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8.51 p.m.

Lord Hunt of Kings Heath: My Lords, I should like to begin by declaring an interest as a policy adviser to the Sainsbury Centre for Mental Health. I also thank the noble Lord, Lord Rowallan, for this opportunity to have a serious debate on mental health services in this country. This is a timely debate, although I regret that I have reservations about certain aspects of the Bill.

I have no objection to the provisions relating to single sex wards. I recognise that there have been considerable problems in this area in a number of psychiatric hospitals and that they have created considerable pressure and strain on both patients and staff. I am doubtful, however, whether legislation is the answer. The noble Lord believed that the Minister required the extra clout to put this into practice. The reality is that ministerial priority backed up by ministerial action is sufficient. But one should not underestimate the practical issues involved in moving very speedily to a solution in this area.

I have considerable concern about Clause 1 of the Bill. I recognise that there are problems in some areas in relation to the sufficiency of in-patient facilities. It is important that appropriate access is available to those who require it. But it is wrong to focus narrowly on the issue of beds in mental health hospitals. The danger is that by focusing solely on the issue of beds we will send the policy on care in the community into certain retreat. It is vital that on this issue we debate the whole context in which mental health services should be provided in this country. Mental health services are a very important part of the NHS. One-eighth of all NHS expenditure is spent on mental health. It has been estimated that mental health problems underlie up to one-third of GP consultations.

Despite the rather gloomy assessment made by the noble Lord, I believe that in the past two to three decades great strides have been made in the way that the health service has handled mental health issues. When I began my career in the health service 25 years ago I visited a considerable number of mental health hospitals. The conditions in those hospitals were pretty deplorable. They were overcrowded, had few staff, provided institutionalised care and lacked support. As we well know, the result was a series of inquiries in those hospitals in which staff had been abused in one way or another.

In the past 20 years we have seen a huge improvement. As we have developed community care thousands and thousands of people have had better support and care and have been able to live their lives in the community. Problems have arisen from the early discharge of patients without proper support. There have also been resource problems. We have been unable to provide investment to maintain some of the old hospitals

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while we have developed new services in the community. There have also been problems related to inter-agency working as between health and local authorities. Despite those problems we should not forget the dramatic improvements that have taken place in our mental health services.

Nothing that has happened in the past few years can justify the hysteria that has been created in relation to a number of homicide cases in which the mental health services have become everyone's whipping boy. Instead of looking just at bed numbers we must look at the much broader picture. I suggest that our approach to mental health services should be governed by three broad principles. First, we need to base it upon a recognition that people who experience mental illness are citizens who retain equality of access according to need to health services, social services, housing and other services. The second principle is that those who experience mental illness should have the opportunity, where possible, to manage their own lives and make their own distinctive contribution to society. The third principle is that good outcomes will flow from the integration of people who experience mental illness within society generally wherever possible.

I believe that the key elements in trying to ensure that those principles are put into practice effectively are the following. First, it is absolutely essential that we have integrated service plans which are agreed jointly by health and local authorities. Secondly, those should be underpinned by the pooling of budgets between those agencies. I very much welcome the Government's approach in this area. Thirdly, at operational level we need to go beyond simply talking about joint working. Health and social care staff must begin to work together and be integrated within the same teams. Fourthly, with the emergence of the new primary care groups under the Government's NHS White Paper we must ensure that they work very closely with community mental health teams so that there is a completely co-ordinated approach to primary and community care.

Further, we must tackle some very difficult staff issues. I do not believe that any of us can pretend that the morale of all staff working in the field of mental health is always at a high level. We must invest more money in the training and development of staff. We require a package of measures to support staff recruitment and retention. We must also concentrate on leadership in our mental health services. I am concerned that the people who manage those services can be isolated from the mainstream managerial cadre in the health service. I should like to see concerted action taken to implement programmes to develop and support that leadership.

The noble Lord referred to the public perceptions of the risks involved in community care. Certainly, they appear to have become negative and distorted in the past few years. I believe that that poses major problems for the morale of people involved in mental health services and those who have to develop and plan services for the future. I question the impact of compulsory inquiries into homicide incidents. I believe that often they have attracted maximum publicity with little new being learnt

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from them. They have undermined public confidence and placed an enormous amount of pressure on the people involved.

All of us recognise that public interest demands a mechanism to carry out reviews of all serious incidents. I wonder whether there can be developed a constructive alternative to public inquiry after public inquiry. I favour the suggestion that we might appoint an ombudsman who, on the basis of the available information, might advise as to whether a public inquiry were warranted in every case. Tackling public perception may be the greatest challenge that we face. It is an enormous task, but it is one to which we must devote attention.

Next, I shall reflect on the impact of the Government's White Paper on the NHS. The overall theme of the integration of services is consistent with what we need to achieve in the mental health field. There are a number of key issues which we must face. The first is our capacity to manage change. That is a large agenda. It is not for just a year or two, it is for a decade. We must look carefully at the support that needs to be given to the people who will have to lead that change in the mental health field.

Secondly, we must be careful about the potential marginalisation of stand-alone mental health NHS trusts. I well recognise why the Government have decided that that should take place. We need to have available a package of measures to ensure that those people working in those stand-alone trusts do not become isolated from the rest of the health service or social care.

We must look carefully at the commissioning skills available in health authorities and primary care groups. I have been worried about the scarcity of talented people available to health authorities to help commission mental health services. As primary care groups take on that role, there is a similar problem in trying to ensure that at that local level they have people who understand mental health services, and who can commission effectively.

We shall have to devise new ways so that scarce skills can be shared between primary care groups and between health authorities. Finally, in relation to the White Paper and its impact on mental health services, it is important that, as between trusts, health authorities and primary care groups it is clear who is accountable. We cannot afford for people to slip through the net. It must be clear as to which agency is accountable for which client of the health service at the end of the day. The White Paper offers overall a strong, positive way forward in relation to the NHS generally and specifically to our mental health services. It offers a much more positive way forward than the narrow concern about the number of beds available within mental health hospitals.

9.03 p.m.

Earl Howe: My Lords, one of the themes running through last week's memorable debate in your Lordships' House on the golden jubilee of the NHS was the progress which has been made over the past 50 years in making the NHS more responsive to patients' needs. That continuing aim, which the previous government

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endorsed, perhaps most tangibly in the Patient's Charter, and which the present Government have also recognised expressly in their White Paper on the future of the NHS, is not merely ethically right, it is also, almost self-evidently, a part of that necessary process which ensures that resources are utilised efficiently.

Responsiveness to patient need is a principle which runs right through the health service. It is a theme which resonates with particular clarity in the area of patient care to which my noble friend has so graphically drawn our attention--that of mental health.

Improving mental health is one of the four key targets in the Government's recent public health Green Paper, Our Healthier Nation. The prevalence of mental illness and its profound consequences on so many aspects of our national life are starkly delineated in that document. I shall quote a brief section from page 76:

    "mental health problems are a major cause of ill health: the 1995 Health Survey for England showed that 20 per cent. of women and 14 per cent. of men may have had a mental illness; mental disorders accounted for an estimated 17 per cent. (more than £5 billion) of total expenditure on health and social services in 1992/93 (the largest single cause); they also accounted for 15 per cent. and 26 per cent. of days of certified incapacity in the early 1990s in men and women respectively".

Those statistics, shocking as they are, reflect a multitude of different conditions and disabilities whose causes are varied and complex. Ever since the Mental Health Act 1959, which did so much to destigmatise mental illness, it has been the policy of successive governments to shift the emphasis of caring for mentally ill patients from the institutions to the community. That process gained added momentum, of course, with the National Health Service and Community Care Act 1990.

However, in implementing that broad policy, which has attracted cross-party agreement, both this Government and the previous one have recognised the importance of in-patient care, and the need to ensure an adequate number of psychiatric beds in hospitals. A great deal of discussion has taken place recently on whether there is a need to create more such beds, both acute and long-stay, and whether, in particular, the apparent pressure on acute beds could be alleviated by better management of admissions and discharges. But those are not issues which need to concern us this evening. What matters in the consideration of this Bill, or more precisely Clause 1 of the Bill, is that there is a clinically acknowledged need for in-patient care which NHS trusts and health authorities have a duty to meet.

My noble friend set out the background to the Bill with skill and persuasiveness. I shall not go over the ground which he covered so ably. But if we accept that there is a clinical need for in-patient care and that provision of that care is not always--for whatever reason--readily available, then two conclusions must follow. The first is that the minds of health authorities should be focused on the task of ensuring that the needs of mentally ill patients are properly met; and the second is that the conditions in which such patients are looked after must meet basic standards of safety and privacy. Those standards are ones which we expect to find, and usually do find, in community psychiatric homes. They

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are also standards which are of fundamental importance for the care and rehabilitation of disturbed, and sometimes highly vulnerable, men and women.

Worryingly, a recent report by the Sainsbury Centre for Mental Health, looking specifically at London, highlighted major differences in standards between NHS hospital wards and community homes. It suggested that, compared to the consistently high standards to be found in community homes, hospital wards were often in a poor state of repair, with residents more likely to be isolated and less likely to enjoy any measure of privacy.

A report published in 1996 by the Royal College of Psychiatrists makes similar points about the standards of care in NHS psychiatric units, laying particular emphasis on the need to improve on standards of hygiene, safety and privacy. But it is perhaps the vulnerability of women patients that has given rise to the greatest concern. My noble friend has already rehearsed the sobering facts revealed by the recent report of the Mental Health Act Commission. It is perhaps impossible for anyone who has not experienced life on a mental ward to imagine the fear and trauma experienced by women who find themselves harassed, molested and sometimes horribly injured by fellow patients whose close proximity in the hospital ward has allowed all too easy a level of access to those unfortunate individuals.

The best efforts of nursing staff are bound to be insufficient in such circumstances. The commission report revealed that more than half the wards it examined had experienced incidents of sexual harassment, some serious. On that issue, a report last year by the King's Fund, London's Mental Health, described the number of assaults and cases of sexual harassment on in-patient wards as "unacceptably high". Over a period of a fortnight in January 1995, 131 assaults were committed by patients in London's psychiatric units, of which four resulted in major physical injuries. The survey was repeated a few months later and the findings were, if anything, even more alarming. The point here is that violence is not only to be condemned in itself, but, as my noble friend emphasised, its prevalence calls into question the ability of psychiatric units to provide a safe and therapeutic environment for patients.

The Government's acceptance of the principle of single-sex wards is on the record. No one doubts their commitment to making that a reality across the NHS over a period of time. The Minister may say that for some health authorities time is needed and that, in any case, legislation is unnecessary because appropriate guidance is already in place. No doubt there is a case for accepting such a response for the generality of NHS hospital patients. But there is a real difference between a general surgical ward and the ward of a psychiatric hospital.

In a psychiatric unit, the issue is not simply one of preserving the dignity of the patient; it is that without the kinds of measure specified in Clause 2 the patient's physical safety is in constant jeopardy. For that reason, and with respect to the noble Lord, Lord Hunt of Kings Heath, I believe that primary legislation is an entirely

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proper way for the issues to be addressed and that it is proper, too, for the necessary resources to be allocated to fulfil the legal requirements which ensue.

The aims of the Bill have attracted support from the major voluntary organisations representing mentally ill people; MIND, the National Schizophrenia Fellowship and SANE. Of those, only MIND has expressed reservations, and then only on the effectiveness of Clause 1 as drafted. I do not believe that this is an all-or-nothing Bill; nor is the wording of the Bill wording to which we necessarily need to feel wedded. Indeed, my noble friend indicated his readiness to look at amendments which might serve to improve the Bill. I hope that the Government will take note of that and respond constructively. In other words, I hope that they will look for ways to accept the key elements of this Bill, even if the precise approach adopted by my noble friend is not one which they can endorse entirely. At the very least, I would like to hear the Minister say tonight that she will go away and reflect on what she has heard and, if necessary, offer to meet my noble friend prior to the Committee stage.

I take serious note of the authoritative and thoughtful speech of the noble Lord, Lord Hunt of Kings Heath. However, the objective of the Bill is to ensure that the requirement on the Government to provide adequate standards of psychiatric care is strengthened by a specific duty to address some of the grave shortcomings which impact directly on the care and well-being of some of the most vulnerable members of our society. I cannot for one moment quarrel with that aim. The Bill deserves the support of your Lordships.

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