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.
