Health and Social Security

Part of the debate – in the House of Commons at 8:06 pm on 22nd November 1994.

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Photo of Tessa Jowell Tessa Jowell Opposition Whip (Commons), Shadow Spokesperson (Health) 8:06 pm, 22nd November 1994

I am pleased to be able to contribute to the debate and I would particularly like to address the proposals contained in the Queen's Speech that will give effect to changes in the law in relation to the community care that is provided to people suffering from serious mental disorder.

I shall draw on my own experience as for 13 years I was assistant director of MIND and, for five years, I was a member of the Mental Health Act Commission, which was a statutory body charged specifically with supervising the needs of people who are seriously mentally ill. It is important to place on record that the legislative proposal arrived in the Queen's Speech belatedly and only as a result of its successful battle for space after the proposal to privatise the Post Office was dropped. It is not a mark of great Government commitment to solving the problems of community care for people suffering from serious mental illness.

The first issue that we must deal with is the number of people who will be, or potentially be, affected by the proposals. The estimates based on research vary enormously from 300,000 to the more tightly defined estimate: that people who are seriously mentally ill are about 1 per cent. of the 1 per cent. of the population who suffer from schizophrenia—between about 2,500 and 4,000. When the Minister replies, I hope that he will be able to shed some light on the size of the group that the proposals are expected to cover.

I am sure that I do not need to remind the House of the background to the new proposals and the public concern about recent tragic cases that has given rise to a crisis in public confidence about the effectiveness of community care. Why do things go wrong? None of the people who committed dreadful acts of violence, which, in some cases, resulted in murder, was unknown to the services. They had all at some time been in touch with the services. Characteristically, that group of people rarely commits an offence without talking to somebody beforehand about their intention.

Those dreadful tragedies occur because the system fails the victim and the patient. Too often, they occur after a culmination of events—after several cards have been posted through the door, saying, "Sorry you weren't in, and I missed you." When the community psychiatric nurse, the social worker or whoever is charged with responsibility fails to make contact, dreadful consequences follow.

In the past two years, there has been more debate about the crisis of confidence in community care for mentally ill people in the leader columns of newspapers, in pubs and on buses taking people to work than on the Floor of the House. We should not forget that, for every murder and every failure in community care, there are a hundred successes which are quickly obliterated. We now need to rebuild public confidence in a tattered policy.

What is causing the crisis in community care? The picture is complex. That there are many causes rather than just one has been the consistent theme of reports during the past 12 months. It has been expertly documented by the Mental Health Foundation and, more recently, by the Audit Commission, whose authoritative report was dismissed by the Government in an appalling and disgraceful way. They accused the report's authors of being unbalanced; I think that when any of us reads an Audit Commission report that is truly unbalanced, we look out of the window to see pigs flying past.

The crisis in care in the community relates not to the intention or the policy, but to the realisation of intention and policy. There is now ample evidence and experience to show what needs to be done to build effective, valued and co-ordinated services and guarantee high levels of professional performance. Living in the community, with a range of support services and practical assistance, is a viable alternative for all but a handful of patients who, for periods of time, need secure hospital treatment: indeed, it is the consistently preferred option for those needing such services.

For the policy to work, however, the needs of those whose lives will be shaped by it must be acknowledged and respected. Both the Mental Health Foundation and the Audit Commission argued that the approach to the development of community care services should be led by the needs of patients. They described the essential framework as including an appropriate place to live, an adequate income, a useful daytime occupation, access to help and support on a 24-hour basis and the opportunity to be consulted about the range of support available.

It should be remembered that—as many survivors of mental illness will say—mental illness is a career. Too often, planning and support are provided in relation to a single episode as though it were a discrete event rather than, as is sadly the case, likely to be one of a series in the individual's adult life.

Although we know so much about what makes community care work—have, indeed, known so much for 30 years, since the long-stay mental hospitals were first run down—we now have a geographical lottery. In only a handful of regions is there anything approaching a comprehensive mental health service capable of providing the support that patients need. What a scandal it would be if a cure for breast cancer were known, but available only to those living in, say, the Wirral or Edinburgh. Precisely that position exists in relation to the long-term care and support of mentally ill people. We know what is needed, but the Government have failed to provide it on a consistent and national basis.

Sixty-six per cent. of resources spent on mental health services are still tied up in the mental hospitals which treat 10 per cent. of those who suffer from mental illness. That means that, in the community, 90 per cent. of mentally ill people benefit from only a third of the mental health budget—an imbalance that desperately needs to be corrected.

The Secretary of State has said that reforms to mental health law have caused the pendulum to swing too far". Interpreting such generalities is always difficult, but the Secretary of State appears to have claimed that patients' freedoms and civil liberties are now respected more than the need for those freedoms and liberties to be restricted or removed in the interests of the patients, or of society.

The changes in the law are primarily designed to adjust the swinging pendulum, and to reassert power and control over the way in which patients choose to live and behave; they are not intended to create any new legal regime whereby patients can be assured of the service that they need and to which they should be entitled. In words that the Secretary of State has been heard to use, "patients must take their medicine".

That is how the Secretary of State's legislative proposals will be regarded by those who fear being subject to the new powers, and by professionals who strive to win more—and more versatile—resources for their clients, only to find themselves being made legally responsible for supervising patients within services that are unable to meet even minimal levels of need.

Last year, I served on the health committee inquiry that examined in detail the case for additional legal powers, and broadly rejected the proposals that the Secretary of State is now presenting. We did so because we felt that a more fundamental review of the Mental Health Act 1983 was needed, and that piecemeal reform was misconceived; in our view, extensive legal powers were already available but insufficiently used, or insufficiently effective.

I still believe that to be the case, but I firmly believe that the time has come for the House to debate proposals of a different nature which would legally oblige health and social services authorities to provide those in need with a minimum level of service. Unless Parliament requires such action, I do not envisage the Government, or those with local responsibility, ever taking seriously their duties to those who suffer from serious mental illness.

In the report of its 1993 review of mental health law, which recommended the creation of a new supervised discharge power, Department of Health officials stated: it must be recognised that the use of the power implies a reciprocal obligation on the statutory services to provide the support the patient needs". Any approach that does not make obligations explicit, easily enforceable and adequately funded will be both unjust and ineffective. I fear that the Government's measure promises to be both.