Category: Health

The speech made by Liam Fox, the then Shadow Secretary of State for Health, at Conservative Spring Forum on 23 March 2002.

Hardly a day goes by without further evidence coming to light indicating that, under Labour, the NHS is failing. Dirty hospitals with high infection rates for patients. Cancelled operations leading to rising waiting lists. A care home crisis resulting in bed blocking, with frustration for patients and demoralization for medical staff.

Yet, despite this bleak picture under a Labour government that promised so much, the public remains ambivalent about the NHS. At the same time as rising intellectual criticism about the quality of the service, there remains a strong emotional attachment to the institution itself. There is therefore both a demand for change but a suspicion that change may threaten the aspects most prized by the public, such as a service free at the point of use for those who need it.

Complicating the picture is the fact that some of the harshest criticism of the NHS comes from those who were previously its fiercest defenders. Often, the combination of their own unhappy experiences and an increased awareness of better healthcare overseas has persuaded them that the NHS is not the only model capable of producing the quality and security of access they seek.

It has been a serious handicap in the health debate in the UK that the terms “healthcare” and “the NHS” have for too long been politically synonymous. Only recently have events conspired to promote change, for example a Labour Government being forced to have British patients treated on the continent because of the explicit failures of the NHS. This backdrop provides a rare opportunity to open up a better quality discourse. That debate needs to begin with a clear understanding about the origins of a peculiarly British approach.

The National Health Service was a product of the 1940s – that is of a collectivist era. Central planning was high fashion, as was the notion that state control was the best way to achieve change. This is unsurprising. The War had seen a massive increase in state regulation, which had been tolerated in the interests of victory. Austerity and rationing were necessary and accepted concepts.

Now, 60 years later, we find ourselves in an era of affluence which the founding fathers of the NHS would not recognize. In 2002, austerity is no longer fashionable or necessary. Yet much of the British public have been willing to tolerate just such austerity in the field of healthcare. It is almost as if inadequate provision has been accepted as a classic case of Britain “muddling through”, with the Dunkirk spirit its guiding force.

Increasingly, the patience of patients is wearing thin. There is a growing demand for the standard of healthcare befitting the World’s fourth richest country. We are no longer a nation emerging from the ravages of a War that almost drove us to extinction. It is no longer acceptable for the public to be constrained within an NHS that does most things quite well most of the time. What is needed, and increasingly demanded, is a system that does many more things very well all the time.

Politically, Labour has been the party most wedded to the politics of the 1940s. But even they have been forced to abandon most of their discredited ideological positions from that era.

On the economic front, they have retreated before reality. They no longer have Cabinet Ministers whose sole responsibility is Food or Prices. The major nationalizations have been overturned. Trades union reforms and labour market liberalization have brought prosperity and individual emancipation in the economic sphere.

In the social sphere, however, individuals are still much more at the mercy of the state. Labour fought tooth and nail against Margaret Thatcher giving council house tenants the right to buy their own homes. In education, too many children pay the price for Labour’s obsessive centralisation, while in health, Labour deny people the right to choice and diversity taken for granted in so many other countries.

Labour supporters cling to the NHS like a comfort blanket, because, in every other facet of policy, they feel that the Labour Party has abandoned its roots. The NHS is the last remaining manifestation of the Attlee government, of the era when Labour believed they had all the answers. But the NHS was never even the Utopia Labour like to portray. Within a few years, they were retreating from their New Jerusalem, with charges for spectacles and prescriptions, thus creating the service which Tony Blair describes as “largely” free at the point of use.

The NHS, as an institution and not merely as the expression of a set of ideals, has thus acquired a totemic identity in the eyes of Labour politicians which has little to do with healthcare. Its continued existence in its present form owes more to the complex psychological needs of a Labour Party which is no longer a socialist party in a world where socialism no longer has a place.

The NHS has now become the fig leaf for New Labour’s vapid core. Indeed, it is just about the only thing that allows Labour activists to live with their consciences, their Party having thrown virtually every other Labour nostrum over the side of HMS Blair in search of the rhetoric to please the focus groups. Politically, the NHS is now the ventilator on the Labour Party’s own life-support machine.

And the joint victims in this tragedy are the patients, denied the care they need, and the medical professionals, unable to provide what they have been trained to do. The NHS, under Labour’s model, pursues equality of access at the expense of excellence, and seems almost to accept mediocrity as a manifestation of social values dating from “the golden collectivist era” of the post-War world.

So, the first problem which Labour are landed with is that the NHS is over-centralized and over-politicized.

For Bevan, this maxim was in full accord with the ethos of the day, and entirely deliberate. He thought it vital that he should be able to hear the crash of every bedpan from his office in Whitehall. This was why he rejected the proposal from the original Beveridge Report that the existing system of mixed healthcare provision should be retained, and instead nationalised virtually the entire system overnight.

Successive Labour Health Secretaries have followed the script for the NHS which Bevan wrote in 1948, all determined to run the Health Service from behind their Whitehall desks.

And, despite its focus group-friendly lexicon, New Labour’s grip on the healthcare system has been similarly vice-like. Time and again, they have brought clinical and political considerations into direct conflict. Ministers have swept aside concepts of clinical priority in favour of their own insatiable PR agenda. Professional freedom is suffocated, and ethics take a back-seat, as clinicians and managers are pressurised into making the political health of the Government, rather than the health of their patients, their main consideration.

Examples of what this means for the patient are legion. There can be no clearer illustration than Labour’s hugely discredited waiting list initiative.

This policy has been roundly condemned in most quarters for encouraging clinical distortion, as a result of which patients with more serious conditions actually wait longer while simple, less urgent cases are dealt with more quickly to bring numbers down. It has been pointed out, quite rightly, that this abandonment of the principle of treatment being undertaken on the basis of need has undermined the entire ethical and moral principles which the NHS was supposed to embody.

It is entirely consistent with the narcissistic nature of New Labour that they are more concerned with how things appear than how they really are.

Waiting lists are controlled by restricting the numbers of patients who get to see their Consultant (it is only then that their official waiting time starts). Thus there is a huge rise in the waiting list for the waiting list. Patients are still waiting in pain and fear in increasing numbers. But Ministers can claim to have met their targets.

Systematic and widespread fiddling of the figures takes place. Consultant to consultant referrals are not counted. Patients who refuse a specific date or refuse to answer letters become “administratively” removed irrespective of their real problems.

Only recently, a GP friend told me that he had just returned from holiday only to find that his daughter had been taken off a waiting list because, while they were away, the health authority sent a letter saying, “If you don’t write back within seven days, your name will be taken off the list.” Now she has to go back to the end of the queue. What sort of system is that?

In another hospital, the maxillofacial surgeons were forced to add patients to the waiting list and give a date of 23 December for treatment, knowing that no patient would volunteer to go in for facial surgery so close to Christmas. Those patients were therefore taken off the waiting list.

In March last year, the British Medical Association described the situation where ‘Artificial targets imposed on an overstretched service cannot be met without resorting to ingenious massaging of the figures. It does not fool, nor does it help, patients’.

But it is the reaction of the Blair Government to exposure by the National Audit Office of fiddled waiting list figures that is most instructive.

As you would expect, the Prime Minister tried to understate the issue, telling the House of Commons that:

“It is important to put this matter in perspective. Over a period of four to five years, 6,000 people were misallocated on the lists.”–[Official Report, 19 December 2001; Vol. 377, c. 281.]

Only 6,000! They are not mere statistics; they are real people, sick people. This outrage is, in my view, one of the greatest stains on this Government’s record and it is a direct result of the mindset of New Labour.

One of the hallmarks of Labour’s stewardship of the NHS has been their clear intent to ensure that as many party political poodles as possible are in positions of NHS authority. Against the entire ethos of public service, Labour have ensured that appointments are made not on the basis of what individuals can bring to the administration of health care, but the loyalty they will bring to their party political masters.

When Dame Rennie Fritchie was confronted with the evidence, she concluded that there were, indeed, an unacceptably high proportion of appointments made to Labour Party supporters. In the wake of this, the so-called Independent Appointments Commission was introduced. What difference has this made? In response to recent Parliamentary Questions, the Government has revealed that the proportion of Labour Party appointees has actually increased! In fact, this is little wonder. Although the Appointments Commission itself is supposedly independent, it is appointed by the Secretary of State.

When Labour came to power in 1997, they promised to put more money into the health service by cutting administration. In practice, quite the reverse has happened. We now have the situation where, for the first time in the NHS, the number of administrators is actually greater than the number of beds. We have the absurd situation of having 1.15 administrators for every NHS. Under Labour the number of beds has fallen by 16,000 and the number of administrators has increased by 27,000.

This problem is made worse by the fact that the increase in administration has largely been accounted for by people whose role is to make the system still more centralised. In other words, we have reached a position in which the NHS as a whole is over-bureaucratised, but individual Trusts might well be under-managed. The main reason for this is the constant interference, in the form of Ministerial circulars, and the resulting obsession with targets in the system.

Under New Labour, if it moves it must have a target. The predictable result of this has been the emergence of target-orientated behaviour amongst hospital managers, whose job primarily is to meet centrally-set targets, irrespective of what this means for the running of their hospitals or the impact on the patients.

We have seen the ridiculous situation where patients have been kept in ambulances outside Accident and Emergency Departments because their waiting time does not officially begin until they are clocked in to the A and E Department itself. This enables hospitals to meet their Accident and Emergency waiting time targets. But it makes no difference to the patients themselves. Likewise, when hospital trolleys have their wheels taken off, they technically become a bed – so, by the most bizarre manipulation of their own equipment, hospitals are again able to reach the Government’s targets with no benefit whatsoever to the patients.

Perhaps most distressing of all is the concept of redesignation of parts of hospitals. Outsiders simply cannot comprehend that corridors could be redesignated as wards, with the result that, technically, patients are not waiting in corridors. Such cynical and essentially dishonest behaviour brings shame on those who have demeaned their own professional status by doing such things and denies patients the level of care and dignity they have a right to expect.

There can be few organisations that will rival the NHS for sheer ability to waste resources. Almost unbelievably, the Head of Controls Assurance at the NHS, Stewart Emslie, identified £9 billion of waste in the NHS in 2001 – almost 20% of the entire budget. Amongst the items of waste that he mentioned were £2 billion as a result of bed blocking, between £1-3 billion of fraud and theft, over £1 billion wasted by hospital acquired infections, £300-600 million on medication errors, £300-600 million on wasteful prescribing, £400 million on clinical negligence and £100 million on avoidable management costs.

It is inconceivable that any Chief Executive Officer of a major company would be able to hang on to his job, given such gross and unacceptable diversion of vital resources. Yet this is a system into which, with characteristic failure to understand the root problems, Labour is simply proposing to pour further huge sums of taxpayers’ money.

The Prime Minister told us on the BBC’s recent NHS Day that more taxpayer’s money will have to be pumped into the Health Service. He is ignoring all the evidence if he believes that this alone will be the answer to the system’s problems. Labour has already spent considerably more in real terms, but to no effect.

A Surrey consultant, Peter Williamson, recently told Hospital Doctor:

‘The Government claims it is putting great sums of money into the system – but this money is seldom seen by the people inside the service’.

Experts at the King’s Fund have highlighted how the Government’s extra funding has had little impact on activity levels. They said:

‘The implication is that any reduction in the waiting list in the last three years has been achieved not through treating extra patients, but through fewer people being placed on to the waiting list each year. The figures show that there has been a fall in the rate of increase in NHS activity, despite a large increase in funding for the NHS.’

Things are so bad that, despite a 30% increase in real terms in the level of health spending over the last three years, there was actually a fall last year in the level of NHS activity.

We do not need to look far to see that spending alone is not the answer. Wales and Northern Ireland are already above the Institute of Fiscal Studies target of 8.9% GDP and Scotland is above the Government target of 8%.

Yet in all parts of the UK the health service is failing, even in Northern Ireland, where spending is commensurate with France. Although Wales and Northern Ireland have higher spending than England, they also have longer waiting lists.

From a significantly higher baseline, expenditure in Scotland is rising, but things are still getting worse. For example, over the period from 1999 to 2001, there has been a marked increase in the number of people waiting for treatment, patients are waiting longer for treatment and fewer patients are being seen. And over the last year, the number and rate of nurse vacancies has also risen.

Despite higher spending in Scotland, a third more people die of heart disease and 40% more people die of lung cancer. It is clear from across the UK that the problems of the NHS monolith cannot be solved by simply throwing in more taxpayer’s money.

“No more for the NHS until it gets better” the Chancellor told the Sun. Did we miss something? What event has occurred to justify the billions extra about to be spent? For, rest assured, billions more will be spent while mere tinkering goes on.

Despite endless upheaval, very little will change in the NHS. The New Labour oxymoron of “earned autonomy” means “you can do what you want but only if it’s what we tell you”. The latest legislation gives many new powers to Whitehall to control activity in the NHS. For example, the Secretary of State will set all the budgets of the new Primary Care Trusts, and can withhold funds if they fail to meet his performance criteria.

Talk of commissioning powers and the emergence of strategic health authorities makes many wonder if Labour are simply recreating the internal market they abolished in 1997, having wasted five years and countless amounts of money in the meantime.

Labour’s relationship with the private sector is equally dysfunctional. They have alternated between support for a monopoly provider, a full partnership and a short-term expedient. The position, of course, depends on the audience, not the analysis. What is clear, however, is that the policy will have nothing to do with choice.

Of all the failings in Labour’s approach to health, perhaps the greatest is their failure to understand the value of individual choice.

From the moment a patient first experiences symptoms, their route through the healthcare system will be plotted by someone else, taking no account of any preferences he or she might have. And at all stages along that route, the patient will be within a system which is State-owned and State-run.

The fundamental and inevitable failings of such a centralised and politicised State monopoly system manifest themselves from the very outset.

The patient’s first point of contact is with their GP. They have little, if any, choice over who this is, they will belong to a “list” and the Government will regulate and restrict the number of GPs in any one area.

If their condition warrants it, the GP refers the patient to a consultant. Needless to say, they don’t have any choice over which hospital the consultant works at, let alone that consultant’s identity. Their time of treatment will be dictated to them, and with increasing frequency may be cancelled. If they fail to observe all the rules set they will go to the back of the queue.

What century is this? Why is it that the consumerist culture is entirely absent from our State healthcare system? The assumption seems to be that patients exist to service the system, rather than vice versa.

Without giving greater control to individual patients over their own medical and surgical treatment, there will never be a liberation from the unacceptable position of the State holding the whip hand.

As in so many other areas, the problems faced by our public services can be traced back directly to the very ethos of New Labour. Like the Clinton Administration, its project is about coming to government and staying in government, not about what to do when it is in Government. Policy consequently is replaced by endless reports and reviews. It is little wonder that a senior United States official was quoted recently as saying that Tony Blair seems more concerned about finessing a problem than dealing with it. How very perceptive.

Any given problem is exacerbated by the fact that the Government has no core beliefs at all. One minute they will call for a monopoly NHS, another a public/private partnership or even full-blown private sector involvement. What they say depends entirely on the audience.

This is a Government of intellectual incoherence, inconsistency and incompetence, in which the Prime Minister becomes ever more detached. And in doing so, he appears to grow increasingly contemptuous of his party – it seems to exist only to glorify the cult of his personality, spawning a Ministerial culture of blame, spin and re-announcement. When things go wrong, they are happy to blame the professionals, their predecessors in government, the Third Way – anyone but themselves. If that fails, they set new targets, shift deadlines and commission new reports. They stand for nothing, but will say anything.

The public have instinctively trusted Labour on health, but their hopes are being, and will continue to be, shattered. The NHS is not delivering what it should. Despite a huge increase in resources, the NHS actually saw the number of patients treated last year fall. Waiting lists are rising. The crisis in care homes threatens to turn care in the community to neglect in the community. The number of cancelled operations is soaring. Hospital acquired infections are at record levels. Morale continues to plummet in the caring professions.

Labour’s response is to pour in more taxpayer’s money and tinker at the edges of the NHS. Sadly, they will not succeed. The NHS is a collectivist model in a consumerist world. It is over-centralised. It is over-politicised. It is over-bureaucratised, yet under-managed. It is obsessed with targets, but failing to meet clinical need. It is wasteful; and spending and outcomes have increasingly become disconnected. Only the dedication of its staff keeps it afloat. Labour will fail because they will not accept these things.

Without a historic depoliticisation and decentralisation, coupled with increased choice for patients, Britain will be consigned to second-rate healthcare.

A solution will require a Conservative prescription. Tony Blair was right on one thing ” Britain deserves better”. Five years on, it is clear that this cannot come from Labour.

I once likened the approach of the NHS to asking Dickensian peasants to queue up for their gruel, and to say thank you because there was nothing else on offer. Like Oliver Twist patients want more. It is what they deserve. But not just more of the same.

The speech made by Liam Fox, the then Shadow Secretary of State for Health, on 25 June 2002.

In the children’s story “The Emperor’s new clothes” it required the simple yet definite and courageous view of one individual to challenge the conventional wisdom and open the eyes of the population to their mass denial of reality. In dealing with the issue of mental illness we need a similar reality check asking whether recently adopted trends and measures are effective and relevant or merely rhetoric and fashion.

The way in which a society treats those least able to play a full role is a measure of how civilised that society is. Sadly, I believe that we accept a level of care for those with mental illness that we simply would not accept for those with other types of illness. If you walk from Westminster up the Strand or into the heart of London and see people, many of whom will suffer from a mental illness, sleeping in the doorways of some of our wealthiest institutions then there is a policy failure that a humane society should not tolerate.

THE UNSPOKEN EPIDEMIC

It will come as a surprise to most people that one in four of us will suffer from sort of mental health problem at some point in our lives. One in four. I doubt there is a single person out there who has not experienced the impact of mental ill-health on someone in their life – be it relative, friend or colleague.

Mental illness is society’s unspoken epidemic, one of its last taboos and so rarely discussed. People regard mental illness as a weakness. They stigmatise those individuals who suffer from it. Why else was Mrs. Rochester locked in her attic? Why else did it take Lorraine Wicks so long to accept her son Joe had schizophrenia in Eastenders, and for him to seek help? If we are to diffuse the stigma surrounding mental health, we must dispel the ignorance of people.

The spectrum of mental ill-health is incredibly broad. It encompasses the Mum with post-natal depression, the Dad struck by depression after a period of prolonged unemployment and the son or daughter with a behavioural disorder who is underperforming academically and is disruptive in the classroom.

It is also about the college friend who commits suicide (seemingly for no reason), the soldier returning from an overseas conflict but unable to adjust to the realities of daily life, and the elderly parent slowly being ravaged by the dehumanising erosion of the human spirit known as Alzheimers.

While the safety of the public must always be at the top of our priorities we need to move the debate away from an obsession with the mercifully few incidents when someone with a mental illness harms someone else and remind ourselves that it is in the interests of that very public safety that we ensure adequate and appropriate treatment for all those who need it.

THE CURRENT SITUATION

Sadly, too many politicians seem to pay more attention to the potential dangers psychiatric patients pose, and issues surrounding their compulsory treatment than to the far more important issue of appropriate treatment of all patients. We need to shift the debate away from those rare incidents of violence which end up stigmatising anyone with a mental health problem.

The situation is currently bleak with widespread staff shortages, acute and day-bed shortages, wide gaps in community provision, and a lack of effective step-down care for those returning to the community.

It is a situation made worse by the knowledge that while funds are earmarked in the health budget they all too often fail to reach those in need. Cutting the mental health allocation is an easy way of balancing the budget. The mentally ill are least likely to complain, make a fuss or write to the newspaper columns.

The evidence that the Government does not consider mental health a priority is stark. Buckinghamshire Mental Health NHS Trust has seen £1 million originally earmarked for mental health diverted into other areas. Half of all GP practices in Cumbria offer counselling to patients in need, and there are plans to axe the £78,000 service. The Avon and Wiltshire Mental Health Partnership Trust faces service reductions amounting to £500,000, and the Acupuncture Clinic at the Department of Psychiatry at North Manchester General Hospital is threatened with closure. It costs £60,000 a year to run. It’s quite clear that far from being a priority, mental healthcare is an afterthought for this Government.

Our inner cities bear more than their fair share of the burden. Those who are homeless, or who have alcohol or drug addictions, frequently also have mental health problems. They end up in our inner cities – where they become invisible amidst the hustle and bustle of city life to those who might otherwise help them.

But mental ill-health is not just an issue that afflicts inner cities. The crisis in our countryside has also led to an increase in mental health problems – such as the well documented tragedy of farming suicides which has touched my own constituency in North Somerset.

A HISTORICAL PERSPECTIVE

Throughout history, mankind has sought to put distance between itself and those deemed mentally ill. In the era of witchcraft, the treatment of the mentally ill consisted of the casting out of devils and theatrical exorcisms. Once civilisation had moved beyond that phase of superstitious fear, the commonly held view, for many centuries, was that insanity was untreatable. Any approach to dealing with the mentally ill had to focus on containment and custody. The mentally ill were hidden from human view in asylums and institutions, with varying standards of care. Locked away out of sight – and literally out of mind – those sent to asylums sometimes lay chained to their beds all day long. The corridors echoed to the screams of the undiagnosed and untreated deranged.

For many the reason they were there in the first place was often forgotten. Having an illegitimate child was sufficient to have you labelled a ‘congenital imbecile’ or ‘morally defective’. You were condemned to an asylum for the rest of your natural life. Even in the 1960s, there were examples at an asylum in the Scottish Highlands of asylum ‘inmates’ having all their teeth removed to simplify oral hygiene, and false teeth being washed communally in a big bucket.

For the countless thousands in these appalling institutions, those who were not ill to start with frequently ended up depressed, if not deranged, by the conditions they were forced to live in.

THE CONSERVATIVE RECORD

The Conservative Party has always been at the forefront of mental health reforms. It was Lord Shaftesbury who began to turn mental health from an instance of private misfortune to a matter of public concern. He highlighted the atrocious conditions in many of the London asylums, and changes began, albeit very slowly, to occur.

The reliance on asylums and other custodial institutions was such that by 1954 the population of psychiatric hospital beds peaked at 152,000 – more than twice the current prison population.

But it was Enoch Powell who took the first decisive step away from this model of care. In his own words, the 1959 Mental Health Act lit a ‘funeral pyre’ beneath the decaying network of asylums.

He was at his most eloquent on this subject in 1961, in what has become known as his Water Tower speech. He talked of asylums which stood ‘isolated, majestic, imperious, brooded over by the gigantic water-tower and chimney combined, rising unmistakable and daunting out of the countryside’ His goal, broadly speaking, was to move treatment of the mentally ill away from remote asylums and into local hospitals ‘in the community’.

With the development of new drugs, the possibility of treating patients actually in the community slowly became a reality. Starting with the findings of a committee into mental health chaired by Cecil Parkinson at the request Norman Fowler when the Conservatives were in opposition in the 1970s, policy development culminated in the 1983 Mental Health Act and Kenneth Clarke’s 1990 NHS and Community Care Act.

CARE IN THE COMMUNITY

Most people accept that it was right in principle to bring an end to the old asylums and have patients treated close to or within the community. Certainly the concept of care in the community had support right across the political spectrum.

But, as Virginia Bottomley wrote in a letter to The Times in 1998: ‘In an institution, an individual can be monitored 24 hours a day. In the community, reporting and fail-safe mechanisms are necessary if tragedies are to be avoided. ….. The pendulum has swung too far.”

That a warning in those terms should have been delivered by such a staunch supporter of the concept of care in the community ought to have set alarm bells ringing in government. But nothing was done.

Now the suicide rate is rising again. The increasing breakdown of the family unit, homelessness, abuse, and the absence of any sense of community in inner city areas are all contributing to increasing prevalence of mental health problems amongst all ages, and particularly the young.

This is not to ignore the fact that care in the community has provided many thousands with an opportunity to experience a quality of life far better than what they would have experienced inside restrictive institutions.

Nor can criticism be laid at the door of medical, nursing and voluntary staff who have made a Herculean effort in the face of the greatest difficulties.

I would reject completely the criticism of some that care in the community was nothing more than an unfortunate or catastrophic meeting of a desire for financial savings and a naïve passion for the rights of the individual.

But the pendulum has swung too far- and too fast. Many now feel that care in the community was implemented too quickly, with inappropriate patient selection and in too many places, there was too little investment in training, finance and related areas.

There has been, at times, too little care, scant support, and a form of community which has exposed the vulnerable- both patients and the public- to danger.

Individuals were sometimes placed in a complex urban environment that they just couldn’t cope with. They lacked understanding of their condition, and their institutionalised background made them unable to deal with the complexities of modern living. And when they needed help, their cries went unanswered.

We need a new balance to be struck which ensures the most appropriate treatment and environment for patients. A balance where those that need treatment in a hospital setting receive it and only those able to cope in the community are placed there.

And we must accept as part of this balance that care in the community has been discredited in the public mind by a series of crimes committed by the mentally-ill who had fallen between the gaps or come off their medication.

The litany of cases represent some of the most horrifying and frightening crimes of the past few decades – Christopher Clunis stabbing Jonathan Zito on the platform of Finsbury Park, Horritt Campbell attacking nursery nurse Lisa Potts, Michael Stone murdering Lin and Megan Russell on a Kentish country lane, the attack on the late George Harrison in his own home, the Liberal Democrat councillor Andrew Pennington attacked by a man with a sword at a Cheltenham advice surgery.

A case from my own constituency: Sarah Beynon from North Weston, just outside Portishead, was sent to Broadmoor in August 1995 after killing her father while on leave from a clinic. An enquiry found that staff at the Southmead Hospital did not ensure she took her medication. Risks were taken unnecessarily, and she was not safely contained physically. There was a lack of communication between social workers at the Fromeside Clinic regional secure unit. At Fromeside, she was the only female in a ward of fifteen patients. The monitoring of her condition was often left to nursing staff without specific training.

But these tragic cases are not just in the past. A 37 year old paranoid schizophrenic woman was ordered last April to be indefinitely detained after an indiscriminate outbreak of violence in which seven people were attacked in Leeds city centre. Formerly an in-patient treatment, she had been asking her doctors to change her medication at the time of the attack. No-one was around to pick up the signs that something was going wrong.

As Michael Howlett of the Zito Trust told the Yorkshire Evening Post (11 April 2002): ‘People don’t just attack people in the street out of the blue. There’s always a build-up over weeks or months. These incidents are usually as a result of services breaking down and the danger signs not being spotted’.

However, it is a misapprehension that because it is preferable not to institutionalise people that the community is invariably the place to locate all mental health patients.

Let me just quote from the Sainsbury Centre’s briefing on in-patient acute care published the other week: ‘We have yet to develop realistic plans to deliver acute inpatient care which is therapeutic and supports recovery. Unless we develop and implement such plans, nationally and locally, we will see an increasing cycle of decline in acute mental health care with increasing user dissatisfaction, incidents and inquiries and the loss of high quality staff – all despite the best efforts of many committed staff. The situation is little short of a crisis and has to be addressed now. In some instances the quality of care is so poor as to amount to a basic denial of human rights.’

A DANGER TO WHOM?

Events involving just a few stigmatise the many – and lead others to overlook the danger some mentally ill people pose to themselves.

The case of Ben Silcock is a good example. Mentally disturbed, it was he who was severely mauled after climbing into the lion enclosure at London zoo.

Incidences of suicide, particularly in prisons, far outnumber the cases where the mentally ill patient harms someone else. Sadly, around 1,000 schizophrenics commit suicide each year. This contrasts with the 40 murders each year committed by people who have been in contact with mental health services, and who are not necessarily schizophrenics.

It will always be the duty of government to protect the public from harm, if necessary by detention or compulsory treatment. But politicians must take care to adopt a balanced approach which does not stigmatise and thereby worsen the plight of those who pose no risk to anyone, except possibly themselves.

WHAT CAN WE LEARN FROM ABROAD?

Gordon Brown says we have nothing to learn from abroad when it comes to health. That is equally ignorant and arrogant, especially in the area of mental health.

I was enormously impressed in Denmark during a visit to a psychiatric hospital at the profoundly calm atmosphere and the sense of patients being treated with dignity and respect.

And some of you may have heard of the Hotel Magnus Stenbock in Helsingborg, Sweden. It is a good example of what might be termed a ‘halfway house’ for those moving between an institutionalised setting and the community. It has 21 single rooms. It offers a balance between private and social space. The hotel is not just about its structure and about the offering of crisis accommodation, but it is also about developing a sense of community, a sense of acceptance and offering a place of safety. It is run by the RSMH, an organisation of mental healthcare users, which runs a million-pound organisation that sustains and nurtures self-help models of care throughout Sweden.

Perhaps the most striking comment I saw about the hotel was that of a shopkeeper who runs a store nearby the hotel. One might have thought the local population would have objected to the hotel being near them, but on the contrary, he said ‘The proximity of the hotel has not had any adverse effects on business, sometimes the general public are a little wary of users, but they see the staff in the shop are not afraid and are treating the hotel residents the same as all the other customers. It makes them more comfortable. We believe everyone has the right to be treated as a human being and at some point in everyone’s life we all encounter problems, some more severe than others’.

This is symptomatic of the approach of Sweden and other countries. They regard mental illness as no different from any other illness. They are prepared to innovate. Variety is what matters. We need to offer services which reflect the diverse needs of those with mental health problems, rather than offering a limited range of services which the individual has to fit their mental health problem round. And the RSMH shows how the state does not need to be the only provider.

MENTAL ILLNESS IN THE YOUNG

It is amongst the young and old that there is the greatest propensity for others to dismiss the symptoms of mental health. The rate of mental health problems amongst children and the young is alarmingly high – twelve per cent suffer from anxiety disorders and ten per cent have disruptive disorders.

The signs of mental ill-health are too often dismissed as growing pains yet mental health problems in the young can quickly lead to juvenile crime, alcohol or drug misuse, self-harm and so on.

These problems affect children in care in particular. For example an Audit Commission report stated that two thirds of young people looked after by Oxfordshire County Council had a diagnosable psychiatric disorder, compared with only 15% living at home.

It is also surely a cause for concern that a third of young men between sixteen and eighteen sentenced by a court are diagnosed with a primary mental disorder.

Mental health problems not only make children unhappy but also retard their emotional development and social skills, and blight their education and life chances. The social problems that can consume young people such as school truancy, teenage pregnancies, bullying and school drop-out rates are as much part of the mental health agenda as the developmental and behavioural disorders more frequently cited.

We have a duty to these children to ensure they receive the appropriate assistance rather than being condemned to a youth spent at the margins of an unwelcoming education system and a fearful civil society.

The causes of mental health problems amongst the young are diffuse. Genetic influences can make children more likely to suffer from serious mental health problems, but very often it is societal influences that can influence the development of anxiety and conduct disorders. The increasing breakdown of the family unit, homelessness, abuse, and the absence of any sense of community in inner city areas can all contribute.

Such problems can manifest themselves in behaviour which is often classified as wilful ill-discipline. Preventative work which involves educating schools and helping them to understand the wider implications of bad behaviour is a sensible step, as is involving the families. One difficulty, though, is that any suggestion of mental health problems is immediately seen as attaching a stigma to the child, and this impacts on the extent to which families are prepared to co-operate. They fear their child will be bullied (perhaps exacerbating the problem) and that the school’s attitude to a child who is potentially disruptive may also change. They wrongly feel that they protect their child by avoiding the issue.

THE ELDERLY- TOO OFTEN FORGOTTEN

Mental ill-health in the young is the wellspring of what I have described earlier as the ‘unspoken epidemic’. That epidemic is just as widespread amongst the elderly, and just as easily dismissed and ignored as with young people.

A quarter of those over 85 develop dementia – perhaps the form of mental illness most associated with the elderly. However, between ten and sixteen per cent of those over 65 develop clinical depression. This sort of mental illness is too often ignored, as younger relatives assume the individual is just ‘slowing down’ and ‘getting on’.

Older people deserve access to mental health services as much as anyone else. It is not enough just to assume that because elderly people have access to care homes, home helps, meals-on-wheels and the like anyway, an extra dimension of care on account of a mental illness they may have, is unacceptable. People are individuals, and they must be treated as such.

PRISON-THE HIDDEN SCANDAL

Enoch Powell may have lit a ‘funeral pyre’ beneath mental asylums when his 1959 Mental Health Act began the process of shutting them. But today, some seventy per cent of the prison population has a mental health or drug problem. Where once we hid our mentally ill in asylums, we now, unwittingly, locate many in our prisons.

The incidence of mental disorders amongst the prison population far exceeds that in the population as a whole.

It is a troubling thought that anyone who is mentally ill and has a brush with the law could find themselves subject to inadequate treatment in Dickensian surrounding at the beginning of the 21st century.

Facilities often amount to little more than sick-bays with limited primary care cover. The assessment of a prisoner on his arrival at prison typically takes five to seven minutes. A retired GP or a locum who may have no specialist knowledge of mental health often conducts it. The level of training of staff does not always match the complexity of the conditions prisoners present with.

Prisoners are thus less likely to have their mental health needs recognised, less likely to receive psychiatric help or treatment, and are at an increased risk of suicide. The number of suicides in 1999 – 91 – is almost double the figure of 51 from 1990.

As a report from John Reed, the medical inspector of the inspectorate of prisons, states: ‘A period in prison should present an opportunity to detect, diagnose and treat mental illness in a population hard to engage with NHS services. This could bring benefits not only to patients but to the wider community by ensuring continuity of care and reducing the risk of reoffending on release’ (BMJ, 15 April 2000). That this opportunity is not grasped is an indictment of the current system.

And John Reed has also said: ‘Many [prisoners] are quietly mad behind their cell door and are not getting any treatment. Care for mentally disordered offenders in prison is a disgrace’ (Nursing Times, 25 May 2000).

The Prison Service must, therefore, as a matter of urgency, consider how to address the mental health needs of the people in their charge. Research is required, in particular, to determine how the prison environment impacts upon mental health. This may include issues such as overcrowding, confinement in cells, and the range of activities available to prisoners.

A second problem is that prisoners with mental health problems remain within the prison service, and are not diverted to the NHS, as the Reed Report amongst others, recommended. It is inappropriate for prisoners with severe mental illness to be in prison. Sir David Ramsbotham has said ‘In my view mentally ill prisoners requiring 24-hour nursing care should be in the NHS, not prison’ (Nursing Times, 25 May 2000).

But for diversion to work, an alternative must exist. More beds would be needed in special and medium-security hospitals. In addition, upon completion of sentence, there are insufficient beds in ordinary psychiatric units to discharge prisoners into. This lack of beds clogs the whole system up.

Of course increasing capacity in the NHS whether for acute hospital beds or secure hospital places will require resources that will have to be contained within the envelope of health spending. Additional research is required to make an accurate assessment of exactly what is required and we shall now undertake this. But it is a question of values and priorities.

Whether patients are within the criminal justice system or not, it is in everybody’s interest to make sure that their mental illness is properly treated, and in the right setting, before they are released from custody with a treatable condition.

The Conservatives have already stated that we will spend what is required to provide better healthcare, but that imposes a duty to make the best use of the resources we already have before deciding what more might be needed.

An NHS which, by its own estimate, wastes some £9 billion a year needs to ask some awkward questions about its use of resources.

In addition, Derek Wanless dealt with the costs of mental illness and the potential savings of a better system in his recent report.

He pointed out that MIND estimate the total costs of mental illness at £37 billion a year. Of this, £11.8 billion is lost employment. In 1995 over 91 million working days were lost as a result of mental illness.

Home Office estimates put the overall cost of crime at £58 billion per year with a significant proportion being carried out by people with a mental illness.

When asked about the cost benefits of better mental health care, Wanless said “It is difficult to estimate the exact value of potential savings, but it does not seem unreasonable to assume that there might be a 5 per cent reduction in the costs of mental illness and a 2 per cent reduction in the costs of crime…..giving a net saving across government as a whole of some £3.1 billion a year.” (Securing our Future Health: Taking a long term view, Interim report, Derek Wanless, April 2002, pp.115 and 116)

A NEW AGENDA

Health policies cannot hope to eradicate the problems of an entire society. That Utopian vision was crushed very soon after 1948. What health policies can do is seek to support those who do suffer in what can be, at times, an atomised and alienating society.

That is why the Conservative Party is making mental health a central part of its health policy agenda. It is an issue that must become a matter of public concern, and not just a private misfortune. A self-enlightened society is one that realises, as they have done in Sweden and Denmark, that it is to the benefit of everyone that mental illness is treated – and if possible prevented – adequately.

And perhaps we need to bring back another concept – ‘sanctuary’. We started off with Bedlam, then we had madhouses, Lord Shaftesbury gave us asylums, and then we looked to the community. Now we have to speak of what all these differing environments ought to provide – a sense of sanctuary.

I recently visited a counselling service in Aylesbury where the described their office as “a place to feel safe.”

And last week I had the very great privilege of visiting the Hillside Clubhouse in Holloway. The Clubhouse network was something I had not heard of before. I was struck from the moment I walked in the door that the people who used the clubhouse – and who had mental health problems – looked on the Clubhouse as somewhere they could go to feel safe. It offered them companionship, constructive activity and the chance to go and get a paid job in the community. It supported them without compelling them. Everyone found their own level, and progressed at their own pace.

It was not somewhere they were forced to go, but equally it was somewhere that would keep in touch if they stopped coming along. In short, it offered genuine care in a real community. It was a sanctuary in an ever more complex and difficult society.

With New Labour’s obsession with celebrity, glamour and the good life, many feel that the vulnerable in our society now have no champions left. Concern about the social welfare of those in society who have no-one to speak up for them is an essential part of any programme for a truly national party such as ours. There can be few more vulnerable groups than those with mental illness.

We are not taking this stance because it is fashionable.

We are not doing it because we have identified some interest group or section of the population who we can make politically beholden to us as a consequence.

We are not doing it because we see some short-term gain to be had by pretending to interest ourselves in ‘soft’ social issues for a few months.

We are doing it because we believe it is the right thing to do.

That is what politics ought to be about.

The speech made by Liam Fox, the then Shadow Secretary of State for Health, on 5 June 2003.

Unless there is fundamental and radical reform, the NHS will never produce the quality of care we have a right to expect. And the people who would suffer most as a result would be the very people who rely most on the NHS.

Labour’s internal divisions mean it is unable to deliver the reform that many
recognise to be necessary. Only a Conservative Government will be able to deliver this.

Our experiences during our extensive travels convinced us that we must undertake far-reaching reform on three broad fronts:

– taking politicians out of running the NHS;
– giving real freedom to health professionals; and
– ensuring patients have real choice in health.

We believe that the NHS is there to serve patients not vice versa.

Freeing health professionals from the burden of red tape and the paperwork which targets bring will enable them to spend more time looking after their patients.

This is vital, since ultimately greater professional satisfaction is the only route to more health care professionals, something which Labour has failed to understand.

Our principle is that we want to see total spending on healthcare increase, but we will want to see the proportion of that spending that comes from other sources increase at a faster rate than that coming from the State. This will bring the UK more into line with the pattern of spending found in most of the European countries we have visited.

We believe that choice – a Conservative word – must be available to all patients who will receive their health care through the NHS.

But this alone is not enough. The standard of healthcare currently available to the British people is far below that which they have every right to expect in the world’s fourth largest economy.

Over recent years, whereas there has been minimal growth in PMI, the number of people opting for self-pay (frequently the elderly, reflecting the high cost to them of PMI and their desperation to avoid excessive waiting times late in life) has increased by an average of over 20 per cent a year.

In order to stimulate the creation of the new, non-NHS capacity referred to above, we will send clear signals that we are fully committed over the long term to measures designed to stimulate and strengthen demand in the voluntary and private sectors.

The most effective way of doing this is to make it more attractive for individuals to supplement what is already being spent by the State through the NHS. This will therefore be on top of what they spend through their taxes, not, as Labour falsely claims, as an alternative.

There are three main candidates which might be thus incentivised:

• Personal PMI;
• PMI available through company schemes; and
• Patients who pay for a single procedure or item of care
(the ‘self pay’ sector).

We saw examples during our overseas visits of cash rebates, tax incentives and reductions of the price at source, with the State reimbursing providers.

Attention needs to be given to companies who provide all their employees with a health insurance scheme and to those who negotiate reduced rates on their employees’ behalf with private insurers.

This will include the large number of Trades Union members who benefit from these types of scheme.

The self-pay market accounted for some 300,000 procedures last year (the age profile for which tends to be higher than that for personal PMI), a trebling since Labour came to power in 1997. If these patients did not opt to pay directly for defined elements of their care, in addition to what they have already contributed to the NHS through their taxes and National Insurance, they would be added to NHS waiting lists. It is doubtful whether the NHS would be able to cope with that extra demand.

Under our proposals, patients will be able to move around the NHS, with the finance for their treatment automatically following them. This will mean that for the first time there will be access to a truly national health service. Patients will be given a greater say over where and when they are treated, and by whom.

GPs could act as independent professional advocates for patients, advising them on factors such as comparative waiting times, outcomes and locations. This informed partnership between the patient and the GP would refute the argument advanced by Labour that patients would be unable to make sensible decisions about what form their treatment should take – a view which is both patronising and outdated.

There is no acceptance in Labour’s centralised monopoly model that patients have any ownership, in part or full, of the funds they have contributed through their taxes to the NHS.

We believe that the concepts of social solidarity – we all accept the need to cross-subsidise others in our society – and individual entitlement to contributions already paid are not mutually exclusive.

We believe it is simply unacceptable for choice to be available to a small proportion of patients. We want it to become the norm that patients are free to get treatment beyond the NHS whatever their income. We will therefore extend the Patient’s Passport to services beyond the NHS – that is to the voluntary, the not-for-profit and the private sectors – as soon as capacity allows.

This will yield two important benefits:

• It will become a realistic option for a much larger proportion of the population to have access to a very much wider range of healthcare providers than is now the case.

• Those who choose to have their health care provided within NHS hospitals will reap the benefit of shorter queues if more patients choose to have care elsewhere. Patients will, of course, be able to stay entirely in NHS hospitals if they choose: nobody will be compelled to go outside.

The value of the Patient’s Passport beyond the NHS – i.e. whether patients take some or all of the standard tariff funding that patients can take to voluntary or private hospitals – will need to take account of several factors: the total cost to the public purse, the level of available capacity from other providers, the predicted effect on NHS demand, the effect on the current private insurance market and the need to promote greater diversity in provision.

During the 1980s, the Conservative Government brought choice in home ownership to millions of people who had been denied it by socialist dogma.

This laid the basis for a home-owning democracy in which all social groups were able to take part.

The next Conservative Government will set patients free from the restrictions they face in the centralised Labour model of the NHS, so that all patients can benefit from the type of high quality and accessible care which is taken for granted by so many of our neighbours.