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Baroness Murphy: My Lords, I thank the noble Baroness, Lady Neuberger, for bringing these reports and this much-neglected topic to the attention of the House. It also gives me an opportunity to pay tribute to the work of the Sainsbury Centre for Mental Health. Our current national policy owes much to the
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vision, knowledge and persistent determination of that centre to demonstrate what really works. I have been proud to be a friend, supporter and occasional co-worker since the centre's inception 20 years ago.

I declare an interest as a fellow of the Royal College of Psychiatrists, and chair of the strategic health authority responsible for the performance of two large mental health trusts in east London. That area generates the highest morbidity in serious mental health problems in the UK.

Between 1987 and 1994, I visited more than 200 psychiatric in-patient units in England and Wales, in my role as vice chairman of the Mental Health Act Commission. That was almost all of them at the time, and I often visited several times. I sometimes got that "If it's Tuesday, this must be Claybury; if it's Wednesday this must be Rainhill" kind of feeling. My observation then was that the rot was already beginning to set in. New community mental health teams set up in the late 1970s and early 1980s had begun to take off in a big way. Mental health nurses, psychologists, OTs and psychiatrists—including myself—with any ambition or vision were leaving the wards in droves for the sort of work they felt they had trained for.

Following that period, the Mental Health Act Commission produced a devastating report about life on acute psychiatric wards in 1998 and, since then, the situation has worsened; although, in my opinion, the past few years have seen a slight improvement. I shall not repeat all the criticisms of acute wards so evident in the reports that the noble Baroness, Lady Neuberger, has so eloquently described. I am not going to dispute any of those findings; if anything, the situation in London is much worse than has been described. There are shockingly poor physical environments, patient boredom and little engagement between nursing staff and patients. We have heard it all before, and I am afraid it is all too obvious as you visit wards.

In London the admission of potentially violent and highly disturbed people adds a further complexity. In inner London, as we have heard, the dual diagnosis of psychosis and drug misuse is now the norm. No one in any state of mind would want to be on these wards. They are often unsafe and quite frightening. They are frightening to visit, never mind to work in.

As a psychiatrist, I am often asked by friends and colleagues with mentally ill relatives if I can recommend a decent place to be admitted. In London, I am profoundly ashamed to say, I can never think of anywhere.

The situation, in some ways, is that people are paying far more attention; but, in one way, one might expect pressures to get worse. It was thought that the new crisis resolution and assertive outreach teams would reduce admissions. They cannot do so at the moment because they are beginning to engage longer with people who used to get lost to the system—those at severe risk of being at the centre of an untoward incident. It will take some years before the economic
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and social benefits of the new ways of working will be seen. We will increase the admissions for a time as such people are picked up and maintained. We know, however, that patients already appreciate the difference in these services. That is reason enough to continue, but these will not for the moment reduce pressures on acute words.

What are we to do about it? I do not blame any government for the situation that we are in, and I do not blame those who work on the wards for the situation they find themselves in. In fact, their heroism in continuing to work on the wards is sometimes quite remarkable. A lot of people are aware of the problems and most mental health trusts have tried various initiatives, although perhaps without sufficient adventurousness to make real differences. I have four brief suggestions. One is easy, others are perhaps less so than they might seem at first. Perhaps I can ask the Minister to respond to the ideas.

The first is to create an integrated service in which community team and ward staff all rotate as one team and are managed under the same budget. That seriously encourages alternatives to acute ward care. The Norfolk and Waveney Mental Health Partnership NHS Trust has done much of this circulating of staff to ensure that people keep up to date and understand each other's work. Other units have tried joint management, but few stick with it. At present in-patient staff never get to know a patient or service user except in crisis and do not get to establish a relationship as the community team worker does. For the community team at the moment there are negative incentives to admit when an alternative residential care or day care place might be better. Budgets are institution bound and do not facilitate movement. Joint management prevents in-patient units being allowed to deteriorate physically while new community health teams get all the capital spend. You see all the time new teams being set up yet the physical environments being reduced.

My second suggestion is that staff—and I think this echoes what the noble Baroness, Lady Neuberger, said—need to feel pride in specific therapeutic skills which enable them to treat people, and wards must be properly managed. Training for ward leadership is cursory; qualified nurses can suddenly find themselves managing 50 staff and a budget of £1.5 million without any training whatever. What nurses should do with their patients is often a mystery. They have control and restraint training but no education and specific training for therapeutic skills or behavioural training, interpersonal support skills, family interventions and so on.

Then there are the other ward staff, who really should be organising activities on the wards. At the moment we employ hardly anybody with the right skills to do that. This is not an OT function and, given the youth and educational disadvantage of many patients, we really need teachers and sports or gym supervisors on our wards.

Thirdly—my medical and nursing colleagues might not like me saying this—wards are still run on traditional hospital ward lines, and I cannot for the life
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of me see why they have to be run by nurses at all. We need nursing skills but wards could be run by bright people with all kinds of skills—social work and management are two examples. This has been done in learning disability services, for example, during the late 1980s, with great success. We are still too stuck in the traditional model of nursing care, which has been abandoned outside the hospital but not inside.

My final point concerns employment. We know that education and training for work and finding and keeping work are at the heart of patients' priorities. We must see the in-patient stay as a time when everything possible is done to keep a job or to get linked to the opportunities to give the person the chance of a job. At present, no one in the service thinks that it is their role to do that. We need mental health employment specialists whose task is just that. Of course, much of that work will go on outside hospital, but we need to keep people linked to those precious jobs and ensure that they do not lose them. That is extremely important in east London and must be just as important elsewhere.

Are those ideas ambitious? Perhaps, but all have been tried at some time in some places and are not impossible, nor do they take a lot of financial investment. Mental health wards have had quite a lot of investment. Most of it has gone in staff salaries, which is perhaps no bad thing, but it needs to be better used. Let us hope that the new mental health foundation trusts will begin to innovate in the area of in-patients, just as we have seen foundation trusts do in acute care hospitals. I strongly support that move and I hope that we will be able to move away from some of the older national patterns of highly unsatisfactory care that we have now.

8.01 pm

Lord Carlile of Berriew: My Lords, my noble friend Lady Neuberger brings to all the subjects on which she speaks and writes intellectual rigour, energy and compassion, and this is no exception. The House should be very grateful to my noble friend for raising the subject for debate tonight.

Unlike the previous two speakers, I am not an expert in this field, but I have had experience very close to a service user. Like those speakers, I have some interests to declare. I was chairman of the scrutiny committee on the draft Mental Health Bill, which has been kicked into the long grass, as the House knows. I have been involved with a number of mental health charities and I am the president of the Howard League for Penal Reform, which, unfortunately, has a very large clientele of 77,000 people in prison at present, of whom approximately one half suffer from a mental illness.

The subject that we are debating tonight is unfashionable but, in my view, it is the most important subject in the health service today. The popular newspapers, the red tops, are not given to running campaigns for improvements in mental health services. I was very sorry indeed to see that that great boxer, Frank Bruno, was suffering from severe mental illness, but that gave us an opportunity to see the red
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tops engaging in the subject. They were very good at it when they were dealing with Mr Bruno. I wish that they did it more often. I wish that we could see campaigns for child and adolescent mental health services from the popular newspapers in this country, just as we see campaigns for cancer care and heart care.

Everyone in this House will have had the experience of visiting a very sick or dying relative in hospital—someone with a physical illness. It is all very definable, is it not? The relative has an illness that has a name. The symptoms can readily be looked up on the internet or in a dictionary. The doctors can usually give a pretty clear prognosis. Above all, the patient knows from what he or she is suffering. When they go to visit, the relatives can acquire that understanding. They can take advice and follow it relatively easily.

With mental health, it is quite different. Most—certainly many; I should not say most—people in acute mental health wards do not necessarily accept that they are ill at all. They sometimes feel that they are being unfairly incarcerated by the law. They sometimes suffer from delusions and severe psychotic episodes. It is very difficult to explain to some, for they will not be able to understand the nature of their illness. It is just as hard for their nearest and dearest. People who visit patients in acute mental health wards often feel angry with their relations because they are not being reasonable or behaving like other members of the family. Our health services do very little really to explain not only to the patient, for whom it may be difficult, but to their friends and relations exactly what is happening to them. It really is time that we treated mental illness like every other illness—like measles, mumps, leukaemia, or any other definable diagnosis—but I suspect that we are still decades away from being able to treat mental illness in that way. I regard this kind of debate as a catalyst in that process and as an opportunity for non-experts such as me to make a plea for better services.

Many studies have been done on mortality from mental illness, and they are very shocking. Lawrence, Holman and Jablensky found that mortality among the mentally ill in Western Australia is two and a half times that of the general population. Similar studies have been done in the United Kingdom, Michigan and elsewhere. The messages that they send to us all is that mental illness is as potentially fatal as almost any other illness, and more fatal than most. Of course, the tragedy is that, in many cases, people who are mentally ill do not die because their bodies give up working; they die at their own hands, all too often.

When so many people are dying at their own hands when they are not suffering from a physical illness, surely it must be logical that there are better ways of preventing them from losing their lives in that way. My plea is for services to be provided in acute care to plan better outcomes. The noble Baroness, Lady Murphy, for whom I have great admiration, spoke of services in London as being, frankly, very poor. I think I heard her say that she would be hard put to think of a real exemplar of good practice. I will give her one that we saw on a visit of the scrutiny committee on the Mental Health Bill. It was the adolescent unit at the Bethlem
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Hospital, which is part of the Maudsley. It is, however, very small. It has a very small number of patients, and a school where they can take all their examinations. But you will be very hard put to find services like that if you go out of the Bethlem and out of London.

The committee visited the equivalent facility in Cardiff, but frankly it was in appalling buildings and depended entirely on the angelic efforts of one middle-aged man who was in charge of the teaching in that school. Adolescents who are acutely mentally ill may lose two, three or four years of education, but if they come out of hospital, as we hope they will in due course, having lost that education, it is almost impossible for them to recover any kind of normal life unless they are very resilient and acquire a deep understanding of their illness.

My plea is that services should be provided to enable young people to return to normal life. I have been involved in a particular small charity in Wales that seeks to provide—it is doing quite well—aftercare services for young people coming out of mental health wards. It does such things as teach them to cook again and to write a CV and obtain a job. But an organisation such as that—it is called Rekindle—has no public money because the public sector is so unimaginative in what it does with the money going to mental health services. Far too much is lost in bureaucracy, and a ludicrous amount is lost in maintaining buildings that should have been destroyed 20 years ago and reduced to smaller units. There are also terrible staff shortages.

I want to say one thing about the Mental Health Bill. We know that the Government intend to introduce a new Bill, which is merely an amendment of the Mental Health Act 1983. I plead with them that we should not find ourselves getting bogged down in the Michael Stone question all over again. Mental health is not about a small number of people who unfortunately are not cured, are released from hospital, possibly by mistake or maybe by negligence, and commit terrible acts. It is tough to say so, but we can say it in this place because we are not elected: those kinds of accidents happen from time to time. We must talk about the real questions in mental health and not the headline questions, such as Michael Stone.

I should also like to make a plea for better CAMHS—child and adolescent mental health services—provision. I have three short points to make. First, no child or adolescent should go into a mental health ward that is not completely age appropriate, wherever he or she is in the country. That is not yet the case. Secondly, there should be universal quality of care for mentally ill children and adolescents. It should not matter that they live in Birmingham or Berriew. In Berriew, there will be very little provision. In Birmingham, there will be rather more. It is not universal at the moment. Thirdly, the quality of mental health care for children and adolescents should be consistent. It is not. One of the reasons for that is therapists are being asked to give therapies for which they are not qualified. It is not satisfactory. A huge amount needs to be done, but we should never lose
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sight of the fact that this is an area of acute care and extreme suffering. I hope that this debate will help towards better standards.

8.11 pm

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