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Earl Howe: My Lords, the noble Baroness, Lady Neuberger, has done us a service in tabling this Question today. I pay tribute to the way in which she so ably articulated many of the serious and widely held concerns about in-patient mental health care. I listened to her with a considerable measure of agreement, as I did to all other noble Lords who have spoken.

We have heard a lot of worries and criticism, one way and another, but I shall begin with a brief reassurance to the Minister. I am the first to recognise—as, I am sure, are we all—that the resources directed by the NHS towards mental health in general have risen considerably in recent years. I am also the first to recognise that, as a result of this investment, we are seeing gradual improvements in the service. Nevertheless, measuring the quality of mental health care, like any other sort of healthcare, is about not inputs but outcomes. That was why the noble Baroness was so right to focus our minds on the patient experience. In this field of care, almost par excellence, the patient experience defines the standard.

In preparing for this debate, I have been looking at a number of recent surveys: the 2004 survey published by the Sainsbury Centre for Mental Health, the Mind Ward Watch survey of the same year, the National Audit of Violence in 2005 and the Sainsbury Centre report, The Search for Acute Solutions. There is an awful lot of information out there, almost a bewildering amount, and it is quite easy, if we are not careful, to get bogged down in the detail. What we need to do, as shapers of policy in the broadest sense, is take a step back and look at the direction of travel, define our objectives and try to identify the key trigger points that are likely to lead to the attainment of those objectives.

For a start, we need to do exactly what the noble Baroness, Lady Barker, suggested: take a long hard look at what we want in-patient mental health care to
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look like, and what we want it to do at a time when we are seeking to deliver greater amounts of healthcare in the community. In other areas of the NHS we are seeing health policy develop in a way that reflects modern values: no longer the pervading assumption of "doctor knows best", but rather professional attitudes that credit patients with being individuals who know their own minds, and who may actually have personal preferences. Autonomy and choice should be just as much a part of mental health care as of any other sort of care.

If we truly believe that, a number of things have to follow. We need to improve the commissioning of in-patient care. We need to create opportunities for people to make genuine choices about where they get acute care, and what sort of care they receive when they come to need it. Flowing from that, we must make in-patient care responsive to the wants and expectations of patients who elect to receive it.

I am sure most noble Lords here have seen the inside of an in-patient mental health ward. I have visited a number—not, I may add, as a patient—and I cannot say that I found it an uplifting experience. There were good, sometimes excellent, staff, but the prevailing mood in those places could be summed up as a mixture of intimidating, institutional and crashingly dull. Where we find, as we did in the Mind Ward Watch survey, 53 per cent of in-patients saying that the ward environment did not help their recovery, a quarter of patients saying that they felt unsafe and half saying they had been abused in some fashion, we know there is a huge amount left to do.

Too often cognitive behavioural therapy is recommended but not available. Too often we have children being treated for mental health problems on adult wards because children's facilities are not there. Nearly 3,000 bed days every month are accounted for in that way. With the recent tightening in PCT funding, we are seeing in some places not an elimination but a reintroduction of mixed-sex wards—the very opposite of what is desirable.

If we look at the trends over the past few years, the number of in-patient beds has gone down, yet the demand for beds has stayed the same; hence the bed occupancy figures rightly mentioned by the noble Baroness, Lady Neuberger. In some areas of the country, particularly London, staff shortages are acute. Very often, the worst shortages are where the need is greatest; London again being the prime example. Part of the difficulty of in-patient care—a major part—is that many staff prefer to work in a community setting, and they vote with their feet. Some staff migration of this kind is needed to form up the new crisis resolution teams and for treating patients at home; but too much of it leaves the acute wards depleted, and it is very difficult in those circumstances for the staff who are left behind, however good and caring they are, to deliver an optimal service.

It is against that background that I say to the Government that should a new Mental Health Bill be introduced which sanctioned in-patient treatment even where there was no illness to treat, or which
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resulted in significantly more people being detained compulsorily, that would be a recipe for huge problems. The audit of violence contains all the warnings we need on that score. We all know that investment needs to be channelled into community services. But as Anna Walker said recently, more attention must be given to in-patients. Something has to be done to recruit and retain good staff in those acute settings, and to make them feel that it is a job that is really valued and worth while. Most of the experts agree that part of the solution lies in new ways of working, so as to create more face-to-face time between staff and patients. There are models of good practice out there from which we can draw.

Allocating the health budget is all about fixing priorities. So let us never forget the cost of mental illness in terms of social exclusion and the drain it represents on the economy, amounting to many tens of billions. It is an area of ever growing importance in our nation's health, on which we look to the Government to give a lead.

8.42 pm

The Minister of State, Department of Health (Lord Warner): My Lords, I am sure that we are all grateful to the noble Baroness, Lady Neuberger, for giving us this opportunity to discuss improving mental health services, especially in-patient care. We should not forget that the shift towards treatment within communities has brought enormous benefits for many thousands of people, but I recognise only too well—as a number of noble Lords have said—the importance of better meeting the needs of those who still need care in hospital. We are quite sure that community teams are having an impact both on admissions to hospital and on better handling through to discharge.

Let me begin by addressing directly the questions asked by the noble Baroness, Lady Neuberger, on the two reports that she mentioned, which were both published about a year ago. We welcomed both reports. Indeed, the Sainsbury centre report was commissioned by the National Institute for Mental Health in England, which is part of the Department of Health. We openly acknowledge the concerns that both publications identified and that the noble Baroness so elegantly described. In fact, by this time last year, we had already begun a significant programme of work to improve in-patient mental health care.

In December 2004, Professor Louis Appleby, the national director for mental health, published his report on progress with the National Service Framework for Mental Health. He outlined a comprehensive modernisation programme embracing capital investment, tackling drug misuse and violence, improving staff recruitment and retention, and better integration with community services. There is a strategy, and that strategy was set out. I believe we have made some real progress, especially in those wards where needs are greatest. I recognise that there
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is still too much geographical variability for anyone to be comfortable. The noble Earl, Lord Howe, is absolutely right in that regard.

We are now in the second phase of funding to support the Enhancing the Healing Environment initiative of the King's Fund, which provides better healing environments and a better overall experience for patients. I am not claiming that that is the end to all the problems in some in-patient environments, but it is a good start and we will continue to make progress in the area. I pay tribute to the noble Baroness, Lady Neuberger, for her work in the King's Fund in starting that initiative.

We have significantly increased capital investment in mental health services. On top of the £1.6 billion capital spent by mental health trusts between 2001 and March last year, we have since made available another £190 million to improve in-patient accommodation and ensure that each mental health trust has access to an "appropriate place of safety" for assessment of people brought in under the Mental Health Act by police. I recognise that that capital investment is not the end of the world, but it makes progress in improving the quality of life for the large number of people who live in that accommodation. It also makes the job of staff easier in that regard.

The latest round of capital allocations announced in February is particularly good news for mental health trusts, which receive a 50 per cent average increase in operational capital compared to the previous financial year. That is double the level of increase in operational capital nationally. That funding goes directly to mental health trusts, allowing local decisions on how best to modernise those facilities. The investment is paying off for patients. A good example of a new, well designed unit is the award-winning Woodhaven mental health unit in the New Forest. The day area has large floor-to-ceiling windows, which optimise the natural light. Outside the building itself, there is direct access to large landscaped gardens and water features. All in all, it is a good physical environment to support service users' recovery. Change is happening on the ground, perhaps not as fast as many of us would like, but the money is going in and showing in new facilities being brought into use.

Let me reassure the noble Baroness, Lady Barker, that a survey published recently showed that planned spending on mental health services in England rose by 3 per cent in real terms in the last financial year. The Audit Commission report may be interesting, but not necessarily in the way that she expects. Since 1999, spending on mental health has risen in real terms by over a quarter. The UK now has one of the highest proportions in Europe of its overall health budget devoted to mental health. I am grateful to the noble Earl, Lord Howe, for his recognition of what the Government have done on investment. While money is not everything, it is difficult to improve services without more investment. However, we have to recognise that we are dealing with a long period of neglect of investment for this service area, and it takes time to make progress.
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Three mental health trusts have already been approved for foundation trust status, which is good news for them and their patients, and I am confident that we will see more in the future. That shows that mental health trusts are effective financial managers of their resources. They use their resources well and have a business planning approach. Increased investment is important, but I recognise that there are other issues, as noble Lords have said. We have developed and published guidance that supports in-patient care and the staff who provide it, often in very challenging circumstances. That includes advice on managing disturbed behaviour.

Let me say a few words to respond to the many concerns expressed this evening about how staff deal with disruptive and violent behaviour. All mental health service providers should have clear policies, procedures and training to ensure that incidents of aggression and violence are managed safely and effectively. Development of policy and training is supported by the National Institute for Clinical Excellence's guidelines on the management of violence in in-patient settings published in 2005. The management of violence initiative has also produced proposals for a national accreditation and regulation scheme for trainers and programmes of education and training later this year. These programmes are starting to have an impact on staff and on the environment in which patients are cared for. To ensure progress, the Healthcare Commission will include safety and the physical environment in its improvement review on acute in-patient care, commencing in autumn 2006 and reporting in 2007. The National Patient Safety Agency's safer wards project will potentially help to deal with disruptive and aggressive behaviour in wards.

The importance of better in-patient care was also recognised by the Chief Nursing Officer in her recent review of mental health nursing. Her report made a number of important recommendations relating to clinical practice and staffing arrangements. For example, she recommended that the amount of time spent in direct contact with patients could be improved by introducing therapeutic time initiatives, whereby administrative tasks will be put aside for a period to allow nurses and patients to have protected time together. The noble Baroness, Lady Neuberger, mentioned that important issue. We know that that can work. The Oxfordshire Mental Healthcare NHS Trust introduced protected time for an hour and a half every day. Both staff and patients welcomed it and the number of complaints at the trust has gone down. So there is good evidence that such an approach actually works.

Other recommendations relate to strengthening career structures in in-patient care to retain experienced and well qualified staff and ensure that those who do not have professional qualifications are suitably developed and supervised. Although long-term vacancies for mental health nurses have fallen over the last two years, we recognise that that remains a significant challenge in some geographical areas, and so guidance has been published on improving
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recruitment and retention. The workforce development strategy to support the national service framework has helped to secure considerable increases in staffing, including in in-patient wards.

I hope that noble Lords would accept that in-patient care cannot, and should not, be neatly boxed off from care outside hospital. The two are inextricably linked. So I would like to stand back and look at the bigger picture of developments in mental health care, because they have an impact on in-patient care.

The national service framework is an ambitious 10-year plan, and I believe that it is working. The significant extra investment that I have mentioned means that we now have over 20 per cent more psychiatric nurses and over 50 per cent more psychiatric consultants than we had when we took office in 1997. By any stretch of the imagination, those are large increases in the professional staff available, both in in-patient care and for out-patient care. It is a good hard fact that the suicide rate has fallen to its lowest recorded level and is now one of the lowest in the European Union.

There are over 700 new community mental health teams working in the community. As a result, crisis resolution and home treatment teams are contributing to a significant reduction in emergency bed days in mental health in-patient units. Since the 1990s, there has been a fourfold increase in the use of modern anti-psychotic medication. It is a tribute to mental health services that last year's survey by the independent Healthcare Commission showed that most patients expressed high levels of satisfaction with their services. All this impacts on the demand for in-patient care and, without such advances, I would suggest that the pressures on our in-patient estate would be much greater.

A number of noble Lords mentioned psychological, or talking therapies. I remind the House that the Secretary of State for Health recently announced the next stages of our programme to help more people benefit from psychological therapies. It will begin with two national psychological therapy demonstration sites, in Newham and Doncaster, linked to a national network of local psychological therapy improvement programmes.

Real progress is being made; however, I recognise that the delivery of services in often very difficult circumstances means that we must congratulate and pay great tribute to the staff who carry out this work—day in, day out. I do not diminish the challenges that they face. There is always more to be done, and we are clear that the remaining commitments in the national service framework need to be met. In the context of in-patient care, there is one other issue that I want to mention; namely, improved mental health care for black and minority ethnic communities, which is at the top of the national work programme.

We know that people from some ethnic backgrounds are significantly more likely to be admitted to hospital, more likely to be detained and more likely to reach hospital through the criminal justice or social service systems. Once in hospital, they
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are also more likely to be subject to measures such as seclusion and restraint. We face up to and acknowledge that.

The reasons underlying those facts are complex but the problem has effectively been left unchallenged by successive Governments for decades. Last year we published a comprehensive five-year action plan for delivering race equality in services. Ridding the system of inequalities once and for all might not be easy but I believe that we should never settle for less. We will continue to work in this area.

I recognise that I have not responded to all the points raised by noble Lords but I shall do so in writing. I reassure the noble Lord, Lord Ramsbotham, that I am well seized of the relationship between the Prison Service's health needs and the NHS. He will recall that the Government transferred responsibility of those often underfunded health services to the NHS. We have put the NHS in a position of responsibility to people who are in prison and are being discharged
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from it. I do not claim that everything is perfect in the system but we have now started to move in the right direction in this area.

What I have described today is a serious, radical and long-term programme of modernisation that is aimed at in-patient care just as much as care of any other sort. Mental health has never been higher up the Government's agenda. I share the view of the noble Earl, Lord Howe, that improving the commissioning of mental health care is vital. That is why improved commissioning is such a vital part of NHS reform. As I have described, the result that we have so far produced is record increases in investment and staffing and—thanks to the efforts of staff who were in place and the newcomers to the service—front-line services have become much more responsive to the needs of the people who use them. I recognise that we are still some way from fulfilling all our ambitions. Until we do, the top of the agenda is exactly where mental health will stay for this Government.

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