Speech to the SANE mental health charity in Oxford
"In recent months, I have spoken frequently about what I have described as a "broken society". It is only natural, as part of that debate, that I should return to the issue of how we deal with mental health problems in our society and the inadequacy of our responses, a cause I have championed over many years.
The way in which a society treats those at 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. When we walk around our major cities, and see people, many of whom will suffer from a mental illness, sleeping in the doorways of some of our most beautiful buildings and venerable institutions then we are witnessing a policy failure that a humane society should not tolerate.
The failure of quality provision for those with mental illness is our national shame. It is one of the great social reforms remaining.
I have chosen, the Prince of Wales international Centre for SANE Research as the venue for my speech today because of my admiration for the work of SANE and its chief executive, Marjorie Wallace, and to show my solidarity in the face of the threat to its helpline, SANELINE.
SANE is unique among mental health charities in having research as one of its core aims and in investigating the cause of psychosis at this groundbreaking research facility.
SANE is also unique in pioneering the UK's largest specialist mental health helpline. I have seen the work of sane line at first hand and I know how important it is not only in supporting distressed individuals and families but in complementing the work of family doctors and mental health teams. With 30% of callers are referred by health professionals and organisations, it plays a key role in the provision of mental health services.
That is why I am extremely disturbed that the future of sane line is endangered. As a result of late payment by the Department of Health of £1 million due on the second year of a contract with SANE to provide the service, and its decision not to renew funding from 2005, the helpline is under threat. Not only has the government broken faith, but it has put at unacceptable risk the only mental health helpline open 365 days a year at a time when over half of those using mental health services are still not able to access help out of hours.
This is short term thinking of the most irresponsible kind. Neither the Mental Health Helpline's Partnership-in which the government has invested its hopes and funding for mental health helplines-nor NHS direct is likely for some time to come to be able to provide SANELINE's tried, tested and accredited help. Ministers, who wasted three quarters of £1 billion on the frivolity of the Millennium Dome must think again about the provision of care for some of our most needy citizens.
To be frank with you, not all my colleagues agree with my focus on mental health issues. Indeed, one of them, who was going to support me for the leadership contest, told me that he would not vote for me if I kept on talking about "issues like this."People" he said, "don't want to hear about the sort of thing". Yet this is exactly the point. It is time that politicians focused on precisely these issues. At least one in four of us will suffer from some sort of mental health problem at some point in our lives. Mental illness is society's unspoken epidemic, one of its last taboos and so rarely discussed.
And the burden often falls disproportionately on women. Few would regard mental illness as a "women's issue" but is women who most often carry the burden as carers when health provision breaks down. It is women who pay the greatest price for the failings of the NHS mental health services.
The spectrum of mental ill-health is incredibly broad. From the young mother with post-natal depression to grandfather with Alzheimer's disease. From the students with exam-induced anxiety to the young victims of bullying who self harm. From the tragic increase in farming suicides to those with drug induced psychosis. Indeed, it is this last group that is back in the news today. Following the government's irresponsible reclassification of cannabis we now have an increased number of young people suffering from psychotic illness. Ignoring the increasing scientific evidence, the Blair government sent out a signal that cannabis use would be more tolerated. How many young people are now paying a ghastly price for Tony Blair's ministers' attempts to buy popularity?
Mental health is not an issue that is easy to get press attention for.When mental health issues do feature in the press, though, it is often because of an incident where someone with a mental illness has harmed someone else. Such incidents are mercifully few and far between. But this type of coverage reinforces the view that mental illness makes an individual a 'dangerous" or a "bad" person'. Such cases should always raise questions about the quality of mental health treatment in this country. But they should not be used to stigmatise everyone with a mental illness.
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 random attack on a cyclist in Richmond Park last year.
I remember a case in my own constituency all too well: 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.
Each of these sad cases has its own tales of institutional failings and inappropriate care. 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. We must always remind ourselves that public safety should be paramount, but that public safety is best guaranteed by ensuring that individuals get adequate and appropriate treatment.
We forget that people with mental illness are a greater danger to themselves than others. We need think only of the case of Ben Silcock who got into the lion's enclosure at London Zoo. It is a tragic fact that over 1,000 schizophrenic patients commit suicide each year - considerably more than the 40 people murdererd each year by someone who has been in contact with mental health services at some point in their lives. Yet the debate all too often focuses on the issue of compulsion that does little to solve the underlying problem of inadequate treatment.
And let me repeat that figure again. Over 1000 suicides every year among schizophrenic patients. Can you imagine the public outcry, the acres of press coverage and the endless cries to do something if they were victims of plane crashes or natural disasters? Yet, their plight is met largely with silence and indifference.
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.
As Michael Howlett of the Zito Trust has said: "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".
The danger signs are not spotted often enough though. The mental health field is frequently characterised among health professionals as the 'cinderella service', ignored and underfunded by Government. We hear regular tales of staff shortages, bed losses, massive gaps in community provision, and problems with step-down care when people seek to return to the community. All too often, mental health is the first specialty to find its budgets cut when the books need to be balanced.
Earlier this summer, for example, the South West London & St George's NHS Trust announced proposals to shut the daycare facilities at the Maddison Centre in Teddington, Middlesex - just one of a number of facilities shut in South West London to deal with the trusts multi-million pound deficit. The daycare facilities enabled many users to maintain independent living whilst having access to care when they needed it. Now that vital link is lost. It has become harder - not easier - for users to maintain an independent lifestyle. Replacing daycare facilities with home visits will make it less likely that people will leave their homes during the day and engage with the community.
Such cuts are not unique to Teddington, the rest of South West London or indeed the rest of the country. They are frequent and widespread.
Care in the Community
Much of the debate over spending often focuses on the balance between the provision of expensive in-patient facilities and the provision of cheaper 'outreach' services. Many believe that tilting the balance in favour of community provision is simply one of saving money. I would reject that completely. Nor is it merely a naïve attempt to promote the rights of the individual. There will always be people for whom one service or the other is the more appropriate, and we should ensure there is adequate provision of both.
It is very easy to criticise 'care in the community'. But we should not forget that in the not-too-distant past, mental illness was a guaranteed one-way ticket to a lifetime institutionalised in an asylum. The care offered was minimal, and there was rarely any attempt to actually treat the underlying condition. Even if people who entered such asylums were not ill to start off with, they frequently became so as a result of the conditions they were forced to live in.
It was Enoch Powell who took the decisive step to turn mental health from a private misfortune into a matter of public concern. By 1954, 154,000 people were in psychiatric hospital beds - twice the current prison population. Powell lit a 'funeral pyre' (as he called it) underneath the network of these decaying asylums.
As new treatments and drugs became available, the prospect of treating people both in community hospitals and the wider community became a reality. The principle underlying 'care in the community' now has widespread support. No-one would want to go back to the dark days of asylums.
But the occasional incident where a person with mental health problems harms a member of the public inevitably calls the reality of 'care in the community' into question. There could be no more staunch supporter of 'care in the community' than the former Health Secretary Virginia Bottomley. Yet in a letter to The Times in 1998, she herself accepted that the 'pendulum has swung too far' in favour of 'care in the community'.
We should not overlook the fact that 'care in the community' has provided many thousands with a quality of life far better than what they would have experienced inside restrictive institutions. 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 could not cope with. Lacking an understanding of their own condition, their institutionalised background made them unable to deal with the difficulties 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.
Mental Health in Prisons
I earlier spoke with approval of how Enoch Powell had lit a funeral pyre beneath the great brooding asylums that had been built to hide those with mental illness. It is clear that we are now, unwittingly, using prisons as a replacement for that asylum system. Two thirds of those in our prisons have a learning difficulty, a mental illness or a substance abuse problem.
It is a troubling thought that anyone with a mental health problem who has a brush with the law could find themselves subject to inadequate treatment in a Dickensian environment. And this 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 prison suicides in the past decade is a scandal over 800. Half of these have been prisoners on remand - prisoners, in other words, who have not yet been found guilty. Yet they make up only half of the prison population. There is clearly a disproportionate suicide rate amongst those on remand. If the state has locked someone up, for good reason, it still owes that individual a duty of care.
Often young, many of those on remand are experiencing custody for the first time, and find it a disturbing experience. I have spoken recently about the generation of 'lost boys', and the pressures on our Young Offender Institutions are not lessening.
Tackling these issues may mean more prison capacity, at least in the short term as we seek to reduce crime, since prison population should be a function of crime levels. But time spent in prison must enable effective rehabilitation. Overcrowded prisons do no-one any favours. We may also need to spend more money on improving health provision in prison. And if it is decided that a youth needs to be remanded in custody pending trial, voluntary groups should be allowed substantial access to support these individuals.
The Medical Inspector of the prisons inspectorate has described a situation where prisoners are 'quietly mad behind their cell door'. Prison should be an opportunity to diagnose and treat underlying mental ill-health as part of a programme designed to reduce reoffending. More research is certainly needed on the environmental impact of prison. It is harsh to lock people up for 23 hours a day, but it seems to be tougher still to develop a prison regime which helps rather than hinders rehabilitation.
Some will argue that this means extra spending. Research is certainly needed into what is required and what it would cost. Ensuring that the system works better might well save money in the long run, however. The Home Office estimates the cost of crime to be over £50 billion a year, and previous government reports have estimated that adequate mental health care would result in a 5 per cent reduction in the cost of mental illness, and a 2 per cent reduction in the cost of crime.
Above all, though, it is a question of our values and priorities as a society.
A New Agenda
Utopia cannot be built out of human suffering. But what we can do is to improve the way in which society deals with those who meet with the misfortune of mental ill health through no fault of their own. A truly enlightened society is one that realises that we all benefit if mental health is treated adequately, rather than hidden away from society's gaze.
Most importantly, we need to bring back the concept of 'sanctuary'. People who are vulnerable because of mental ill health need a place to feel safe. One the most powerful visits I ever made as Shadow Health Secretary was to the Hillside Clubhouse in Holloway in 2002. The Clubhouse offered the users, who had a wide range of mental health problems, somewhere they could go to feel safe. It offered companionship, constructive activity and the chance to go and get a paid job in the community. Everyone was allowed to find their own level, and progress at their own pace.
No-one forced them to go there, but equally the Clubhouse would keep in touch if they stopped coming alone. In an ever more difficult and complex society, it offered genuine care in a real community - a sanctuary.
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. Taking an interest in healing our broken society is not something the Conservative Party should do for a few months, pretending we are into 'soft' social issues for some short term gain. I do it because I believe it is the right thing to do.
That is what politics ought to be about."