Patient Security (Mental Health System)

Paul Burstow Excerpts

Monday 7th November 2011 Commons Chamber

[The Minister of State, Department of Health (Paul Burstow)]

I congratulate my hon. Friend the Member for Loughborough (Nicky Morgan) on securing the debate, and on the thoughtful way in which she set out her case. Let me begin my speech where she ended hers. The coalition Government are totally committed to securing parity of esteem between mental and physical health. Quite simply, that is the right thing to do, and it is long overdue. We are determined for it to happen as part of the strategy that we are currently delivering and the changes currently taking place.

I am well aware of the tragic incident to which the hon. Lady referred, and which was undoubtedly the spur for the debate. I also thank her for sharing the coroner’s report with me. I am keenly aware of the fact that the trust involved in this sad case fully accepts the coroner’s verdict and has undertaken an overhaul of its patient security arrangements. It is important for public confidence in the system that lessons are learned and actions are taken to improve patient safety and service quality.

The coalition Government are committed to patient safety. It is a high priority in our strategies and in the outcomes on which we are judging the NHS. Our cross-Government mental health strategy, “No health without mental health”, includes two core objectives to which I wish to draw attention: ensuring that people who are acutely ill receive safe, high-quality care in an appropriate environment, and thereby ensuring that fewer people suffer avoidable harm. The NHS outcomes framework also prioritises patient safety and emphasises treating and caring for people in a safe environment and protecting them from avoidable harm.

My hon. Friend rightly referred to the invaluable work done by the national confidential inquiry into suicide and homicide by people with mental illness. Although the suicides rates in England have been at a historical low and are much lower than those of most of our European neighbours, the most recent figures, dating back to 2009, show that there are still about 4,400 suicides in England; that is one suicide every two hours.

Over the past decade, good progress has been made in reducing the suicide rate in England. However, there has been a slight rise in the last couple of years. It is therefore important that we maintain vigilance. We know from experience that suicide rates can be volatile as new risks emerge. That is why we recently completed a national consultation on our suicide prevention strategy. We are considering the responses received, and intend to publish the final strategy next year.

The draft strategy aimed to set out a broad and coherent approach to suicide prevention and to helping us sustain, and reduce further, the relatively low rates of suicide in England. In particular, it sets out to reduce the suicide rate in the general population and to provide better support and information to those bereaved or otherwise affected by a suicide.

Substantial improvements have already been made in in-patient services. The most recent national confidential inquiry into suicide and homicide was published in July 2011. It shows that the long-term downward trend in in-patient suicides continues. In 1997 there were 214 in-patient suicides, falling to 94 by 2008. That is still 94 too many, so there is still more to be done.

I applaud my hon. Friend on her initiative in gathering the statistics she has presented to the House. However, she is right to sound a note of caution about how the figures might be interpreted, and what they reveal to us. For example, information about the length of time for which patients are missing or the level of risk that they pose either to themselves or to other people is relevant to gauging the true scale of the problem on which she seeks to persuade the Government to take action.

There are a wide variety of reasons for recorded unauthorised absences. These include situations that pose minimum risk to the patient or the public, such as a delay in return to hospital from authorised leave because of a missed or delayed bus. We could be talking about a delay of no more than a couple of hours before some patients return safely to their unit. However, that return has to be recorded, even if it is for just a matter of a couple of hours.

Recent statistics from the confidential inquiry show that between 2004 and 2008 the number of suicides per year by patients who have absconded from mental health services has dropped by more than 50%, from 50 cases to 21 cases per year. That is a substantial improvement, but it is still 21 cases too many.

That is why we are not complacent. We know that a significant number of suicides still occur during a period of in-patient care in spite of the improvements. Managing risk effectively is therefore essential, and the confidential inquiry collects and analyses the detailed clinical information on all suicides and homicides committed by someone with mental illness, and more latterly also on sudden and unexplained deaths of psychiatric in-patients. It also makes recommendations for improvements, which goes to the heart of my hon. Friend’s representations tonight. Its December 2006 report sets out some compelling statistics—for example, that 27% of in-patient suicides occurred after the patient left the ward without permission. Those deaths were clustered in the first seven days after an admission.

In mental health services, respect for the patient’s wishes must at all times be balanced with the concern for the individual’s safety and well-being. There is no doubt that that balancing act can, and does at times, present significant challenges for services. However, the solution to the problem does not have to be heavy-handed or coercive in its approach. A significant body of research, guidance and best practice has demonstrated practical strategies that can be implemented and can help to reduce significantly the number of people going missing. Such strategies include: early assessment; ensuring that staff begin to form a meaningful, therapeutic and collaborative relationship with patients straight away; understanding the factors that trigger a decision to leave the ward, such as a disturbed environment or an incident affecting the patient; recognising that patients will have social responsibilities such as paying bills or ensuring that their property is secure—staff need to identify these issues early to prevent anxiety and stress that may lead to the patient choosing to leave—and making greater use of technology, such as CCTV or swipe cards, to observe and control ward entry and exit.

Key to the successful delivery of those approaches will be the ongoing development of an acute specialist work force with the right skills and attitudes, and a culture of inquiry and service improvement based on evidence and regular service user and carer feedback. The law is clear in the obligations it places on services. The Mental Health Act 1983, to which my hon. Friend referred, sets out the legal provisions relating to keeping patients in legal custody and bringing them back if they abscond. The Mental Health Act code of practice is equally explicit in the guidance it gives to services about the systems and processes that should be in place to safeguard detained patients. Hospital managers should ensure that there is a clear written policy about the action to be taken when a detained patient, or a patient on a supervised community treatment order, goes missing. These policies should, in turn, be agreed with other agencies, such as the police and ambulance services, which have significant roles to play in safeguarding patients who are absent without leave.

Just last year, it was confirmed for the first time that the detaining authorities would be required by statutory regulation to notify the Care Quality Commission, without delay, of any absence without leave of any person detained or liable to be detained under the Mental Health Act. A failure to take adequate measures to keep a detained patient safe from fatal harm is potentially a breach of article 2 of the European convention on human rights. The CQC asks services that are designated as low, medium or high security, and psychiatric intensive care units, to notify it of all incidences of absence without leave. There are different reporting requirements depending on the security level of the service. I can tell my hon. Friend and others who are listening to this evening’s debate that the CQC will be reporting its first round of these statistics next month. The CQC monitors trends in absence without leave and has followed up with the particular providers in relation to specific incidents or patterns of absences. The CQC recommends that providers monitor and review absences without leave to understand why patients go absent and to help develop strategies to address these identified issues.

My hon. Friend identified concerns about what she described as the variation that she encountered in the definitions that appeared to be being used by different trusts when she undertook her freedom of information requests. I can, however, assure her that the definitions of “escape”, “attempted escape”, “abscond”, “failure to return” and “absent without leave” are applied consistently in mental health services. Indeed, most of those definitions relate to the three-part description that she listed. I suspect that the differences in the returns she received are due to the mixture in the type and size of mental health services within one trust, and therefore the mixture of type and number of absences reported. For instance, a trust may include a high-secure hospital, two medium-secure units and also low-secure and non-secure mental health services. The numbers from that trust may give us no understanding of the type of risk of the absences recorded. That is why my hon. Friend is right to say that we need good data collection in this area, and that is why we have asked the CQC to collect those data in such a way that we can meaningfully segment them to understand what is going on. I shall write to her about the statistics that she has collected.

The Government believe that people with acute mental health needs have a right to receive the care and support they need in a safe and comfortable environment in which they are treated with the dignity and respect they deserve. As my hon. Friend has said, there is a cross-Government mental health programme in place to drive whole system and cultural change in mental health services. However, this cannot and should not be seen as solely the Government’s responsibility. The essential building blocks are in place but, as always, the responsibility for the quality and safety of front-line care crucially depends on three things. First, providers have a duty of care to each individual for whom they are responsible—ensuring that services meet individual needs and that there are systems in place to make sure that services are effective, efficient and deliver high-quality care. Secondly, the regulator is responsible for assuring the quality of the system itself. Thirdly, the commissioners are responsible for securing the care that meets people’s needs.

My hon. Friend was absolutely right to bring this important debate before the House, and she was also right to point out that we often debate issues of physical health in the House but rarely debate mental health issues except in extremis. I assure her that the Government are determined to invest in mental health services to ensure that more therapies and therapeutic services are available. Indeed, that is why we are investing in talking therapy services. It is important that with mental health we look at the whole-life course, intervene earlier to provide more preventive services, and invest in services that deliver dignified outcomes. I am grateful to my hon. Friend for securing the debate and allowing us to shed some light on those important issues.

Question put and agreed to.