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10.6 p.m.
Baroness Ramsay of Cartvale: My Lords, I believe that some considerable time has elapsed since your Lordships have debated the issue of mental health. I very much welcome the debate this evening and the valuable contributions that have been made. We have benefited from an impressive breadth of experience and expertise from all sides of the House, and we are all grateful for that. In declarations of interest and experience by noble Lords throughout the House we have heard the names of organisations with proud
records in the field of mental health: SANE, MIND and the Sainsbury Centre for Mental Health. At the same time, noble Lords have an impressive record of present and past health service management experience. Last but not least, we have heard from a noble Lord who is a practising consultant psychiatrist. In this debate there has been an impressive degree of caring, experience and knowledge.I agree with the noble Lord, Lord Rowallan, that mental health is not a political issue. The Government accord mental health a very high priority. We have identified mental health as one of the six medium-term priorities for the NHS in 1998-99. We agree with the desire expressed by the noble Lord, Lord Rowallan, and other noble Lords who have spoken tonight, to develop strong mental health services which are responsive to different levels of need and in particular the varying needs of different groups of service users and their carers.
While I agree that this is not a political issue, I cannot completely disregard the legacy that the Government have inherited of inadequate action on mental health services over the past 18 years. Some progress has been made in developing local services. Many dedicated people have worked very hard to make the policies work. But, as my right honourable friend the Secretary of State for Health said recently, for many the move from institutional care to care in the community has failed to deliver the necessary levels of support. The noble Lord, Lord Alderdice, spoke of that in his very impressive contribution.
We are determined through our policies to build public confidence and trust in the mental health services. Although I agree with the noble Lord, Lord Rowallan, that improvements to the infrastructure are necessary, I am afraid that I cannot agree that the proposals set out in the Bill are the right way forward. It is not just a question of resources, although I am sorry to spoil the dramatic imagery of the noble Lord, Lord Swinfen, of Treasury hands around my throat. It is true, as the noble Lord, Lord Alderdice said, that we have accepted the overall spending limits, but the spending will be to our priorities.
The intention in Clause 1 of this Bill is to extend the provisions of the Mental Health Act 1983 to establish an entitlement to separate and therapeutic environments for patients who need care and treatment. To go down this road would, in our view, severely restrict the capacity of health authorities to plan services flexibly while taking account of national priorities.
Any statutory provision for a right of access to such services would cut across fundamental principles of the National Health Service Act 1977 which place a duty on the Secretary of State to continue to promote a comprehensive service and to provide services as he considers necessary to meet all reasonable requirements. Current gaps in mental health services result to a large part from chronic under-investment in the past 18 years. But as the noble Lord, Lord Rowallan, is well aware, new resources to redress the situation are not available as if one could turn on a tap. In this context it is vital
that health authorities retain the flexibility to commission and develop services, within government priorities, according to local need.Health authorities are, in any case, already required to have a strategy for the provision of an appropriate range of facilities for the care and treatment of people with a mental illness; for example, in-patient facilities, 24-hour nursed beds and crisis care, form part of this range of provision.
We agree that it is important to ensure an individualised programme of care for each person who requires admission. Those principles are embodied in the care programme approach, introduced by the previous government to ensure continuity of care, and which we are keen to see remains in place as the cornerstone of policy.
We do not believe, however, that physically separate in-patient facilities for different conditions are the way forward.
The reservations in that connection expressed by my noble friends Lady Young and Lord Sainsbury, and other noble Lords, are well-founded. First, the benefits for patients of a supportive and therapeutic milieu are well documented. The low prevalence and incidence of certain conditions could result in some patients being kept in almost total isolation and that would not be to their benefit.
Secondly, there is sufficient common ground between different conditions to mean that it is of positive benefit, and not merely an expedient, to continue to provide for their needs for a generally supportive and therapeutic environment in one place.
Thirdly, operationally and in terms of the diagnostic framework, it is not clear where we would stop creating separate environments. The principles outlined in the care programme approach reinforce the fact that what matters is what care is provided rather than where. Asylum can be provided effectively in the community. Points in connection with that aspect were excellently made by my noble friend Lord Sainsbury. I agree with his point that in-patient care does not take place in a vacuum.
The noble Lord's Bill would also place health authorities under a duty to monitor progress in implementation of the suggested strategy and place an obligation on health authorities to provide the Secretary of State with an annual report on progress. Monitoring progress on the implementation of comprehensive mental health services already forms a part of the NHS Executive's performance management framework. A review of mental health services was carried out this year and similar exercises were undertaken in the previous two years. There is no reason why Ministers should not continue to request an annual review to be undertaken and for the findings to be reported to them. There is nothing to be gained from enshrining these requirements in primary legislation.
I turn to Clause 2. I wish to reassure the noble Lord, Lord Rowallan, and other noble Lords, who have expressed concern about single-sex wards. I acknowledge in particular the concerns raised by my
noble friend Lord Acton, the noble Lord, Lord Rowallan, the noble Earl, Lord Howe, the noble Lord, Lord Swinfen, and others. We abhor, as does everyone, attacks upon vulnerable women within in-patient units and we want to create a framework which minimises such risks and ensures the privacy and dignity of individuals. I repeat what has been said at this Dispatch Box on many occasions; that we are totally committed to working towards the elimination of mixed sex accommodation. I am grateful to the noble Earl, Lord Howe, for accepting that our commitment on that point is real and sincere.It might further reassure your Lordships to know that health authorities have been required to set local performance targets for trusts within their boundary in order to deliver the following objectives. First, to ensure that appropriate organisational arrangements are in place to secure good standards of privacy and dignity for hospital patients. Secondly, to achieve fully the Patient's Charter standard for segregated washing and toilet facilities across the NHS. Thirdly, to provide safe facilities for patients in hospital who are mentally ill which safeguard their privacy and their dignity.
The noble Lord, Lord Rowallan, confirmed that he discussed the matter with my honourable friend Paul Boateng. Therefore, he knows that many health authorities have already achieved or made considerable progress towards these objectives. However, a substantial number of health authorities have told the NHS Executive that they will not be able to deliver these objectives until after April 1999. That is not acceptable. The NHS Executive is reviewing with health authorities any target which has been set for after April 1999 and is considering what scope there is to bring that forward. A cental monitoring system is being developed which will provide further, regular information on authorities' performance against those objectives. It has been piloted and will be issued as soon as possible.
I turn now to the noble Lord's suggested amendments in relation to the security and design of psychiatric units. Guidance prepared in 1996 by the NHS Executive Estates Agency already contains advice on both issues.
The guidance makes clear that, where possible, patients should be able to lock their bedroom door for safety and security and to safeguard their property when they are not in their room. But also it recognises that staff need to be able to open the door rapidly in the event of an emergency. The guidance also explains that it is desirable to have en suite toilet facilities whenever possible to avoid situations where female patients have to move about the ward in night attire.
Wards should be capable of flexible use and sub-division to separate sexes, where appropriate, to safeguard the needs of in-patients. But staff observation of the patients is a fundamental requirement for safety both of the patients and staff.
Staff are expected to supervise ward entrances to prevent access by people who have no valid reason for attendance. At night closed-circuit television surveillance of the entrance at a staffed base should maintain the necessary level of security. Security may
be achieved by temporarily locking doors but care must be taken to ensure that such arrangements do not contravene safety measures, including fire regulations.The guidance also explains that staff at the reception desk need to be able to see clearly through the entrance area in order to greet people arriving and also as a security measure. They should be able to raise an alarm in case of danger from violent behaviour or other emergency situation. We require project directors to ensure that design teams are familiar with the standards issued by the NHS Estates Agency as the basis for any new health buildings.
The noble Lord, Lord Rowallan, raised the problem of the mentally ill who are homeless. The noble Lord will wish to know that through the Department of Health's homeless mentally ill initiative--and I should say that that initiative was announced in July 1990 in response to concerns about the visible concentration of homeless and mentally ill people on the streets of central London--the Government are making available £4.2 million to local authorities in areas where rough sleeping causes a significant problem to assist with the care costs of homeless people with mental health problems. The initiative has recently been independently evaluated to determine its effectiveness. My honourable friend Paul Boateng is currently considering the report of that review.
In that connection, the work of the Social Exclusion Unit is also relevant. That has been established by the Prime Minister to help co-ordinate action across government policies; to move towards preventing social exclusion; and to find more integrated ways of tackling the worst problems. The unit's early priorities include considering ways to reduce further the extent of rough sleeping. The role of the Department of Health's homeless and mentally ill initiative will be encompassed within that programme.
I hope that your Lordships will begin to understand why we are not convinced of the need to legislate along the line of the noble Lord's Bill. Our views are shared by others, as has been mentioned by other noble Lords who have spoken this evening. MIND has said that it does not support Clause 1. The Mental Health Aftercare Association, while expressing its support for improvements regarding single-sex accommodation and security devices, does not believe that primary legislation is necessary, and similar views have been expressed this evening by my noble friends Lord Hunt and Lady Young.
Generally we do not favour piecemeal changes to a complex piece of legislation such as the Mental Health Act. Significant changes to the legislative framework should, in our view, be taken as part of a full review of the Mental Health Act. I can confirm that we will be considering the need for a review of the Act and will take into account the views of all interested parties.
As I have already said, mental health is and remains very high on our agenda. My honourable friend, Paul Boateng, has established an independent reference group to advise him on mental health issues. This group of experts in the mental health field includes service users and carers. Ministers will be looking to them
particularly for help in identifying what needs to be done to strengthen existing arrangements to ensure that we have a range of mental health services throughout the country. We have asked the group, as its first priority, to consider the issue of the closure of the remaining long-stay mental hospitals. We are anxious to ensure that no more closures should go ahead without proper consideration of the needs of all the patients involved and that, as a result, there are proper plans to put in place the full range of services that are needed.The noble Earl, Lord Howe, raised the question of the state of mental health services in London. The review of London's mental health services, which was published last week, showed that London's mental health services face greater problems than many parts of the country. In real terms, London health authorities have received increases in their 1997-98 allocations and will also receive real-term increases for 1998-99.
The Mental Health Challenge Fund has been used in the past to target some of the problems in London. London boroughs also receive core funding from the mental illness specific grant. Moreover, 85 authorities receive target fund support, including 23 London boroughs. The mental health task force also visited 12 London health authorities. An interim review in the autumn of 1996 showed that, despite some progress, barriers remained. A further review is currently under way and its outcome will be included in a national report to be submitted to Ministers in early 1998.
As the White Paper, The New NHS, sets out, we will be introducing new National Health Service frameworks to promote consistent access to high quality care across the country. In future patients with continuing health and social care needs will get access to more integrated services as a result of joint investment plans, which all health authorities are being asked to produce with partner agencies. We will also be exploring the scope for even closer working between health and social services through, for example, a pooling of budgets. I felt that my noble friend Lord Hunt spoke most convincingly on that point.
At this point I must say to the noble Lord, Lord Mottistone, that, even if our faces are new to him, his reputation and interest in this subject are not unknown or new to all of us. So he should rest assured in that respect. I am sure that the noble Lord will welcome the action that we are taking to stimulate public and patient involvement in the NHS. We have set out our vision in the White Paper, which proposes a stronger role for health authorities in communicating with the public and ensuring that the public has a greater say in decision-making about local health services. We envisage a greater emphasis on openness through the publication of more local information about strategic plans and on how local services are performing. A new national survey of patient and user experience will ensure that patients' views and concerns are listened to and acted upon.
The noble Lords, Lord Rowallan and Lord Hunt of Kings Heath, both addressed issues concerning shortfalls in the workforce. The White Paper emphasises that we attach the utmost importance to ensuring that
mental health services are staffed adequately. In April 1996 new arrangements for non-medical workforce planning and commissioning were introduced. The Department of Health has emphasised the importance of staffing issues in planning guidance. We are concerned about the vacancies in psychiatry. We have been addressing this in collaboration with the Royal College of Psychiatrists. Psychiatry has a high priority for targeting available funding to create posts for training future consultants. Some £5.7 million was provided to implement the 1996-97 increases and a further £4.5 million for 1997-98.There are already good examples of partnership working, including working with service users. I know that the noble Lord, Lord Rowallan, visited mental health facilities at Homerton Hospital in Hackney recently, as indeed has my honourable friend Paul Boateng. I think the noble Lord, Lord Rowallan, would agree that City and Hackney Health Authority has a positive approach to working in partnership with the local authority to develop mental health and social care services which address the broad range of needs of their communities.
There are also examples of innovative multi-disciplinary co-operation, for example the Vista Road Centre in Warrington, which provides a holistic approach to mental health, from listening and advice to medication and psychological therapy. The north Birmingham model provides a range of services--for example 24 hour cover for psychiatric and emergency treatment and outreach for people with severe mental illness--and it also involves several multi-disciplinary teams covering the whole of the local population.
The noble Lord, Lord Sainsbury, has made a valuable contribution, as one might expect from someone who has such a keen interest in this important subject. He was absolutely right to stress the need for the full range of services. This is at the heart of the work now being undertaken by the independent reference group on which the Sainsbury Centre is, I am glad to say, represented.
As regards reviewing the legislation, I have already said that we are considering the need for a review of the Mental Health Act. My noble friends Lord Sainsbury and Lady Young of Old Scone also spoke about assertive outreach. Assertive outreach teams currently exist in small numbers within mental health services. One such service is provided in north Birmingham and, as the noble Lord, Lord Sainsbury, will be aware, is funded from a combination of moneys from the Sainsbury Centre for Mental Health and the Department of Health. Assertive outreach may form one part of the range of provision including 24 hour staff, beds, psychiatric in-patient facilities and other elements of provision in primary and secondary care.
My noble friend Lord Hunt of Kings Heath questioned the virtues of mental health inquiries into serious incidents as they are implemented currently. I think he said that he would like us to consider an ombudsman to determine whether an inquiry was necessary. I acknowledge my noble friend's concerns
about the effect of mental health inquiries. We shall certainly take into account his views as we develop our thinking around this issue.The crucial point here is that we learn lessons when things have gone seriously wrong. Locally commissioned independent inquiries play a crucial role, but we need to develop a better understanding of the overall picture, and that is why we have the national confidential inquiry into suicide and homicide by people with mental illness to look into the factors leading up to serious incidents of this nature. We have asked the inquiry to make recommendations on measures which it believes should be taken to reduce the number of deaths.
But having good specialist mental health services alone is not enough to tackle mental health problems and inequalities in our society. The Green Paper, Our Healthier Nation, published last week is a major step in the Government's push to reduce inequalities in health. It forms the basis on which we can develop a health strategy.
The Government have identified mental health as one of the four priority areas for the strategy. The Green Paper proposes that we should aim to reduce deaths from suicide by a sixth by the year 2010. This will be a challenging target. To achieve it we shall have to consider not only how to improve services for people with severe mental illness but also other factors associated with poor mental health such as unemployment and stress in the workplace. Our Healthier Nation is being widely circulated as part of the consultation process to ensure that everyone can have an opportunity to influence the detail of the strategy, including those involved in the mental health field.
I hope that your Lordships' House has been reassured by the initiatives I have outlined this evening. They show that the Government are genuinely committed to improving mental health services in a flexible and responsive way. I should like to pay tribute to the valuable contributions which noble Lords have made tonight. If I have omitted to deal with specific points raised, I shall of course write to noble Lords.
We have had a useful, serious and well informed discussion on a topic of great importance to our society. I thank the noble Lord, Lord Rowallan, for providing us with the valuable opportunity to have this discussion. The noble Earl, Lord Howe, asked whether I would be prepared to meet the noble Lord, Lord Rowallan. I have done so already before this Second Reading debate. I shall always be happy to meet him to discuss any aspect of this matter. Therefore I am at his service for that.
We shall take the points raised tonight into account as we determine the future direction of mental health policy. However, I hope that your Lordships understand why this Bill is not, in our view, the way to advance.
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