Mental Health Wards

Part of the debate – in the House of Lords at 7:39 pm on 12th June 2006.

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Photo of Baroness Neuberger Baroness Neuberger Spokesperson in the Lords, Health 7:39 pm, 12th June 2006

rose to ask Her Majesty's Government what is their response to recent reports by the Royal College of Psychiatrists for the Healthcare Commission and the Sainsbury Centre for Mental Health on in-patient care in acute mental health wards.

My Lords, I am delighted to hear that we are to have longer for this Question. I do not know what to add to that, other than I am sure that the Back-Benchers will be delighted, and I presume that I have a little licence to go beyond 10 minutes—perhaps even to 11—although I hope that I will not need to do so.

Like everyone else who is taking part in this debate—and, I am sure, the Government—a year on, I welcome the two reports to which I refer in my Question, as I have welcomed all the follow-up reports since, most of them making some of the main points. Along with those go the King's Fund's London's State of Mind, which came out in 2003, the Mental Health Act Commission's In Place of Fear?, not to mention, significantly, the report of the Sainsbury Centre for Mental Health, The Search for Acute Solutions, published earlier this year, in partnership with—we should all be delighted that this is so—the Department of Health, the Royal College of Psychiatrists, the Royal College of Nursing, the NHS Confederation and the College of Occupational Therapists. So people are working together.

Before I go much further, I declare some interests. I am one of two advisers—the other is sitting diagonally opposite me—to the trustees at the Sainsbury Centre for Mental Health. I am the former chief executive of the King's Fund and I am the former chair of Camden and Islington Community Health Services NHS Trust, which had a large mental health component.

There is a considerable amount of criticism in these two reports, but we also see a very mixed picture. Among the criticism is a comment concerning bed occupancy. Reports show that the bed occupancy rate was an average of 100 per cent; in London the average was 107 per cent; but the Royal College of Psychiatrists' guidelines say that the ideal bed occupancy rate is 85 per cent. In my days of chairing an NHS trust, I remember that our bed occupancy frequently reached 120 or 130 per cent, which I thought was terrible. Our patients would go away on leave at weekends or during the week and would come back to find that they had nowhere to stay. It was a truly appalling situation.

That is important not only because it is overcrowding per se but it adds to the atmosphere of tension and violence in the air in many of the acute in-patient wards in the UK. To add to that, there are high levels of staff vacancies and staff turnover. The vacancy rate for qualified nurses was 13 per cent, but in London it rose to an astonishing 22 per cent. The average ward on any one day has two nursing posts vacant; it employs four agency or bank staff to fill gaps in the service; and staff in a quarter of the wards surveyed have to work unpaid overtime. In addition, half of all wards lack a lead consultant; 13 per cent have no ward manager; 12 per cent have no administrative support; and three-quarters have no housekeeper.

To add to that, the reports suggest that there is far too much administration and paperwork for the nurses to do, at least partly because there is insufficient administrative support on the wards, and the physical environments are often poor. That is combined with what the patients—the service users—told the people who compiled these reports: time and again, they said that they were bored. Boredom is commonplace.

Meanwhile, there is very little engagement between nurses and patients, and the staff generally do not feel competent to deal with the increasing numbers of patients with complex needs. That is particularly the case with those with dual diagnosis—a mental illness or disorder combined with an addiction to drugs or alcohol. The staff themselves complain that they are insufficiently trained and insufficiently skilled.

In the national survey of 300 acute in-patient psychiatric wards for adults, commissioned by the National Institute for Mental Health in England and published by the Sainsbury Centre for Mental Health—the acute care report—it was found that most wards have single-sex sleeping areas but that 8 per cent lack separate bathrooms and 4 per cent lack separate toilets. On 7 per cent of wards, service-users' rooms have no natural daylight. That must be so horrible that I find it almost unimaginable, as many of the patients are there for a very long time. On 9 per cent of wards, the patients cannot control the lighting, which often means that the lighting is on at night when they are trying to sleep.

Meanwhile, less than half of wards have quiet places to spend with visitors, and only 65 per cent have a safe place for visiting children. That means that 35 per cent do not have a safe place for visiting children, so children very frequently do not visit adult parents when they are in an acute ward.

On race, when the Mental Health Act Commission, with the Healthcare Commission, undertook the Count Me In census of all acute wards on 31 March last year, it found that black African and Caribbean people are three times more likely to be hospitalised with mental health problems than the rest of the population, but that once in hospital, black men are 50 per cent more likely to be secluded and 29 per cent more likely to be subject to physical control or restraint than white men. That adds to the air of violence in the wards.

It gets worse. In the Royal College of Psychiatrists College Research Unit/Healthcare Commission's 2005 National Audit of Violence report we learn that one-third of service users, 41 per cent of staff and 18 per cent of visitors to acute units experienced violent or threatening behaviour. Meanwhile, Mind's 2004 Wardwatch survey found that 53 per cent of in-patients said the ward environment did not help their recovery, 27 per cent of patients felt unsafe in hospital and 51 per cent had been verbally or physically abused there. Most worryingly, only a third of those experiencing abuse reported it to a staff member. I wish to focus on that today. I know other speakers will cover some of the other areas of concern.

What do we learn from these two reports? There is a clear picture of violence on the wards and a clear picture of boredom. The two are not unrelated. Working practices urgently need to be changed. We clearly need better staff training and more time for staff to engage with patients rather than doing administration which they should not be doing.

On 31 May this year, the King's Fund held a conference and heard from three projects where it has been demonstrated that changes in practice could improve the experiences of patients and staff for very little financial input. They relate to the boredom and lack of activity syndrome. I draw one point to your Lordships' attention: protected engagement time, when the staff office is closed and the ward shuts down to phone calls, paperwork, visitors and other professionals for a specific regular time of day during which staff engage with those who use the services. We should not need to shut down wards in that way, but clearly we do. It has become very popular with patients who often feel they have no time with staff except when they receive their medication or when they are in a real crisis.

There are many other initiatives—there is no time to go through them now—and there are wonderful people working with the patients. Many people in those reports have commented on the calibre of some of the staff, even though there are real staffing problems in many areas. At the launch of the violence audit, Paul Lelliott, the director of the Royal College of Psychiatrists' research unit, actually praised the staff and said:

"Despite the problems illustrated by the Audit, we were struck by the dedication and enthusiasm of front-line staff of all disciplines and the extent to which they were committed to working with service users to improve safety".

Projects that deal with boredom levels lead to a more relaxed atmosphere, better patient satisfaction, and a reduction in levels of adverse incidents and conflict on wards. People are to be praised for doing that. Staff also feel empowered by being given the opportunity to do that kind of thing and to help to design and innovate practice on the wards. They find networking—sharing with other staff in other wards and other places—enormously useful; that is a great way to learn and to share practice.

That is for everyone in the acute sector, but when it comes to violence we should ask some very specific questions. Seventy per cent of staff report problems with dual-diagnosis patients, yet it is abundantly clear that good services, with a well trained and full complement of staff, can crack many of these problems. We know that detoxification is still a reason why some patients are brought in. One recommendation of the Acute Care report was that trusts should review the number of detox beds against the actual number of service users brought in, liaise with drug action teams locally, and form an agreement on appropriate admission to adult acute in-patient wards. As yet, there is no evidence that that is happening. Does the Minister have any evidence that that is happening, either in local pockets or nationally? They also recommended reviewing staffing levels, skill mix, quality of training and safety in view of the numbers being brought in solely for detox purposes, particularly when the beds are not ring-fenced for that. Again it would be good to hear whether that is happening.

The Royal College of Psychiatrists is running an excellent accreditation programme for acute wards. It includes self-review against the guidelines, following with peer review and then validation and affirmation. Eventually, it will lead to full accreditation. The first tranche is some 19 wards, coming to an end in October. Applications for a second tranche are out to invitation. The question we should be asking, however—maybe the Minister can give us an answer—is why so few wards are, as yet, involved. How easy is it for staff to get away to engage with this kind of accreditation programme for acute wards when we have such acute staff shortages? The various reports suggest that it is hard to get away. Are the Government going to do more to push staff to get involved, and reward those who do so and do further training?

Secondly, the National Audit of Violence has been going on since 1999; it is not new. The chairman and chief executives of trusts have to sign off a memorandum of understanding, so they must know what is going on and how it will appear. What will the Government do to encourage chairs and chief executives to get their staff into the accreditation programme and ensure that staff get the chance to be more innovative and less defensive in their practices?

I shall shortly run out of time, so my last point is that Anna Walker, the chief executive of the Healthcare Commission, spoke at the launch of the National Audit of Violence. She said that the national audit had found that one in three users had experienced violence and threatening behaviour while in care, along with 41 per cent of clinical staff and nearly 80 per cent of nursing staff. She said:

"These figures are deeply worrying".

While acknowledging that is not easy to deal with, she said:

"We must do more to protect the people who use and work in our mental health services. This audit gives us hard evidence on an area of growing concern. It suggests that while community services have been really important, more attention must be given to inpatients. Nobody must take their eye off this ball".

This Unstarred Question is to ask the Minister whether the Government are seriously keeping their eyes on this particular ball.