MENTAL HEALTH DEBATE – 12 December 1997
[NOTE: Julian was drawn second in the Ballot for Private Members' Bills in the 1997-98 session. He chose to introduce a Mental Health (Amendment) Bill. Government front- and backbenchers talked it out on 12 December 1997. It was then reintroduced in the Upper House by Lord Rowallan, passed all its stages there, with useful amendments, but was repeatedly blocked by the Government in the Commons until it ran out of time.]
Dr Julian Lewis: I beg to move, That the Bill be now read a Second time.
In preparing for the debate, I thought long and hard about the best way to try to convey to hon. Members the gravity, the horror and the utter desperation of people who suffer mental breakdown. In the end, I decided that reference to medical books, case histories and academic studies would not convey what I wanted to put across, so I went back to literature and film.
Hon. Members who have read Orwell's futuristic nightmare novel "1984" will never forget the last two chapters. In the penultimate chapter, the central character, Winston Smith, is still unbroken. He has been tortured, imprisoned and abused, and has said anything, more or less, that his torturers wanted him to say. Finally, he is sent to room 101, where the torturer, O'Brien, tells him that the worst thing in the world awaits him. [Interruption.]
Mr Deputy Speaker (Mr Michael Lord): Order. Will the hon. Member for Southampton, Test (Dr Whitehead) leave the Chamber please? Electrical devices are not supposed to be brought in unless they are under control.
Dr Lewis: To be interrupted in that way is perhaps another form of psychological torture.
The worst thing in the world for Winston Smith is a fear of rats. In the end, he cracks, even though no physical damage is done to him; that has already been done without breaking apart his mental stability. Finally, something that he fears more than anything else causes him, though the words are never used in the novel, to have an acute mental breakdown. In the final chapter, he has come out of it, but nothing will ever be the same again.
Moving from the written word to the visual image, one thinks of Alfred Hitchcock and the psychological films that he produced, which often dealt with the inner mysteries of the mind. To give an idea of what people go through when they have acute catastrophic mental breakdowns, I refer hon. Members to the film "Vertigo", where the central character is played by James Stewart. He has a fear of heights which leads him wrongly to believe that he has failed to save the life of the woman he loves, who he thinks has thrown herself from the top of a high building. Again, despite his courageous record as a policeman, it is that psychological pressure which causes him to break down and collapse. That is significant in relation to clause 1 of the Bill, which I hope will get a Second Reading.
In the film, James Stewart recovers from his breakdown. Having become thinner and thinner, woken time and again in the night, and having collapsed mentally, he is taken into a quiet, solitary, therapeutic environment with proper care so that he can come out of the trauma. A safe, separate and therapeutic environment is what people need to have any chance of recovering from catastrophic mental breakdown.
For someone who belongs to another category of person who goes through this ordeal – someone who has extra vulnerabilities due to her gender – protection and security are even more important. I refer of course to the situation in which a woman finds herself when admitted to an acute psychiatric unit. It may come as a surprise to hon. Members to know that, in all too many cases, women are on mixed sex wards against their will.
I should like to refer to the report of the Mental Health Act Commission, which relates to clause 2 and provisions that I believe to be essential, long overdue and bound to come sooner or later. We need single-sex ward areas, and special security devices on doors so that patients and staff can let themselves in and out at will, but predators and intruders cannot get into rooms and assault female patients.
During my researches on this subject, I visited a number of units, including a national health service unit in which an experienced ward sister was on duty. She said that her constant nightmare was that in the evening hours, when perhaps three members of staff were on duty, a male would get from his sleeping area into a woman's room and assault her. Yet there are security devices to prevent that. Such devices are already installed in something less than half of the existing units.
The Mental Health Act Commission's seventh report touches on those matters. On page 63, it says:
"The Commission recommends as a measure to secure privacy and safety that, wherever practicable, patients' single rooms should be lockable from the inside, but with staff having a master key."
Sensible enough, one would have thought. On page 158, referring to women's issues, the report says:
"Only a minority of wards have policies dealing specifically with women's safety. Features of the physical environment of particular importance to women, such as lockable bedroom doors, self-contained washing and toilet facilities or a suitable place for visiting children, are too often lacking, although some units have made great efforts to improve."
On sexual abuse, I will, with the permission of the House, read a slightly longer extract which is very telling. It is on page 175 of the report:
"Safety for women on psychiatric wards is a major issue, especially where staffing levels are low and violence considerable, as in the London area. A patient mix including men with a history of violence and young women with a history of abuse occurs on some wards. It has been reported to the Commission that Approved Social Workers are having to take such risk factors into account when considering applying for an admission."
I break off from the quotation to refer to the question of beds in acute psychiatric units. This is not simply a debate about lack of beds. All too often, the problem is that beds are available in such units, but the mixture of patients is such that the general practitioner or consultant psychiatrist is reluctant to recommend that a patient suffering from a schizophrenic condition or mental breakdown be admitted.
The principal author of the Bill, without whom I would never have been able to progress beyond the starting point, is Dr Mike Harris, sub-dean of the Royal College of Psychiatrists. He has allowed me to point out, in the spirit with which I hope we all approach the matter, that he is a lifelong supporter of the Labour Party. He has told me that in 1982, when he started to work as a consultant psychiatrist on an acute psychiatric voluntary ward of 20 people, an average of four were seriously disturbed; now, perhaps 15 are seriously disturbed. The admitting medical officer now has to decide whether such a ward is a suitable or therapeutic environment for someone who is already in the depths of clinical acute suicidal depression.
I return to the quotation from the report:
"Women are particularly vulnerable in Regional Secure Units where there may be very few other female patients, and a lack of female staff.
"Mother and baby units are sometimes unsuitably placed in a corner of an acute ward. Staff generally are not trained to care for babies and Health Visitors do not visit the wards.
"The Patients' Charter standard, offering a choice of single sex accommodation, is rarely met. This is a particular need for women from ethnic minorities whose cultural and religious practice forbids contact with men.
"Although many units have made considerable efforts to provide safe facilities for women and to preserve their privacy and dignity, there remains much room for improvement. The findings of the Commission's National Visit show that just over a third (35 percent) of women have access to women-only sleeping areas . . . a quarter (27 percent) have to pass male parts of the ward to reach women-only toilets, baths or showers; a third (32 percent) have access only to mixed sex toilets, bath or shower facilities. A small number (3 percent) use sleeping areas also used by men.
"Only a minority of units in the National Visit reported having policies dealing specifically with women's safety, although, when questioned, 58 percent of nurses thought there were issues of sexual harassment of women patients by male patients on the ward. One nurse saw 'no problem', but recalled two sexual assaults the previous year! There is a need for staff to be continually alert to women's sexual vulnerability."
The aim of the Bill is to save the lives of potential suicides, aid the recovery of in-patients and protect them from assault, and, in short, to restore the role of the acute psychiatric unit to one of sanctuary, support, and asylum in the true sense of the word.
The Bill is designed on what might be called an a la carte basis. It has four provisions and is constructed in such a way that if the Government felt that they could not in all conscience approve one of the provisions, there would be no need for them to knock out the entire Bill.
I have had a number of meetings with the Under-Secretary of State for Health, who has regaled me with his legendary charm and courtesy. I never knew that a brick wall could be so charming or so courteous. I was fortunate enough to draw second place in the ballot for private Members' Bills. I have repeatedly offered to make my Bill available to the Government so that they can use it as a vehicle for any additional changes to the Mental Health Act 1983 that they might think beneficial, but unfortunately that offer has not been taken up.
I have started by trying to create as much consensus as possible. The Bill's principles, which I shall explain in a moment, have been endorsed by a number of organisations. SANE has stated:
"The Bill is designed to ensure that some of the most vulnerable members of our society are given care and treatment in safe and therapeutic environments, where their privacy, dignity and security is protected. ... People with mental illness are being neglected and lives lost. Dr Lewis's proposals may well prevent many unnecessary tragedies."
Those are the words of Marjorie Wallace. I should make it clear that I am not a medical doctor; my doctorate relates to an entirely different subject.
The National Schizophrenia Federation has stated:
"NSF wholeheartedly supports the principles outlined in the Mental Health (Amendment) Bill and encourages all Members to support it."
The Manic Depressive Fellowship has said of the proposal for single-sex wards:
"there is significant evidence amongst our members that this is the provision women want . . . In order to ensure that a hospital admission will benefit rather than add to the trauma . . . it is vital that the NHS provide single sex ward accommodation, particularly in emergencies."
Although the mental health charity MIND has some reservations about clause 1, which refers to separate and therapeutic environments, and which I shall discuss later, it has said of the clause dealing with single-sex ward areas and security devices on doors:
"MIND welcomes Clause 2 of Dr Lewis's Bill which imposes a duty on health authorities to provide single-sex ward areas in existing psychiatric units and to fit appropriate security devices to doors."
The mental health and disability sub-committee of the Law Society has stated that it has
"long been concerned about the needs and safety of vulnerable patients, particularly women patients, and would welcome a duty being placed on Health Authorities to provide single-sex ward areas and to make other security arrangements for the protection of patients."
Perhaps it is time for me to pay tribute to all those people who have helped me and whom I have consulted at various stages. I have already singled out for particular thanks Dr Mike Harris, the sub-dean of the Royal College of Psychiatrists. Dr Adrian Yonace, who runs an NHS acute psychiatric unit at Poole, has also been fantastic in showing me at first hand the situation in such establishments. I have had many useful discussions with Dr Charles Tannock and with Mr Richard Jones, a specialist solicitor, who helped me with the technical details involved with drawing up key parts of the Bill. Mr Steve Priestley, the Clerk in charge of private Members' Bills, and an employee of the House, was incredibly helpful in turning the ideas into the format necessary to bring it to the Floor of the House.
Others who have helped include Dr Trevor Turner, Dr Austin Tate, Dr Pippa Brookes-White and all the parliamentary sponsors of the Bill – I hope that hon. Members have noticed that they come from both sides of the House. I have had useful meetings with Miss Marjorie Wallace and Miss Grainne McMorrow of SANE and Mrs Margaret Pedler of MIND. As I have already said, I have also had a couple of useful meetings with the Minister.
Before I submit my reasons for pressing for a Second Reading, let us look at the Bill's clauses in more detail. Clause 1 states:
"Each Health Authority shall be under a duty to ... prepare a strategy for the provision of in-patient"
care for people going through acute episodes of mental illness
"within separate and therapeutic environments."
Of course, that will be subject to the judgment of the medical officers in charge of the case. Where those officers are happy with the mix of people on a ward, there is no problem and no need for a separate environment.
I draw the House's attention to the introductory words of the clause, which state that a health authority should "prepare a strategy". The clause is written in those terms so that objections cannot be made on the ground that there are enormous financial implications behind it. To prepare a strategy does not cost a great deal of money. Indeed, it could be argued that it costs practically no money. I should have loved to lay a duty on local authorities to provide such separate therapeutic environments from the outset, but that would involve colossal expenditure.
The clause calls on each health authority to draw up a strategy so that, as and when resources become available, steps towards that ideal goal can be taken. If one does not plan ahead, one has no sense of direction, no target at which to aim and no goal to score in the battle to improve the conditions of people in such desperate circumstances.
I am not seeking to suggest in clause 1 that people suffering from certain types of schizophrenia or mental breakdown, which would result in their suicide if they were left out in society, should be treated separately because their conditions are more important, more deserving and superior to those of disturbed violent patients. The latter are just as much in need of care and protection.
Those who support clause 2 may argue that they cannot support clause 1, because they do not recognise the special vulnerabilities of people who have suffered a breakdown or are at risk of committing suicide if they are treated as out-patients and who will recover only if they are in a therapeutic and quiet environment. However, how can such people, in all conscience, support clause 2, which recognises that women are another group who have special vulnerabilities, which are just as serious in their own way? I believe that the principles underlying clauses 1 and 2 are identical.
Clause 2 calls on each health authority to provide single-sex ward areas. MIND and I would have liked the Bill to go further and refer to "single-sex wards", but the Bill could then have been shot down by the Government on grounds of unacceptable cost. Such areas can be provided at minimal cost. I am not talking about big open spaces with male patients at one end of the room and female patients at the other, but all wards should have an area reserved for women if they want that. It would be a refuge room not unlike the ladies waiting rooms provided at some railway stations for women who want to wait in a women-only environment. The difference between such areas and single-sex wards is that wards would require the duplication of all the necessary infrastructure and facilities.
New section 142B(b) in clause 2 refers to what are known in the trade as half-spindle locks, which are the devices fitted to the doors of rooms and wards. There is an ordinary handle on the inside, but one needs a key or a removable handle to operate the lock from the outside. Such devices are fitted in fewer than half of the psychiatric units run by the NHS. Once again, I have tried to keep the cost implications to a minimum; but the Bill also refers to the need to plan for the future. Clause 3 lays a duty on health authorities to ensure
"that all future psychiatric units are, so far as is practicable, designed and constructed in a manner which fulfils the requirements"
of new sections 142A and 142B of the Mental Health Act 1983.
It has been suggested to me that I am going about this the wrong way and that a private Member's Bill may not be the appropriate vehicle to bring forward such proposals, but there is a long history of major measures that have reached the statute book through the medium of the private Member's Bill, not least the Abortion Act 1967.
It has also been suggested that the provisions of my Bill are a little too precise, pedantic and prescriptive to be included in the 1983 Act. I had a quick look at that Act and I wondered which of its quite prescriptive sections I should highlight. I wondered whether I should refer to sections 7 and 8, on appointing social workers or relatives as guardians; or sections 13, 14 and 15, about the duties and obligations of approved social workers; or section 117, about the duties of health authorities and social services to provide aftercare. In the end, I settled – for reasons that will soon become clear – for section 141:
"Members of Parliament suffering from mental illness."
The section states:
"Where a member of the House of Commons is authorised to be detained on the ground (however formulated) that he is suffering from mental illness, it shall be the duty of the ... person in charge of the hospital or other place in which the member is authorised to be detained, to notify the Speaker of the House of Commons that the detention has been authorised ... Where the Speaker receives a notification under subsection (1) above, the Speaker shall cause the member to whom the notification relates to be visited and examined by two registered medical practitioners ... The registered medical practitioners shall be appointed by the ... Royal College of Psychiatrists and ... shall report to the Speaker whether the member is suffering from mental illness and is authorised to be detained as such."
And so on and so forth – [Interruption.]
I recognise from the sedentary comments that there are those on both sides of the House who feel that that provision will one day be applied to the speaker – not the Speaker of the House, but me.
Mrs Angela Browning: Never.
Dr Lewis: I thank my hon. Friend; I was hoping to attract a hostage to fortune.
Mr Dennis Skinner: It was tried once on Thatcher.
Dr Lewis: The hon. Gentleman was unsuccessful, to the great benefit of the whole country.
I have been drawing my remarks to a close – I hope on a lighter note, although a slightly more solemn note might be more appropriate. Unless one has either gone through the catastrophe of an acute mental breakdown or has seen it happen to someone close, one can have no conception of what it involves.
Anecdotally, I can refer to a friend of mine from the opposite end of the political spectrum. That young lady had, in fairly rapid succession over two or three years, two bad accidents to her health. One was an acute breakdown from which, after a year or so, she eventually recovered; the other was a multiple fracture of her leg. She was crossing the road in the rain, laden with shopping, when her dog pulled on its leash and she slipped and fell. She was in hospital for months with that severe fracture. When we were discussing the Bill some months ago, she said:
"Julian, if I had to choose between having another breakdown or another broken leg, break my leg again any time."
Breakdowns are so serious, so horrifying and so impossible to live with that it is no surprise that if people cannot get a bed in a helpful, healthy and therapeutic environment, their will to live is extinguished.
I do not wish to be partisan, but I am disappointed that all the signs are that the Government intend to resist giving my Bill a Second Reading – even though it is drawn up in an infinitely flexible way, which would allow some measures to go through and others to be cast aside, and which could only benefit the cause of improving in-patient access and conditions by detailed scrutiny in Committee. It will be denied that if, as I fear, the Government have their way.
On Tuesday, the Government published the White Paper "The New NHS". Paragraph 1.5 on page 5 states:
"The Government has committed itself anew to the historic principle of the NHS: that if you are ill or injured there will be a national health service there to help; and access to it will be based on need and need alone".
If the Government's tactics are to talk out or vote down the Bill, that statement will, I am sorry to say, be no more than an empty boast.