as they need to be. As the relatively new Minister with responsibility for mental health, I am passionately determined that we improve our mental health services, in terms of the continuum of interventions and care in every community.
It is true that the nature of support for people with personality disorders is changing and an increasing number of people are receiving intensive support within their own homes. However, in the context of changing care and a different way of doing things, there will always be a need for high-quality tier 4 services, and there can be no dispute about that.
The responsibility of commissioners is reasonably straightforward. It is to secure two things: quality outcomes for patients and value for money. The two go hand in hand, and any political party, particularly in opposition, which focuses on only one of those things is entirely dishonest. If such a party ever held responsibility for any service or any organisation, as Opposition parties do in many local authorities, part of the decisions it would have to make would involve achieving value for money as well as giving the local population what they clearly need and want.
The other issue on which I agree with hon. Members is that we are talking about a specialist service. It cannot be commissioned on a PCT-by-PCT basis. In my view, it must be commissioned through regional networks. I think that is a really important statement.
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