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 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 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 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.