MENTAL HEALTH WARDS
House of Lords debates
Monday, 12 June 2006
Mental Health Wards
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 minutesperhaps even to 11although I hope that I will not need to do so.
Like everyone else who is taking part in this debateand, I am sure, the Governmenta 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 withwe should all be delighted that this is sothe 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 advisersthe other is sitting diagonally opposite meto 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 was 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 patientsthe service userstold 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 diagnosisa 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 Healththe acute care reportit 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 initiativesthere is no time to go through them nowand 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 networkingsharing with other staff in other wards and other placesenormously 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, howevermaybe the Minister can give us an answeris 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.
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 psychiatristsincluding myselfwith 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 systemthose 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 inpatient 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 inpatient 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 staffand I think this echoes what the noble Baroness, Lady Neuberger, saidneed 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.
Thirdlymy medical and nursing colleagues might not like me saying thiswards 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 skillssocial 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.
My Lords, my noble friend Lady Neuberger brings to all the subjects on which she speaks and writes intellectual rigour, energy and compassion, and this is no exception. The House should be very grateful to my noble friend for raising the subject for debate tonight.
Unlike the previous two speakers, I am not an expert in this field, but I have had experience very close to a service user. Like those speakers, I have some interests to declare. I was chairman of the scrutiny committee on the draft Mental Health Bill, which has been kicked into the long grass, as the House knows. I have been involved with a number of mental health charities and I am the president of the Howard League for Penal Reform, which, unfortunately, has a very large clientele of 77,000 people in prison at present, of whom approximately one half suffer from a mental illness.
The subject that we are debating tonight is unfashionable but, in my view, it is the most important subject in the health service today. The popular newspapers, the red tops, are not given to running campaigns for improvements in mental health services. I was very sorry indeed to see that that great boxer, Frank Bruno, was suffering from severe mental illness, but that gave us an opportunity to see the red tops engaging in the subject. They were very good at it when they were dealing with Mr Bruno. I wish that they did it more often. I wish that we could see campaigns for child and adolescent mental health services from the popular newspapers in this country, just as we see campaigns for cancer care and heart care.
Everyone in this House will have had the experience of visiting a very sick or dying relative in hospitalsomeone with a physical illness. It is all very definable, is it not? The relative has an illness that has a name. The symptoms can readily be looked up on the internet or in a dictionary. The doctors can usually give a pretty clear prognosis. Above all, the patient knows from what he or she is suffering. When they go to visit, the relatives can acquire that understanding. They can take advice and follow it relatively easily.
With mental health, it is quite different. Mostcertainly many; I should not say mostpeople in acute mental health wards do not necessarily accept that they are ill at all. They sometimes feel that they are being unfairly incarcerated by the law. They sometimes suffer from delusions and severe psychotic episodes. It is very difficult to explain to some, for they will not be able to understand the nature of their illness. It is just as hard for their nearest and dearest. People who visit patients in acute mental health wards often feel angry with their relations because they are not being reasonable or behaving like other members of the family. Our health services do very little really to explain not only to the patient, for whom it may be difficult, but to their friends and relations exactly what is happening to them. It really is time that we treated mental illness like every other illnesslike measles, mumps, leukaemia, or any other definable diagnosisbut I suspect that we are still decades away from being able to treat mental illness in that way. I regard this kind of debate as a catalyst in that process and as an opportunity for non-experts such as me to make a plea for better services.
Many studies have been done on mortality from mental illness, and they are very shocking. Lawrence, Holman and Jablensky found that mortality among the mentally ill in Western Australia is two and a half times that of the general population. Similar studies have been done in the United Kingdom, Michigan and elsewhere. The messages that they send to us all is that mental illness is as potentially fatal as almost any other illness, and more fatal than most. Of course, the tragedy is that, in many cases, people who are mentally ill do not die because their bodies give up working; they die at their own hands, all too often.
When so many people are dying at their own hands when they are not suffering from a physical illness, surely it must be logical that there are better ways of preventing them from losing their lives in that way. My plea is for services to be provided in acute care to plan better outcomes. The noble Baroness, Lady Murphy, for whom I have great admiration, spoke of services in London as being, frankly, very poor. I think I heard her say that she would be hard put to think of a real exemplar of good practice. I will give her one that we saw on a visit of the scrutiny committee on the Mental Health Bill. It was the adolescent unit at the Bethlem Hospital, which is part of the Maudsley. It is, however, very small. It has a very small number of patients, and a school where they can take all their examinations. But you will be very hard put to find services like that if you go out of the Bethlem and out of London.
The committee visited the equivalent facility in Cardiff, but frankly it was in appalling buildings and depended entirely on the angelic efforts of one middle-aged man who was in charge of the teaching in that school. Adolescents who are acutely mentally ill may lose two, three or four years of education, but if they come out of hospital, as we hope they will in due course, having lost that education, it is almost impossible for them to recover any kind of normal life unless they are very resilient and acquire a deep understanding of their illness.
My plea is that services should be provided to enable young people to return to normal life. I have been involved in a particular small charity in Wales that seeks to provideit is doing quite wellaftercare services for young people coming out of mental health wards. It does such things as teach them to cook again and to write a CV and obtain a job. But an organisation such as thatit is called Rekindlehas no public money because the public sector is so unimaginative in what it does with the money going to mental health services. Far too much is lost in bureaucracy, and a ludicrous amount is lost in maintaining buildings that should have been destroyed 20 years ago and reduced to smaller units. There are also terrible staff shortages.
I want to say one thing about the mental health Bill. We know that the Government intend to introduce a new Bill, which is merely an amendment of the Mental Health Act 1983. I plead with them that we should not find ourselves getting bogged down in the Michael Stone question all over again. Mental health is not about a small number of people who unfortunately are not cured, are released from hospital, possibly by mistake or maybe by negligence, and commit terrible acts. It is tough to say so, but we can say it in this place because we are not elected: those kinds of accidents happen from time to time. We must talk about the real questions in mental health and not the headline questions, such as Michael Stone.
I should also like to make a plea for better CAMHSchild and adolescent mental health servicesprovision. I have three short points to make. First, no child or adolescent should go into a mental health ward that is not completely age appropriate, wherever he or she is in the country. That is not yet the case. Secondly, there should be universal quality of care for mentally ill children and adolescents. It should not matter that they live in Birmingham or Berriew. In Berriew, there will be very little provision. In Birmingham, there will be rather more. It is not universal at the moment. Thirdly, the quality of mental health care for children and adolescents should be consistent. It is not. One of the reasons for that is therapists are being asked to give therapies for which they are not qualified. It is not satisfactory. A huge amount needs to be done, but we should never lose sight of the fact that this is an area of acute care and extreme suffering. I hope that this debate will help towards better standards.
My Lords, like the other speakers, I, too, should like to the 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 peopletwo 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.
"It is important that some short-term investment is made by leaders and managers to enable staff to participate in bringing about change given the potential for long-term gain derived from a more effective service. This does not necessarily mean money. Using existing resources differently and flexibly is possible but good management and leadership are necessary to achieve this. Advanced unit-wide planning, sound organisation, consultation and communication are required so that staff can feel comfortable about taking time to develop and implement change".
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:
"Inactivity and boredom can delay recovery and can sometimes cause increased levels of aggression and frustration".
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:
"However, whatever the place that acute in-patient care comes to occupy, there can be no excuse for poor environments and low-quality services.
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 disorderssleep, worry, anxiety, depression and so onthe 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 treatmentthe ones suffering from psychotic disordersthe 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:
"The scale of the problem is huge. Based on the best research we've got, it may be that about 4% of the prison population need to be in hospital beds, and, in current terms, that means that something in the order of 3,000 prisoners, possibly up to 3,700"
which is much more likely now given the increase in numbers
"need to be in a psychiatric hospital".
That is a large number. The trouble isand I fully sympathise with the NHS and all the people who plan itthat we are not coming at this problem from a good 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 outremember that all except just over 30 people in prison will come outbringing these needs with them into the community, with no arrangements made for them.
As a result, to go on with what Dr Grounds said:
"We commonly see mentally ill men being released at the end of their sentences who, at the very least, should go to suitable accommodation, be registered with their GP and have had follow-up by their local mental health service arranged. Distressingly often, and notwithstanding efforts by their probation officers, they leave with no address, only an instruction to present themselves as homeless to their local housing authority. In the absence of an address, the relevant mental health team either cannot be identified, or will refuse to see the patient, or both. There will be no GP registration. Housing authorities may refuse to accept a prisoner on their waiting lists before he is released because he is not potentially available to take up a tenancy should one arise".
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 largeand I do not pretend that it is notwe 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.
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 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 treatmentto be sat 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 crisisnot 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 trueand I am sure that the Minister will tell us in his replythat 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 200102. 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 much greater emphasis 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 sayI always amabout 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 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 methe 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-handand so frequently it is not. Much of what the noble Lord, Lord Ramsbotham, said played well into that point. We know that there are many people sitting on acute wards who 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 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 and where they should be based and how they should be configured to achieve the optimum therapeutic outcome? If we did that, we might perhaps 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.
My Lords, the noble Baroness, Lady Neuberger, has done us a service in tabling this Motion 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 recogniseas, I am sure, are we allthat 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 not about inputs but about 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 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 numbernot, I may add, as a patientand 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 wardsthe 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 carea major partis 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 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.
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 wellas a number of noble Lords have saidthe 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 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.
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 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 outpatient 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 of 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 workday 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 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 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 andthanks to the efforts of staff who were in place and the newcomers to the servicefront-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 of our ambitions. Until we do, the top of the agenda is exactly where mental health will stay for this Government.
House adjourned at three minutes before nine o'clock.
Written answers Monday 5th June 2006
To ask the Secretary of State for Health what the findings were of the race equality impact assessment of the 2004 draft Mental Health Bill; and when she expects to publish the assessment.
As the draft Mental Health Bill published in 2004 no longer represents current Government policy on mental health legislation we have not and do not intend to finalise the report of the race equality impact assessment (REIA) that was undertaken last year. However, we have listened to what people said during the consultation on the 2004 draft Bill and we will carry forward their comments when developing the REIA for the amending Bill.
We will be publishing a summary of the responses collected from the former REIA process, to assist in the development of issues for the current REIA. The summary will be available on the Department website shortly.
Information about the Mental Health Bill REIA is available on the Department's website at www.dh.gov.uk/Consultations/LiveConsultations/LiveConsultationsArticle/fs/en?CONTENT_ID=4134722&chk=UugHb7.
MENTAL HEALTH SERVICES
House of Commons debates
Tuesday, 16 May 2006
Oral Answers to Questions Health
Mental Health Services
What assessment she has made of the impact of financial deficits on budgets for mental health services for 2006-07; and if she will make a statement.
Which mental health trusts are making cuts as a consequence of NHS deficits.
Planned expenditure for mental health services in 2006-07 is still being negotiated as strategic health authorities finalise their local delivery plans. In 2005-06, 11 out of 84 mental health trusts reduced planned expenditure by £16 million overall, while the complete expenditure increased by £368 million.
I thank the Minister for her response. At the last Health questions, she assured me that mental health services were one of her Department's top three priorities, notwithstanding existing NHS deficits. If that is the case, why is mental health not included on the list of the six key national NHS priorities specified in the Department's operational framework and setting out the key principles for financial management for health trusts for this current year? Does she appreciate that the effect of that is that spending on mental health services by health trusts is likely to be frozen or cut this year as a consequence?
We should be clear about the improvements that have taken place in spending on mental health servicesan increase of something like £1.6 billion over the past five years. Also, if we consider what happened last year, again, 11 out of 84 trusts reduced planned expenditure. They were going to spend £384 million more than they spent the year before, but in fact they spent £368 million. That means that overall expenditure on mental health has increased. It is clear, through the targets that have been set and the local delivery plans, that the actions we have adopted contributed towards that increase in mental health spending. Mental health under the previous Administration was a Cinderella service, suffering from years of underinvestment, unlike the situation under this Government.
Berkshire Healthcare Trust faces cuts of £10.2 million in mental health care provision. One area particularly affected by those cuts is early intervention services which, as the Minister knows, are a key Government target in the national strategic framework for mental health. Will she carry out an assessment of the human costs of such cuts?
The hon. Gentleman is right that early intervention teams are important, which is why we introduced them. One of the many changes made under the Government to the delivery of mental health care is the greatly increased emphasis on care in the community. In Berkshire, I believe that the spending figure is about £200,000 less than was going to be spent, so it is not quite the same as what he suggested. I will look into his point, but I understand that the figure is about 0.1 per cent., because the overall budget is £77 million. There have been improvements in his area, and I hope that he welcomes them. I accept the point that he made about early intervention, and I will look at what cuts are proposed for early intervention teams, as I would be concerned about them.
Due to the actions of our Government since 1997, mental health care has recently ceased to be the Cinderella of the NHS, but it is still something of a poor relation. Can the Minister reassure the House that people and patients have not been put at risk by budget reductions, about which Louis Appleby, the national director for mental health, is unhappy?
Given the extra investment in mental health services, we are anxious that primary care trusts and strategic health authorities should maintain a high quality of care. As I have said, when we looked at planned and actual expenditure last year, the difference was £16 million, but that does not mean that overall expenditure did not increase on mental health services. It did, and it has done so consistently in the years since the national service framework was introduced, along with new teams, modernised ways of working and increased investment. That has made a genuine difference to people who use our mental health services, and we certainly want to maintain those improvements.
Last week, Shropshire County PCT announced the closure of Whitcliffe mental health ward in Ludlow community hospital, not because of patient care needsthe patients will be transferred to the only remaining Victorian asylum operating in this countrybut entirely as a result of financial deficits. The mental health trust operated at surplus in 2005-06, and it is due to break even in 2006-07, but it has been forced to make cuts and close that ward purely because of the financial deficits that affect the rest of the NHS in Shropshire. Why?
It is difficult for me to comment. As the hon. Gentleman said, the trust will break even this year, so I am not certain why he said that that in-patient ward will be closed. In-patient wards are often closed because services are provided in the community, thus reducing the need for in-patient beds. That may be the case in his constituency, or some of the patients may be transferred elsewhere because that is more appropriate. However, he should accept that in some instancesI will, of course, look at the point that he madethose decisions are made for good reasons, as the fact that there are teams in the community may mean that there is less need for in-patient beds.
On Friday, the Department of Health produced a press release headed, "End of the 'Prozac nation'more counselling, more therapy". It trumpeted a "ground-breaking initiative", "a major new programme". What we get is a couple of pilot schemes, while in Oxfordshire, Cambridgeshire and other places around the country that we have heard about, front-line mental health services are being cut. Is that not another case of the Department of Health being out of touch with what is happening on the ground?
I am disappointed by the sneering attitude that the hon. Gentleman is taking towards an initiative that has been welcomed by all the mental health charities and by mental health service users, who know the importance of psychological therapies. They know that we need to build up the case for saying that psychological therapies can be a very good alternative to drug therapies. We have always been clear in every White Paper and in our manifesto commitments that we would start a gradual programme of introducing psychological therapies. We need to showwhich is why we have set up demonstration sitesthe benefits of the approach not just to the individual, but to the local community. The programme is a good way of doing that, and I am sorry that the hon. Gentleman's attitude goes against everything in which we have been supported by service users and mental health charities.
I presume the Minister was disappointed with Rethink when it published a damning catalogue of budget cuts to mental health services around the country: the closure of mental health day hospitals in Suffolk; mental health wards closed at St. George's, Tooting or forced to become mixed sex wards; and 5 per cent. cuts in Hertfordshire mental health services. Was she disappointed with the Mind report yesterday, which highlighted the absence of appropriate services for the one in six women who suffer mental health problems around childbirth, with 25 per cent. of them waiting more than six months for any support? Will she be disappointed tomorrow, when Pulse magazine brings to Parliament general practitioners who are alarmed at its survey showing 93 per cent. of GPs prescribing antidepressants contrary to National Institute for Health and Clinical Excellence guidelines, because of a lack of available alternatives? Does she really think that our mental health services are having their best year ever?
Following the Rethink survey, we carried out a survey of all 84 NHS trusts whose full details we will publish tomorrow. I have been finalising everything that I want included in it. The figures show that, as I said, planned expenditure increased, but not by as muchby about £16 million less than was intended, out of a total expenditure by those trusts of £893 million. On psychological therapies and the Mind survey, the hon. Gentleman is right to say that, for post-natal depression, we need to increase the services available. That is why we have set up the demonstration sites that we announced last Friday. We know that much more can be donefor example, through health visitors to assist with post-natal