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Lord Ramsbotham: My Lords, like the other speakers, I, too, should like to thank the noble Baroness, Lady Neuberger, for obtaining this timely debate on a subject on which, as she has already indicated, we share a joint interest as advisers to the trustees of the Sainsbury Centre for Mental Health. She persuaded it to invite me, so I follow her. My particular interest in going there is because the Sainsbury Centre for Mental Health has recently announced that it will concentrate its activities on the treatment of mentally ill people in prison and the problems of finding employment for mentally ill people—two hugely important and sadly neglected subjects.

It may seem rather perverse to raise in-patient care in acute mental health wards for people who are acutely ill and for whom there are no acute mental health wards in prisons. I do so because until 2004 the Prison Service had its own healthcare for which it paid. In 1995, when I took over as Chief Inspector of Prisons, I was amazed to find that prison healthcare was not in the hands of the NHS. After all, all prisoners came from the NHS and would go back to it when they left prison. So why did they go into a sort of medical limbo when they went into prison? That seemed particularly perverse. Prisons, when people are locked up, present an opportunity for identification and treatment of problems both physical and mental. Therefore, to suggest that they had left the care of the NHS to go into this limbo suggested, as I was soon to discover, that that opportunity was not being seized.

In my first inspection of Holloway, which I was told was the largest women's psychiatric prison facility in the country, I discovered large numbers of seriously ill women who were utterly neglected with totally inadequate services. That set the tone for what I found. As a result, in 1996, I produced a paper called Patient or Prisoner, which recommended that the NHS should take over responsibility for those people. Prisons are a public health issue. The health of people when they come out of prison matters to the public. Therefore, it is irresponsible for the Prison Service not to make arrangements to deal with their health while they are inside.

So it was that I was very interested in this debate and I was particularly interested in the reports of the Sainsbury Centre. The noble Baroness, Lady Neuberger, has already referred to a follow up to the original report, called The Search for Acute Solutions, and I should like to quote three short messages from that report which have a great resonance with what goes on in prisons.

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Hear, hear to that! Strong leadership, strong management and strong direction, to my mind, are more important than money. We have got to see that existing facilities are used better. I was horrified to find when inspecting prisons that there is only one secure unit in the whole system: it is at Aylesbury and it is used as a classroom because it has not even got a psychiatrist there for the young offenders.

Secondly, as my noble friend Lady Murphy has already mentioned, the report states:

Hear, hear to that! What on earth is going to be done for acutely mentally ill people left locked up in prison cells all day? It is doing absolutely nothing for them except, as my distinguished psychiatrist, Dr John Reed, used to say frequently, merely making them worse.

Finally, the report states:

Hear, hear to that!

Noble Lords may wonder what numbers we are talking about because the numbers in the NHS are huge and the numbers in the Prison Service may not be. Let us look at it proportionally to start with. If you take the percentage of people who suffer from two or more mental disorders, in the general population it is 5 per cent of men and 2 per cent of women; move to prisons and the figures show that 72 per cent of males sentenced and 70 per cent of females sentenced are suffering from two or more mental disorders. Moving on to neurotic disorders—sleep, worry, anxiety, depression and so on—the figures are 12 per cent of men and 18 per cent of women in the general population, but 40 per cent of males and 60 per cent of females in prison. As to the numbers of people who need acute treatment—the ones suffering from psychotic disorders—the figures are 0.5 per cent of men and 0.6 per cent of women in the general population, but 7 per cent of all males and 14 per cent of all females sentenced in the prisons are suffering to that degree. And yet there are no acute mental health wards for them to receive treatment.

To put the numbers into a more reasonable proportion than mere percentages, perhaps I may quote an article by Dr Adrian Grounds, written in 2004. He states:

which is much more likely now given the increase in numbers—

That is a large number. The trouble is—and I fully sympathise with the NHS and all the people who plan it—that we are not coming at this problem from a good
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starting point. Because prisons were not part of the NHS, the needs of people in prison were not included in NHS estimates. Therefore a large number of people were coming out—remember that all except just over 30 people in prison will come out—bringing these needs with them into the community, with no arrangements made for them.

As a result, to go on with what Dr Grounds said:

The reason I mention all this is not merely in connection with the acute bed report. The fact is that in our society, as a responsibility of the NHS, are people whose treatment in prison and subsequent treatment after they leave will make them candidates for the over-stretched acute beds and whose needs should be looked at, as well as the people who should be identified by courts and prisons and referred to the acute system even earlier. My contention is that although the cost is large—and I do not pretend that it is not—we cannot afford not to do this, because the cost of not doing it will be greater.

It seems to me perverse that the Prison Service has made £126 million over three years available to treat the 200 to 300 people said to be very seriously disturbed, which works out at £180,000 per person, whereas it has made only £122.5 million available for healthcare, which means £817 only for all the others, a large number of whom are acutely ill. Therefore, I hope that in responding to this very important debate, the Minister will not forget the needs of this part of the population, which is the latest addition to their budget.

8.22 pm

Baroness Barker: My Lords, I, too, congratulate my noble friend Lady Neuberger on such a timely debate and, as one might have expected in a debate secured by her, on assembling such a wonderful list of contributors.

I say that the debate is timely for two reasons. We await with eager anticipation whatever is due to emerge as the new Mental Health Bill. My noble friend Lord Carlile said that the draft Bill had been kicked into the long grass but only a few weeks ago, the Minister in another place, Rosie Winterton, assured Members of both Houses that a Bill would be introduced in this Session and that, contentious as it might be, it would not be subject to pre-legislative scrutiny.

There is an element in the timing of tonight's debate that is slightly unfortunate. The Audit Commission will tomorrow publish its report on managing finances
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in mental health. Unfortunately, the report is embargoed until tomorrow, but I suggest that it will make extremely interesting reading.

I had the privilege of being on the Joint Committee on the draft Mental Health Bill, chaired so ably by my noble friend Lord Carlile. As we sat there week after week, listening to people tell us how much they hated the Government's draft proposals, the evidence of one young man stood out. He came to talk to us about the Child and Adolescent Mental Health Services; he had been a service user. He talked about just what being subject to compulsory treatment does to somebody and how disempowering it is. He then talked about what it was like to have been subject to compulsory treatment—to sit in a ward where nothing much is happening, one does not know when one will get out, it is hot and one cannot go outside, and there is an immense amount of boredom. He said to us, "You know that in that situation, the smallest of things can tip you over into a crisis—not being allowed to decide which TV programme you can watch or being locked up with people you don't like". For the first time, he began to make me understand what this whole system does to individuals and why it does not work.

It is true—and I am sure that the Minister will tell us in his reply—that there have been increased resources for mental health. There has been a 10 per cent real increase in investment in adult acute inpatient facilities since 2001–02. At the same time, there has been an overall increase of 25 per cent in adult mental health services. As my noble friend Lady Neuberger said, problems that we thought would be addressed by crisis resolution teams, assertive outreach teams and so forth have not managed to decrease the number of people being referred for acute services.

What then can one draw from this welter of reports, all of which indicate problems in acute mental health services? Perhaps one of the first things is that care plans are not implemented. If an emphasis were placed on involving users in the design of care plans and in their implementation, many of the acts of violence and so forth to which my noble friend Lady Neuberger referred would not happen, because the source of such aggravating problems would have disappeared from the lives of people who were already feeling pressured and largely ignored.

Secondly, links between the acute and community sectors must be improved. Throughout the rest of the acute services within the NHS, much greater emphasis is now put on the process of rehabilitation and discharge and on the transition from an acute setting to a community setting. I was very interested to listen to what the noble Baroness, Lady Murphy, had to say—I always am—about how community teams and acute teams never see the person they are treating in the other setting. If they were to do so, that process of transition and discharge could be made more accessible. There could be far fewer avoidable re-admissions.

My noble friend Lord Carlile was absolutely right when he talked about this as being an illness, but one that we simply do not treat in the same way as any
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other illness. For example, we would not in any other setting where people were receiving treatment put together young people and old people or men and women. It is staggering that, despite the investment in resources, adult wards are still receiving children as young as 14. That is inappropriate, in some cases dangerous, and, to them, it is frightening. We would not let it happen in any other healthcare setting.

What can we take from these many reports that might be hopeful? One thing in particular stood out for me—the emphasis on access to talking therapies. When my noble friend Lord Carlile and I were privileged to go to those centres in south London, we met a marvellous assertive community outreach team. But we also met service users who told us that they were going into debt in order to pay for talking therapies which they needed and could not access any other way. Individual people should not be driven to the point of knowing that there is a source of healthcare that they need and then having to pay for it. It does not make sense for the NHS either, because the lack of access to talking therapies in community service almost inevitably leads to a build-up of demand on the acute services when people reach a crisis point.

Much is going on and much notice is being paid in the world of mental health to Professor Layard's recommendations about the use of cognitive behavioural therapy for depression. We should also recognise that NICE has recommended that cognitive behavioural therapy should be available for people with schizophrenia. The lack of access to that is taking a great and unnecessary toll on many of the acute services within the NHS. If one were to talk to many of the professionals, they would say that that would be one thing that the Government could do that would make a real difference to the picture overall.

My noble friend Lady Neuberger and others talked of the ongoing problem of the disproportionate numbers of people, particularly young men, from black and minority ethnic communities, who are in our acute mental health services. I sympathise with those from the Sainsbury Centre for Mental Health who wonder how often they have to raise this before the issue is really taken on board, because they have been quite explicit that what we are talking about is the impact of institutional racism within mental health services, disproportionately adversely affecting one part of our community.

Many times when people talk about mental health, they talk about the much-forgotten need to remember that the physical health of people with mental health problems should be treated hand-in-hand—and so frequently it is not. Much of what the noble Lord, Lord Ramsbotham, said played well into that point. We know that many people sitting on acute wards are smoking and engaging in other activities that are simply not conducive to all-round physical health. That is a contributing factor overall.

Finally, I want to raise one question that is central to all of this. We are at a point with our mental health services when professionals are working with outdated legislation and there is a great deal of uncertainty and
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anxiety about the appropriateness of what legislation may come down the track shortly. We have a great deal of good advice and guidance in the national service framework, much of which is not being implemented. In many ways, the world has moved on. Is it not now time to ask what acute mental health services are for, where they should be based and how they should be configured to achieve the optimum therapeutic outcome? If we did that, we might abandon some of the PFI building plans, which have been so dominated by the acute sector. We might free up resources to spend on some of those innovative services that noble Lords have mentioned. We might invest in the voluntary sector rather than taking services away from them, as I understand to be the case. Organisations such as Mind are struggling to fulfil their advocacy role, among others. When we answer the question of what our acute services are for, we shall begin to see the beginning of the end of those inappropriate buildings, of staff working in isolation from those involved in provision of community services, and we shall begin to answer the many questions raised by the many reports.

8.34 pm

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