Mental After-care

HL Deb 31 March 1981 vol 419 cc153-90

5.41 p.m.

The Earl of Longford rose to ask Her Majesty's Government whether they will take urgent steps to provide a more effective system of mental after-care.

The noble Earl said: I shall do no more than scratch the surface of this tremendous subject which has been neglected for far too long in this House and elsewhere. I shall confine myself to speaking about the mentally ill, though other speakers I believe will deal with the mentally handicapped and indeed with any other branches of the subject which occur to them. I have no doubt that the Minister will deal with us all judiciously at the end.

There is one aspect of the subject—apart from that of the mentally handicapped—which is certainly vital and can be rather tragic. I refer to the supervision of people on leaving mental homes, and in particular those people who leave special hospitals. But I shall not deal with that matter, either. I have visited Broadmoor fairly often over the years, and I wrote the introductions to two books about Broadmoor and its aftermath by my friend Peter Thompson, who has done so much work in this field, having himself been a patient in Broadmoor and who, 10 years ago, suggested a system of national after-care for mental patients.

The question is perhaps specially relevant today for two reasons, one immediate and the other long-term and semi-permanent. We are currently in the International Year of Disabled People. Most of us, when we hear of the disabled, think of those who are physically disabled or are suffering from mental handicap, and certainly we can never do enough to provide them with much fairer treatment than they now receive. But when one thinks of the disabled one must surely think also of the mentally ill. This applies all the more when we reflect that one in 12 men and one in eight women, I am informed, will enter hospital because of mental illness at some point in their lives.

It is worth asking ourselves whether there is any long-term issue involved here apart from the fact that this is the year of the disabled. I would submit that there is no area of national policy where the yawning gap between the stated intentions of successive Governments and their implementation in practice is quite so wide as it is here. We might ask ourselves why this should be. It may well be that because we are all aware, consciously or sub-consciously, of our vulnerability in certain circumstances to mental distress or even collapse, we are very reluctant to admit the whole existence of the subject. A natural tendency is to adopt the attitude which says in effect, "If I have coped, why shouldn't someone else?" In other words, we tend to see mental illness as a sign of weakness or inferiority in others, or as a self-imposed infliction, for which the sufferers must bear the consequences. Whether that is, or is not, the explanation, I am sure that your Lordships rise above such weaknesses; but I am afraid that that attitude is very widespread in the community.

Since the 1950s successive Governments have recognised that where appropriate mentally ill persons should be cared for in the community, rather than in hospitals or other instutions. We have all been saying that. Certainly the leaders of the authorities have been saying that for a good 20 years. It would be a mistake to believe that simply closing institutions will solve the problems of the mentally ill in our midst. It would be inappropriate to say that no one should ever be in an institution, and it would be lamentable to refuse people facilities that they are promised when they are returned to the community.

In any just society mentally ill persons should receive the form of care most relevant to their needs. In the vast majority of cases this means either preventative care or, at most, short-term hospitalisation, followed by support in the community from family, friends, doctors, psychiatrists, social workers, and community psychiatric nurses. The trend away from hospitalisation has certainly been quite marked in this country. In 1955 there were 140,000 patients in our mental hospitals. In 1979 the number was down to 64,000, but even the youngest and most innocent Member of the House will not suppose that we are therefore twice as mentally sound as we were a quarter of a century ago.

The policy of taking people out of the hospitals is eminently sensible on all grounds, provided that it is accompanied by provision outside. There is abundant research to indicate that non-institutional care is at least as effective, both therapeutically and in terms of cost, as institutional care, and usually more so. The moral and social grounds for providing community care are self-evident and have been stated again and again. However—this is the first point that I want to stress; it provides the background to what I am saying, and I am sure that it will be said by other speakers who are expert in the subject—despite brave public pronouncements over many years about the need to step up community care provision, and despite the obvious merits of doing so, the implementation has been poor, indeed lamentably feeble.

In 1975 the DHSS published the White Paper Better Services for the Mentally Ill. In that document guidelines were laid down for provision of community facilities. Some progress has been made, but we are light years away from achieving even the modest goals laid down in the document. Let us take the question of hostel care for the mentally ill. In 1975–76 local authorities in England spent £4½ million on residential care for the mentally ill. Admittedly, the figure has doubled since. However, the higher figure is a reflection on more of inflation than of additional provision. If the DHSS guidelines were being adhered to, local authorities would be spending not about £10 million, but about £40 million. I am bound to say that, for a mixture of reasons, at the moment the local authorities are cutting back spending on and provision for the mentally ill. The same applies to day care provision, adult training centres, and facilities for the mentally handicapped.

So on the one hand the country is wisely and humanely choosing not to institutionalise the mentally ill. Well, so far, so good. That is a cheap way of dealing with the problem. But on the other hand we are not offering the mentally ill a viable alternative, and more by accident or negligence than by design we are returning to the pre-asylum attitudes which prevailed about 150 years ago. We are failing to treat many people outside hospitals who ought to be treated, and as a result of the failure to implement a coherent community care policy many thousands of people have remained needlessly in hospital. Had they been liberated from hospital, it would have been found that no provision had been made for them. We have the absurd situation, which noble Lords may not be aware of unless they happen to be deeply versed in this question, that there are many vacancies in hostels but the local authorities cannot, or think they cannot, afford to take them up, so that thousands of people who ought to be in the community are left to decline in the mental hospitals, to their own detriment, of course, and also at much greater cost to the state.

Where do the solutions lie? I am, in a humble way, a pioneer this afternoon, starting up this subject. We shall hear contributions of various kinds, and, as I shall say at the end, I hope the matter will not be left there; so at this point I am speaking only in general terms. But I have consulted with the leading voluntary bodies, and what I am saying, therefore, is based on their wisdom rather than on my unaided genius. Where do the solutions lie? First and foremost, we must strengthen considerably the statutory duties of the local authority services in relation to the mentally ill. I am of course aware that any proposal of this nature will not be popular with the local authorities, certainly in the first place. They believe that it is for them to determine, on the basis of assessed local need, the nature and extent of the social services required.

However, there will always be a conflict of interest between the principle of local government freedom and an acceptable level of local authority provision for the mentally ill. Traditionally, the mentally ill have been politically and publicly unpopular. Although their interests have been effectively articulated by organisations like MIND, the Mental After-care Association and the Richmond Fellowship, the latest figures show that 33 local authorities in England and Wales out of 107—that is, less than one-third—have reached the guideline figure of 19 places per 100,000 for residential provisions laid down in the 1975 White Paper; and, of these 33 local authorities, 20 were in London, so outside London there were only 13. Only two local authorities (again in London) have reached the guideline figure of 60 places per 100,000 for day-care provision.

So that is the actual position; the failure of the system. In the short run, if you like, or in the immediate argument, you could say that it is the local authorities who have failed, but the state, the central Government, cannot absolve themselves of a heavy obligation. Clearly, any increase in the statutory responsibilities of local authorities towards mentally ill people would have to be met by an equivalent increase in central Government funding to those local authorities in order to assist them to provide the necessary expansion of services. I am setting out, if you like, the problem, and others will develop it today and later. I am also advised by some of the voluntary bodies that local authorities should be prevailed on to extend their responsibilities under the Chronically Sick and Disabled Persons Act 1970, which at present can include the mentally ill on a discretionary basis.

The second major solution lies in forging closer strategic planning and operational links between the health services for mentally ill people and the local authority social and housing services. One could go into that in considerable detail, but I will only say this for this afternoon. As the mental hospitals run down, it must be possible to begin a transfer away from the health service to the local authorities, and that means not only joint funding—and some steps have been taken in that direction—but joint planning, so that mentally ill persons may have access to adequate community provision.

Thirdly, we must do much more than we are doing to support the voluntary organisations. The contribution of the voluntary organisations to the provision of our national psychiatric after-care services has been remarkable. Here again, I mention the Richmond Fellowship, the Mental After-care Association and MIND. All of them have done magnificent work, and between them they have created a network of hostels, group homes and sheltered units up and down the country. The present Government—and here I am accounting it to them for righteousness—have made it an article of faith, as I understand it, certainly in words, to promote the cause of voluntary organisations generally. By common consent voluntary organisations have a flexibility, a grass-roots sensitivity and a capacity to pioneer which statutory authorities cannot be expected to match.

The voluntary sector is absolutely crucial to any proper policy of community care for the mentally ill. Indeed, voluntary organisations provide well over a third of all residential places. But far from encouraging them, the Government's present policy is having precisely the opposite effect—and I say that without any party animus; this is a subject which really does take us outside party. The whole voluntary effort appears to be in imminent danger. I do hope that the Minister, whose heart, I know, is in this subject, will be able to say something reassuring this afternoon.

The service rendered by the voluntary bodies is, of course, one may say, intertwined with that provided by the local authorities. As I indicated earlier, the voluntary bodies have a number of vacant places, for example, in hostels, and it is up to the local authorities how many of those places they are ready to pay for and fill. So we come back again to what I said earlier about the need to strengthen the local authorities, to induce them to play a larger part than at present, and if necessary to provide them with the required financial assistance.

There is one point that I have been asked to mention, though it is not one which I would have fully understood without assistance. The most productive partnership, I am assured, does not lie in trying to force the voluntary bodies to take on work now undertaken by the statutory services. It lies rather in encouraging them and in assisting them to pioneer new methods of care, and therefore, in that sense, to complement the statutory service.

I am coming to an end. It is always a sin, as we know—it is, indeed, a sin against the Holy Ghost—to despair, and I see no reason to despair in this field. The fact that we have not really tried very hard as a country is in a sense encouraging, because it shows what could be done, or at any rate it leaves a wider area open to us if we do at last make the effort. I received a letter a day or two ago from someone with whom I have kept in touch for about 20 years and who in that time has been in and out of mental institutions, though now, and for some time, he has been living in the community. He begins his letter: God is in his Heaven. I am perfectly happy", and then he sends me some verses which may not be great poetry but which express a courageous and happy spirit.

Of course, large numbers of people are not as afflicted as this particular man—their period of mental illness may be quite brief—but some people who spend their whole lives afflicted by mental illness, so that they cannot lead a normal life, can still be happy if they receive sufficient kindness and care. That cannot be done entirely by the state, by the local authorities or even by the voluntary bodies; we all come into it. But, still, talking in this place and appealing to the Minister for support, I am asking him to give us a strong lead.

I should just say before I sit down that I hope, when this debate is over, to take steps to initiate a voluntary inquiry into the whole subject. I have already been promised assistance—not financial assistance, but what is more valuable to me, personal assistance—from some of those who work within the voluntary field and who, on personal grounds, are deeply respected. I do not know whether the Minister would feel it possible to say a few kindly words of encouragement. They will not commit him to any expenditure, though we shall be looking for enough money to launch this inquiry. Therefore, I leave the matter there. I am anxious to learn from other speakers. As I said at the beginning, this subject has been neglected for too long, and we must make a start somewhere.

6 p.m.

Lord Winstanley

My Lords, it is a pleasure to follow the noble Earl, Lord Longford, with his very timely and, if I may say so, very necessary Unstarred Question. I must be mindful of the fact that this is an Unstarred Question and not a major debate, for were it the latter I would have no difficulty in detaining your Lordships for some hours on a subject in which I have been deeply involved for many years. I think the noble Earl will forgive me if I say that we share the same disadvantage in that this is a subject about which we both know rather too much, and therefore we have to be very careful in trying to concentrate our remarks into what is proper for an Unstarred Question. I think that in the main all I would wish to do would be to amplify one or two points in the noble Earl's Unstarred Question and perhaps point to some of the areas in which the Government might care to search for some of the answers.

In the course of his remarks the noble Earl spoke about the very clear and recent trend away from hospitalisation in the field of mental health. I would say that there is no doubt at all that in the public mind there has certainly been a trend away from the idea of hospitalisation. There is a growing number of people who, rightly, have come to terms with the reality of mental illness of one kind or another and have gradually come to an acceptance of the fact that it is much more desirable for the community as a whole and for the patients individually for these people to be cared for at home or in the community wherever possible. As the noble Earl rightly said, there has been that trend. But, to be effective, there has to be another and corresponding trend; and that is a trend towards the greater provision of home-care facilities and provisions.

I am bound to say from my personal experience of many years in National Health Service general practice that the recent trend, so far as domiciliary services are concerned, has been in the reverse direction. If I go back over my years in the National Health Service general practice—and I can go back to a time before the National Health Service started—I recall that we then had a functionary who I think was known as the relieving officer. There are perhaps some noble Lords who are old enough to remember the relieving officer. At least, you knew who he was. He was the chap with whom the buck always stopped. He was always there; he was never away at weekends; he was never off duty. If you had a difficulty with a patient who was mentally disturbed you contacted the relieving officer. With the inception of the National Health Service we had new people. We had somebody called "the duly authorised officer". Rather later than that, he became the "mental health officer" and then, when we had the system of generic social workers (under which we no longer had the children's worker or a mental health officer) every social worker became a universal genius who was required possibly to do everything. I do not want to enter the argument about whether that was advisable or otherwise. I say from my own practical experience as a general practitioner who from time to time has had the job of endeavouring to mobilise the after-care services to which the noble Earl's Unstarred Question refers, that in recent times it has sometimes been very difficult to mobilise those services because you could not find them. It was very difficult to know who was responsible for what.

I would concentrate my remarks on two areas. First of all, substantially the responsibility for providing the kind of services about which the noble Earl is so concerned rests with local authorities. Like the noble Earl, I have no wish, once we establish local authorities, to take all power away from them and say they must do this, that or the other; but it is really very odd that we should have such an extraordinary diversity and disparity of provision as between one area and another. I would not take away the freedom of local authorities. Certainly, there will be different needs, different requirements and different desires in different areas; and local authorities ought to have the autonomy and the ability to provide services of a different kind to suit local needs and desires.

But should local authorities have a right to opt out altogether? It is a fact that at the moment there are 34 local authority areas in which there are no day-care centres or other day-care provision at all. If necessary, I could give the noble Lord a list of those 34 different local authority areas at some stage; but he will be able to find them out for himself. Of course, we also have some areas which do have day-care centres but which are at the moment under financial pressures of cuts of one kind or another, and they are threatening to close certain centres which now exist. I am reliably informed that much of the energy and time of admirable bodies such as MIND, and some of the other voluntary bodies to which the noble Earl referred, are spent fighting off the threatened closures of existing day-care centres—occasionally with some success because they mobilise local public opinion on subjects which are very emotive and on which feelings run very high in local communities. The community health councils are able sometimes to alert local health authorities to the possible consequences of certain closures and it is a fact that, as a result of the work of some of these voluntary bodies, certain of these threats have been removed and some of these day-care centres have been reprieved when, as it were, under sentence of death. But I think it right to mention that there are some local authority areas in which there are no day-care centres at all.

If we are to care for mentally disturbed, mentally handicapped or mentally ill people in the community, we really must be conscious of the potentially damaging effect of (if you like) the psycho-geriatric patient or the mentally-ill child on the family and on the local community unless there is some kind of day-care centre to which the person can occasionally go so that the family can get a bit of a rest and so that other assistance can be brought to bear. I think that without facilities of that kind this trend away from hospitalisation, to which the noble Earl referred, will be reversed. There is already ample evidence that there are many mentally ill patients who could have been cared for in the community and at home but are having to be admitted to hospital or taken into other institutional care, at great cost to public funds, purely because of the inadequacy of services in the community.

Concentrating purely on the services provided by local authorities, I think that when the noble Lord replies he ought to be able to tell us what the Government intend to do about those areas in which local authorities are really failing to provide facilities. My recollection of the Mental Health Act (and I know there have been other Acts since) is that it is said that local authorities "shall provide" these kind of facilities. Some are not providing them, and I should like to know what the Government intend to do about that. Some are providing excellently. If some can do so well, how is that we have to put up with others that do almost nothing?

Going more specifically into what is provided, I personally would believe from my own experience of working in this field that there is a need for a little more integration of the social services provisions (which in some areas are excellent) with the hospital mental health staff. I have had experience of certain hospitals where that works very well (or did work very well at the time I was involved) at Winnick Hospital, for example, in Lancashire, where the local social services mental health officers worked closely in the hospital, assisting sometimes in the occupational therapy departments so that they got to know the patients well; they knew the patients' background and were able to deal with those patients much more effectively when they were eventually discharged to return home. They already knew them, knew about their case and very practical efforts were made to integrate the two. The more that that is done the more effective will be the contributions that both can make.

A very minor point in dealing with hospitals is this. I do wish that hospitals could get away from the very common habit of always discharging patients home on Fridays—the very time when it suddenly becomes impossible to find anybody in the social services department. Sometimes it is not very easy to contact a general practitioner although you can sometimes find the emergency call service or some other body. Very frequently when a patient who has been mentally disturbed is discharged home he can suddenly have acute difficulties over the sudden change of environment. When patients are discharged home on a Friday afternoon it becomes almost impossible to mobilise resources until Monday.

Regarding local authorities and the Government, the Government at the moment, rightly and necessarily, are making certain cuts. But there are cuts in local authority spending which could, at the end of the day, prove very costly indeed. The less that is provided in the way of domiciliary care by local authorities and social services departments, the more will have to be spent by hospitals and other institutions financed in other ways.

Now I should like to refer to what the Government frequently talk about as the private sector but certainly in this field they really mean the voluntary sector. I entirely agree with the noble Earl that there will always be a place for voluntary work. I should like to look forward to the day when the National Health Service—using that term in its fullest possible sense—could provide free at the time of need all the services which are necessary for all the different kinds of patients that there happen to be.

Having said that, I wholly accept that at the moment it is necessary to rely to a considerable extent on voluntary work and various voluntary organisations. In this country we are very happily placed in having a vast potential pool of man and woman power in volunteers who are not thin on the ground at all, and who are not unwilling to come forward to carry out voluntary work in day-care centres with mentally handicapped children and with disturbed elderly people. There are many people willing to volunteer. But there is nothing more inhibiting to potential volunteers, having volunteered, than to find that they have their time wasted because the organisation is not sufficiently structured and developed to mobilise and use their work. It is my experience that for every volunteer in any organisation, be it MIND, the Richmond Fellowship or any other bodies to which the noble Earl referred, one needs about one full-time paid professional worker to every 10 volunteers. It is a little bit disturbing at the moment to find that some of these voluntary bodies, on whom the Government propose to rely so heavily, are themselves in great difficulties—sometimes as a result of Government policy.

For example, the recent increase in petrol prices—which is not altogether unconnected with Government policy—will cost the Spastics Society an additional £30,000 a year. Is the Spastics Society going to get that £30,000 a year from Government? We should bear in mind that it is the Government who require it to pay it. There are other bodies with which I am connected. Let us take MIND. Twenty per cent. of their income comes from the Department of Health and Social Security. MIND's financial year starts tomorrow. For some time now they have been trying to set up a meeting with Ministers in order to find out what will be their grant for the coming year which starts tomorrow. They were told only yesterday that their application has not yet been looked at.

I am not saying for a moment that it will not be looked at with great sympathy and that they will not be given help. But they must be given help if they are to take on the duties which will inevitably fall upon them. MIND at the moment provides 1,470 places for the mentally ill in group homes, hostels and special bed sitter accommodation. The need is for 10 times that number. I am assured that there is no shortage of buildings. They could obtain extra buildings very easily without additional cost or public funds. But they would need additional volunteers to man them. However, they cannot have additional volunteers unless they have the structure that is there to train the volunteers, organise their work and make effective use of their work.

The National Society for Mentally Handicapped Children and Adults have branches all over the country and they are in the same kind of difficulties. I have seen over and over again the invaluable work that they do with day-care centres, removing disturbed children so that their families can have a little rest and so that the community can be kept together. They too are in grave difficulties. The Richmond Fellowship provides hospitals and therapeutic communities especially for recently discharged young patients. Unless they get the kind of financial support that they need—and it is all very well the Government talking about leave it to the voluntary sector—they will be in difficulties.

The pump must be primed. If the Government will put in sufficient in grants to these bodies they will find that these bodies will be able to mobilise an enormous amount of work and additional funds themselves. Unless the Richmond Fellowship get the kind of help they need then the young patients will find that they will not be discharged at all. They will have to remain in institutional care at very great public cost. I could go on—and I said that this is a subject that I know too much about. I must exercise a self-denying ordinance and come to some kind of conclusion.

I should like to have talked about the provision of regional secure units as recommended by the Butler Committee many years ago in the excellent report on mentally abnormal offenders. We have not heard much about those and nor has there been much development. I should like to see more provision for psycho-geriatric patients. That is a desperate need in many urban communities. Without adequate domiciliary provisions an intolerable burden is placed on hospital services which are very costly indeed and you block up hospital beds with patients who do not really require costly hospital treatment at all but merely require supervision and the kind of care which could so easily be given by the voluntary sector if the voluntary sector itself was given the kind of help by the Government which they will need if they are to do the job which the Government are going to leave to it.

The noble Earl asked the Government whether they will take urgent steps to provide a more effective system of mental after-care. I hope that we have demonstrated that the present system is not wholly effective and therefore needs to be made more effective. My final point is that this is urgent. From personal practical experience I say that, unless the Government act rapidly, they will find at the end of the day that there will be a very big price to pay indeed. Saving money at the moment in these areas will cost a great deal of money later.

6.18 p.m.

Lord Richardson

My Lords, by a happy chance there was published last year a booklet called Psychiatric Rehabilitation in the 1980s. This was produced by the Royal College of Psychiatrists in response to a request from the Department of Health and Social Security. The committee was chaired by Professor John Wing who heads the Social Psychiatric Unit at the Institute of Psychiatry at the Maudsley Hospital. I have had the benefit of consulting him and the President of the Royal College of Psychiatrists, Sir Desmond Pond, about the points that seem to them, as practising psychiatrists, of particular importance in this aftercare of mental sickness problem. Both these distinguished professors expressed to me the great gratitude that I personally feel to the noble Earl, Lord Longford, for having asked this Question.

I am going to take a different line from the noble Earl and the noble Lord, Lord Winstanley, and talk about matters that are nearer to the hospitals and not so far into the periphery as they have taken as their main subjects. Together with them, I must stress the word urgency and I must stress also the need for local authorities, and for those who vote for them, to recognise the strength of our duty to our fellow citizens in this particular area.

The noble Earl, Lord Longford, has pointed out that there are now half the number of patients in mental hospitals who were there in 1954. That, as he has said, is in itself satisfactory. These patients all fall into three groups, according to the length of time they have spent in hospital. The first group is that of patients who have been in hospital for under one year; over that group I can be very brief. It is sad that two-thirds of those in under one year are those who have been in hospital previously, perhaps more than once. This is sad, because it means that although there are outpatient facilities and psychiatric social workers there are not enough of them—or perhaps the time they can give is insufficient—to keep these people from having to return to hospital. The problem is one of numbers and of training—the invariable problem in medical matters of staffing ratios.

The second group is a very important one. It is the group of patients in hospital between one year and five years. Over half the people in that group are over 65 years of age and, unhappily, many of them are demented, and, because of their age, the majority of them are female. It is not those people I wish to speak about, because probably they are destined to spend the rest of their days in hospital. It is the smaller number of patients under 65 years of age who are really important. They are mostly schizophrenic and the treatment of schizophrenia by drugs and psycho-social treatment has been to a great extent responsibly responsible for our ability to reduce the hospital population. With these treatments, and if facilities outside the hospital are available, there is a real chance that the number of patients in that second group, which is at present static, can be further reduced.

The third group is that of patients who are in hospital for five years onwards. Here, surprisingly, there are rather more patients under 65 years of age than over. This group is diminishing in numbers by the natural process of death. How far it will reduce is not yet recognised, but unhappily it is being fed to some extent by those from the second group, many of whom have just given up of any hope of getting back to the community, and have become hopelessly hospitalised in their institutions.

How are these problems being faced? There is a new experiment being undertaken in the unit at Maudsley Hospital which I have mentioned. It is called the bed-hostel, the ward-hostel system. In brief, it amounts to this. Instead of having a hospital facade and a large building, they have developed from an ordinary building with a door, so to speak, facing on to the community—in a private house—what inside amounts to a ward. The back faces on to the type of facilities that will help these people towards the community; the "day care-type" work facility that is well supervised. This experimental unit is staffed by nurses trained in psychiatry and is well supervised. The staff is resident. So far the results have been very satisfactory and, to my knowledge at any rate, the patients have not had to return to psychiatric hospitals. The numbers accommodated are few, with only 14 beds, but according to Professor Wing's calculations for Camberwell, which has a popluation of 130,000 people, they need only 30 such beds backed up with facilities in the community.

In addition to this experiment, there are, and have been for some time, hostels which have resident supervision. Initially these are paid for by the Department of Health and Social Security, as is the "experiment ", but after a seven year period they have to be paid for by the local authority. Here comes the difficulty—the question of willingness, the ability and the motivation for the local authority to do so. There is another useful form of accommodation, which is less sophisticated than the two that I have mentioned, called group homes. These are houses containing bed-sitting rooms, a communal kitchen and sitting room with a television, and so on. From these group homes, the residents can go out to suitable—and I stress, "suitable "—and meaningful protected work or to day centres. The point of these group homes is that the supervision need not be residential and this means that such homes can be set up and looked after by housing associations. In addition, as noble Lords have already heard, there are all the community facilities which are, one hopes, available and used. I need not touch on those at all, but what I want to ask the Minister is this. Can he give some hope that this concept of the ward-hostel may be extended and that the present hostels may be more widely used and set up, because, in view of the difficulties facing local authorities, which we all know about, this will need a strong lead.

Before I sit down, I should like just to tell you about one particular case history from this unit at the Maudsley Hospital that will illustrate to you why it seems so very important that, even in this particular time of difficulty, special consideration should be given to persons such as the young man whom I have in mind. As long ago as 1966, he developed very severe and distressing schizophrenia—hearing voices abusing him and saying terrible things—and the effect on his family was devastating. He was admitted to a mental hospital and there he did not respond to the drug treatment that is often so helpful. He was discharged on three separate occasions and each time he had to go back. Each time there was despair and disappointment. He was allowed out and, with the noble Lord, Lord Winstanley, I suspect that it was on Fridays. At any rate, he used to go home for short periods but he would come back accompanied by the police, because he had got himself into trouble and had tried to cope with life by drinking. Then despair set in upon him, and for seven years he stayed in a mental hospital with no wish whatsoever to leave it.

Four years ago, he went into this unit of the Maudsley Hospital and things are now quite different. Of his own initiative, he has asked to take part in running this ward hostel. He now goes out to day units and takes an active part in them. It is expected that he will be able to go to a group home where he will live in semi-, and ever-increasing, independence. Now there is hope, and not only for this now middle-aged man, because the effect on his parents is enormous. A burden has been lifted from them. As the noble Lord, Lord Winstanley, has pointed out, when we are talking about these most unfortunate people, we are also talking of the suffering of the family. So that this is a very wide problem indeed for which there is a solution in many cases, if we have the determination and the will.

6.33 p.m.

Lord Lloyd

My Lords, it is, I am afraid, many years since I last inflicted a speech upon your Lordships. Indeed, so long is it that I almost feel as if I am making my maiden speech all over again. But I feel that I must intervene briefly in this debate, because I happen to be a member of the management committee of the Richmond Fellowship, whose sole purpose in life is to provide the mental after-care which is so desperately needed and which is at present so inadequate.

One hundred years ago, people with mental problems used to be put into a lunatic asylum where they probably languished for the rest of their lives. Happily, those days are past and, with the progress of psychiatry, modern drugs, et cetera, it is possible for many people with mental problems to be cured. Yet to imagine that when a patient is discharged from a mental hostel the whole job is done is really to deceive oneself. There is an important part done, but there is an equally important part which remains to be done.

When a patient is discharged, he is probably lonely and depressed. Certainly, he feels quite incapable of coping with modern life and needs a period of rehabilitation, such as is provided by the Richmond Fellowship. The basis of the Richmond Fellowship's organisation is what we call the "halfway house", of which we have 34 in this country. Each of these halfway houses accommodates a small community of about 20 adults or 16 adolescents. We try, so far as possible, to put patients who suffer from the same kind of trouble—be it alcoholism, schizophrenia, drug addiction, et cetera—into the same houses.

Once a patient is in a halfway house, he does not need to feel lonely, because he finds himself among other people who understand his problem. Each house has a trained staff, who encourage the patient to work on his problem and to share in the running of the community. They also teach the patient to start accepting responsibility, not only for himself but for others, with the ultimate aim of finding a job and keeping it. The Fellowship does its very best to find jobs for people when they are ready to leave. The length of stay varies from three months to three years, an average of eight months.

There is much more that I could say about the work of the halfway houses, but, for the sake of brevity, I have given only an outline picture of what we try to do, a lot of which I think we do quite successfully. What I really want to do now is to turn to the financial aspect of the problem. These halfway houses are expensive to run. We provide not only full board and lodging, but a highly-trained staff. The kind of price that an adult pays is £86 a week and for adolescents that goes up to £150, because they are much more difficult to look after. None of these people can possibly afford that kind of money, unless they get a grant from the local authority.

There is a large amount of legislation dealing with the obligations of local authorities to provide after-care, including residential accommodation, for persons who have been suffering from mental disorder. Again, for the sake of brevity, I propose to refer not to individual Acts but to the effects of those Acts.

Until 1974, the power of a local authority to assist mental patients was, so far as I can make out, purely permissive. In 1974, the Minister concerned directed local authorities to provide accommodation. Yet although the Minister is provided with very strong powers to declare local authorities to be in default in carrying out the functions imposed upon them, and to take steps to enforce the remedying of such default, successive Ministers seem always to have shown a marked reluctance to take such steps. Thus, in March 1977, of 108 local authorities in England—I think that the statistics were mentioned by the noble Earl, Lord Longford—only 31, or 29 per cent., had met the guidelines planning ratio for residential places, and 11, or 10 per cent., did not record any residential provision whatsoever. Nor does there appear to be any monitoring machinery by the Government to ensure that local authorities fulfil their obligations. All this is reflected in our own affairs in the Richmond Fellowship. We have a waiting list of applicants which would give us more than 100 per cent. occupancy, yet our present occupancy is only two-thirds of our capacity. This is entirely due to the inability of applicants to obtain local authority grants.

I feel sure that your Lordships will agree with me that this is a penny-wise, pound-foolish policy. Low occupancy increases our costs in the Richmond Fellowship, and therefore the cost to the local authority, and it denies care to many who would otherwise have received it. Such people often relapse and have to return to a mental hospital where all the good work already done has to be done again. This is what we call the "revolving door syndrome".

There are no votes in mental health from the point of view of the local authority. In an economic situation where there are strong pressures on local authorities to cut their expenditure, I suppose it is inevitable that mental health should be an obvious target for economy, though in my opinion many other less important targets are available. But from the national point of view it is a false economy. Those who do not receive after-care almost certainly return to mental hospitals. Thus any saving on the rates is more than balanced by an increase in the cost of the National Health Service.

I think the House should be very grateful to the noble Earl, Lord Longford, for raising this matter. The present situation is extremely unsatisfactory. Urgent and positive action by Her Majesty's Government is, in my opinion, absolutely essential.

6.42 p.m.

Baroness Masham of Ilton

My Lords, may I, too, thank the noble Earl and say that it is always a pleasure to speak in his debates. He always chooses such important subjects. As I am the speaker who follows the noble Lord, Lord Lloyd, who said that he thinks he has just made his maiden speech, it falls to me to congratulate him and to say that as he speaks with such experience on this subject I hope he will be heard more often in your Lordships' House.

The death of a baby at birth is tragic and sad, but what is the reaction of parents when they realise that they have had a severely mentally handicapped baby? There will always be disappointment. There may even be revulsion and rejection. I have heard such varied reports of how the parents are told and of what advice and counsel are given. Some doctors say, "Put it into care". Others say, "Put the parents in touch with supportive agencies", and encouragement to keep the baby at home is given. From parents who keep their mentally handicapped children and bring them up at home I have heard expressions of concern over what will happen if something happens to them. These parents have a terrible fear that their child will be, put into one of the large, impersonal institutions.

For 365 days each year after-care has to go on in some way for these mentally handicapped people, from the day that they are born until they die. Throughout the country, the support and services offered are very varied. Sometimes the best services come from a voluntary source. Is it not time that this country had an acceptable code of practice for local health authorities, social departments and voluntary bodies to work towards so far as mental health is concerned?

I have been appalled by the clinical austerity in some mental hospitals. It seems to be quite unnecessary to have white walls, white beds and empty lockers so that each ward looks as if it is uninhabited. This is what I found at the Clifton Hospital, York. When I remarked upon how colourless and boring I found it, the charge nurse agreed that it had a "touch of the Army" about it. I find that there is no excuse for these unstimulating conditions. At least there could be some coloured walls and bright posters to cheer the place up. Coloured paint is no more expensive than white or grey paint. If our mental hospitals continue to be such large, impersonal places, then getting the patients back into the community will not be made easier, as the contrast is too great.

A helpful asset to after-care in the health district where I live, which has no psychiatric beds, is the employment of some community psychiatric nurses. When I was on the Community Health Council, concern was expressed about the fact that there was no after-care follow-up service for patients who had been admitted to the general hospital as attempted suicides and with other mental problems. The waiting period to see a consultant at an outpatient clinic was, and still is, at least six weeks. We pressed for community nurses, and I am pleased to say that this service has been established. These nurses can visit patients in their homes and give support and advice which is of great benefit, especially in rural areas. A great deal of extreme worry and fear can be alleviated by an effective after-care service which psychiatric community nurses can organise. I hope that they will be employed in all districts.

I should like to tell your Lordships about a splendid project which is giving support to parents who have young, mentally handicapped people at home. This is a short-term family support unit which has been built near to where I live in North Yorkshire. The building of this unit was made possible by joint funding between the health authority and the social services. It is run by the social services, and from what I hear they are doing an excellent job. There are 16 beds, but they can take more, when necessary. There is a 24-hour emergency service.

The unit serves several purposes. It caters approximately for people from the age of three to 16 years, but there is flexibility, which is essential in an emergency service. It gives short-term residential relief, holiday relief, so that a family can go on holiday knowing that their mentally handicapped youngster is being looked after by caring, understanding people. There is an answering and advice service on behaviour modification dealing with psychotic children. There is a baby-sitting service, a day créche, assessment facilities and weekend relief.

When parents look after profoundly handicapped children, this service seems to me to be essential if the family is not to crack up. The normal children in a family need their parents for at least some of the time, otherwise there will be grave problems with them. This unit can relieve the family of the handicapped child for a period of time so that the parents may devote to their normal children the time that they need and can also take them on holiday. Just knowing that this family support unit exists gives parents the encouragement to soldier on. When problems become too great, they know they can ring in and get support. Some handicapped young people spend six weeks at home and two weeks in the unit. This enables the family to cope. It seems also that there is a need for an adult hostel for short breaks. This sort of support is saving resources and preventing mentally handicapped people from going permanently into full-time residential care. This support unit seems to be money well spent.

The last point I should like to mention is that of the tragic and bewildering condition of anorexia nervosa. As noble Lords will probably know, this is a condition which seems mainly to affect teenagers, and most often girls. They start slimming and cannot stop. They go to all ends to make this effective. It is a condition which seems to be on the increase. The girls I know of who are anorexic seem to be attractive and intelligent. This is a very serious problem, as in their conduct they can be infectious to others in their classes at school.

I have discussed this problem with paediatricians and they have told me that the problems are so complex that they are now being dealt with in psychiatric units. But what after-care is there? What advice is given to parents, teachers and class-mates? Are there any guidelines to follow? I know that there are many worried parents, siblings, friends and teachers. These young people with anorexia nervosa seem to be possessed of an uncontrollable wish slowly to waste away. When their weight drops too low they are admitted to hospital for treatment. When they regain weight they will go back to school. What is the risk to other children being attracted to doing the same sort of thing? I hope that there will be a concerted effort by the Government, with co-operation from the health department and the Department of Education, to find out what is the most helpful after-care for the anorexics and those who are closely associated with them.

6.51 p.m.

Lord Taylor of Gryfe

My Lords, I am pleased to be associated with the plea made by the noble Earl, Lord Longford, this evening that the Government should take urgent steps to provide more effective support for mental after-care. I believe the noble Lord, Lord Lloyd, stated that his was almost a maiden speech—and he will forgive me if I do not congratulate him on an "almost maiden" speech, but may I simply add that this debate on an Unstarred Question gives me the opportunity of making a maiden speech from these elevated Benches.

The speech of the noble Baroness, Lady Masham of Ilton, enables us to pay tribute to her for the impressive and spendid work which she has done in connection with the International Year of the Disabled. That leads me to the point that frequently the care of the mentally ill is not included in that category of disabled because the physically handicapped person's disability is perhaps more apparent than the individual who suffers from mental illness. It is possible of course for a mentally ill person to register as disabled, but on the whole that is not common.

I lack the professional knowledge and experience of some of the noble Lords who have participated in this discussion. My concern in this field arises from an association with the Glasgow Association for Mental Health and a very impressive voluntary organisation associated with it, called Link. If I quote the statistics of the problem in Scotland it is simply as a sample of what is in fact a national problem. We have a civilian male working population of around 1,400,000 and the admissions to mental hospitals and psychiatric units last year numbered 24,500. It is interesting to examine the diagnosis of the cases being treated. In the case of males, 34 per cent. of their mental illness could be attributed to alcoholism and 10 per cent. to depression. In the case of females the figures were 10 per cent. due to alcoholism and 19 per cent. to depression. Alcoholism in my part of the world is a particular problem and these may not be exactly paralleled in national statistics but there is no doubt that alcoholism is a major contributor to mental illness and can be treated by after-care services.

The number of working days lost due to registered mental disorders among men last year was 3 million and the number of residents in hospitals and psychiatric units in 1978 was 24,000 admissions—a 19 per cent. increase on 1965, of which 10,000 were first admissions and 14,000 were readmissions. This was what the noble Lord, Lord Lloyd, referred to as the "revolving door" in operation. We have not coped with the people who are discharged from psychiatric units and mental hospitals in a way that prevents them from returning again and again, and that in fact is the nub of the problem.

In 1979 the proportion of all National Health Service hospital bed spaces in Scotland occupied by the mentally disordered was 45 per cent., which indicates the impact of this problem on the total expenditure of the National Health Service. The total cost of National Health Service in-patient care for the mentally disordered was £95,373,200. That gives one some idea of the magnitude of the problem and if we can contribute by sensible and well organised after-care we may in fact be able to effect economies in National Health Service expenditure.

The major problem in Scotland generally, as nationally, is the continuing reliance on hospital and medical approaches to care and treatment. No community mental care service exists and there is insufficient joint planning between local authorities and health boards, each preferring to leave the problem to the other.

Reference has been made to the Government White Paper, Better Services for the Mentally Ill, of 1975. It recommended that for the future the main aims must continue to be the development of much more locally based services and a shift in the balance between hospital and social service care. This shift must be accompanied by the co-ordination of local authorities, health boards, voluntary services, not only in terms of the use of resources but also in the pooling of the skills among the variety of professionals currently providing care.

A major requirement of an after-care psychiatric service is therefore to be community based, multidisciplinary in approach, and seeking to design recovery programmes which meet the emerging needs of the ex-patients in a graded and flexible way. Good aftercare reduces relapse and re-hospitalisation and is therefore preventive in the real sense. It requires the attachment of psychiatric social worker counsellors to health centres and GP practices; it requires a continuity of management between hospital and community services, including pre-discharge planning and supportive follow-up. It requires a flexible series of housing accommodation facilities,ranging from short-term hostels, group homes, joint tenancies and longer-term supportive accommodation, and so on. It requires facilities within which social, interpersonal, family and marital problems can be worked on by counselling. It requires in the field of employment, as in housing, a graded system of facilities from industrial therapy to sheltered workshops, such as was described earlier in the discussion this evening.

Work experience schemes, manpower services schemes and quota systems would provide the best chance for individuals to reach their potential level of activity. I have found in this regard that by the establishment of resource centres, such as have been organised in my native city of Glasgow, former patients are brought to after-care and they work on a three-months' contract programme with counsellors who assist them and prepare them for employment. They have worked closely with the Manpower Services Commission, and despite the difficulties of employment at the moment they have been able to secure employment for a large number of these patients. This has brought them back into the community; this has achieved the necessary adjustment, and has avoided the all too frequent vulnerability which might bring them back again into hospital care.

In the activities of Link, with which I have some association, they have worked with one of these resource centres and have had a high success rate. In addition, the voluntary workers associated with the organisation have organised social clubs so that people who are discharged from mental hospitals can find social activity; they can combat the problem of isolation which is a major problem after they are discharged; they can regain some personal and social confidence as a result of being associated with others of similar experience. They can come to terms with having been mentally ill and they can gain access to information about how to use existing services with regard to particular problems of medication, employment, housing, income and so on.

That kind of work has been done successfully frequently by volunteers. The Link organisation, with its resource centre and with its six social clubs, exists on a state-supported budget of £50,000. How much more sensible it would be to spend more on this kind of after-care, rather than have patients return to a hospital bed as a further cost on the National Health Service. For these reasons, I commend the plea of the noble Earl, Lord Longford, to the Minister.

7.3 p.m.

Lord Auckland

My Lords, for many years the noble Earl, Lord Longford, has taken a very practical interest in the subject of mental health and allied causes, and once again this evening we are very grateful to him for raising this extremely important question. There have been in this debate Members of your Lordships' House who are far more clinically and professionally connected with this problem than I, but for nearly 20 years I served on the house committee of a large mental hospital in the Epsom area of Surrey, where, as some of your Lordships may know, there are seven or eight of these hospitals. I should like to say just a few words about the particular hospital in which, until the reorganisation of the National Health Service, I was concerned, because I believe it has an important bearing on this question.

Before doing so, I think we ought to acknowledge that since the Mental Health Act 1959 much progress has been made in the provision of after-care and in the recognition that those who are receiving treatment for mental illness and mental handicap can frequently be returned to society, if not cured altogether. I recall shortly after the last war frequently visiting a hospital in Bedfordshire near where we then lived; the medical superintendent was a family friend. Of course, in those days the patients were classed as lunatics, and in many of these establishments, depending very much on the hospital superintendent, they received little or no treatment; it was simply custodial the whole time. In this particular hospital, even in those days, there was much more emphasis on therapy rather than keeping the patients locked up the whole time. It is really only since 1959, as I understand it, that there has been some kind of progress towards returning many of these handicapped people to society.

The noble Baroness, Lady Masham, in a characteristically well-informed speech, spoke of a hospital in York which was, to say the least of it, seemingly very regimented in its appearance. There are all too many of these hospitals, and in this kind of règime one cannot really prepare patients for after-care. But the hospital with which I was concerned as a humble committee member is on the villa system. Every Christmas my wife and I still visit the hospital and go round the wards. Many of the patients themselves, helped by the devoted staff, have decorated these wards, not only at Christmas but the whole year round. It is an excellent form of therapy and it enables them to have a high standard of morale.

The real problem of this hospital is the vexed question of the catchment area. I was talking only yesterday to the chief nursing officer. As I understand it, under the present set-up of these hospitals they take patients, particularly in areas where there are a number of hospitals concentrated, from all parts of the country. If they were able to take exclusively people who needed treatment from the local catchment areas, it would save much cost, because parents and other relatives could visit far more frequently; it would give a great local interest in the general work of the League of Friends; it would mean that local people would take much more interest and would have an incentive to take much more interest in these hospitals. If one has a situation where patients from all parts of the country are admitted, there is, I think, a danger of lack of communication between the hospital and particularly those who work in a voluntary capacity concerned with these hospitals.

I have not given my noble friend notice of this question, so I do not expect a reply this evening, but I wonder whether he would look into this situation, particularly where there are these large groups of hospitals, to ensure that the catchment areas are more localised so that the services can be more localised. It also, of course, provides a more important asset to after-care. In many cases at least some of the patients who are able to work can work locally. Of course there are the industrial workshops within these hospitals. This particular hospital has an excellent industrial workshop which is very well staffed.

Some of your Lordships may have seen a very disturbing programme about one of the special hospitals. I fully realise that this question is not specifically directed towards the special hospitals where one has a very different type of patient, many of whom are essentially under custodial care. However, in the hospital which was the subject of this programme, the television crews were allowed to go where they liked and to talk to whom they liked, where they liked. There were instances of youngsters swabbing floors and doing the type of menial tasks which would give no hope whatsoever of their every really contributing to society in later life. Some, I believe, had a modicum of schooling. But my impression of the programme was that custodial care and security were the main guidelines.

As I have said, for many of the inmates of these places such guidelines are essential; but where there are young people in these special hospitals it seems that there is much more needed at least to try rather more emphatically to get them into some kind of hostel training. When listening to some of these youngsters speak on being interviewed, one realised that they were not the sort of people who one would expect to be violent. Of course there are always risks in these hospitals of too early release, with unfortunate consequences. But certainly in some of the cases featured in this programme that was not so. Indeed, the visiting panels who one saw in action were themselves almost deploring the lack of hostel accommodation and the lack of suitable people to run these establishments. One wonders what the Department of Health and Social Security is doing towards this end. This is a very important point.

Often when one mentions special hospitals people say, "Ah yes, these people are being treated inhumanly". The point must be made, as was made in the programme—and one saw it—that the nursing staffs and all those concerned with the welfare of the patients were most human and solicitous, as far as they could be in the terms of reference, for the welfare of their patients.

The Warnock Report had a particularly interesting passage dealing with young mentally handicapped people who could be put into hostels for after-care treatment. I shall not quote the paragraph for reasons of brevity, but in Chapter 10 paragraph 114—and I hope that the Department of Health and Social Security will take note of this in due course—there is a scheme noted which takes place in Denmark, and in which it is generally accepted that, where possible, handicapped young people should leave home at 18 and live independently in flats where they can have the support of a home visitor who can visit them at least twice a week. My point is: how many patients in this category in our hospitals could be similarly treated so that they were able to live in reasonable conditions and conceivably do a proper job of work, and thus probably save the ratepayer and the taxpayer a great deal of money? Of course it may mean more social workers; it may mean more home helps. But it will, I think, help to allow these people, many of whom can work, to do so.

I think that there is much food for thought inherent in this Question and it gives the Government a real opportunity to look closely into a vital social problem.

7.16 p.m.

Lord Soper

My Lords, this is not the first occasion on which I have been glad to be led by my noble friend Lord Longford in discussion of matters which to me, to him and I take it to this House—even as sparsely as it is now attended—are matters of great import. I am glad to take part in this particular debate. I perhaps ought first to congratulate my erstwhile noble friend on his maiden speech from other benches and perhaps I ought to add that my physical proximity to him tonight is not due to any political shift on my part, but because I am rather hard of hearing and want to get nearer to the sound of the gunfire!

I am grateful to my noble friend because he has introduced into this discussion the word, "alcohol" and I make no apology for inviting your Lordships to consider that the question of alcohol and alcoholism comes very properly into the ambit of this discussion. Certainly no one would doubt that alcoholism needs care and increasing systems of care, and it may be not irrelevant to remark that the problem of alcoholism is endemic and historically endemic. There is apparently as great an alcoholic problem in Soviet Russia as there was in Imperial Russia. There is a continuing and increasing problem of alcoholism in France. No civilisation so far as I remember, except the Islamic one, has dealt with it radically, even if it might be of the persuasion of your Lordships that that particular cure is worse than the disease. Nevertheless, I make no apology for attracting your Lordships attention, if I can, to the proper place that alcoholism occupies within the general circuit of this debate.

There are those who regard addiction to alcohol as a purely moral problem. They are wrong. I would not seek to evacuate it from its moral content and would give you no comfort that it is not a moral issue in many of its aspects. But anyone who has had any experience of trying to be with, as well as to deal with, alcoholics will be in no doubt that some alcoholics are of model behaviour in so many other fields, are thoroughly estimable people, and that it would be an impertinence, an insult, to regard them as sinners greater than the rest. What is more is that if it is a moral problem they are totally incapable of treating it as such and dealing with it as such. Is it, therefore, a moral problem which belongs to the realm of metabolism? I speak with great care because I am not qualified in this regard, but many years ago when I began to take an interest in this matter of alcoholism, I used to hear words like "apomorphine" and "antabuse". I was told that there are chemical reactions in some people's bodies which predispose them to alcoholism, whereas others have no such temptations to meet.

In endeavouring to put that so-called chemistry into practice, my evidence would be that it has been singularly and almost totally unsuccessful. After many years in this field, I am now quite convinced that the question of alcoholism falls very properly into that area of disablement which is mentally, spiritually and psychologically caused, and therefore I shall not delay your Lordships to claim that what I now say about the problem of alcoholism is pertinent to the basic meaning of this debate.

It seems to me that if you once agree that the problem of alcohol is a mysterious problem dealing with areas of our make-up which cannot be heated over Bunsen burners or plotted on graphs and which certainly defy exact definition, it is reasonable and sensible to think of the alcoholic and the perpetual drunkard alike as disabled by certain environmental circumstances and their own pre-disposition to react to them in a particular way. The success that has come to such efforts as I have been able to think about and, to some extent, as I have been able to have something to do with over the past 20 years, has come when the concept of alcoholism has been treated, first, as something which needs a drastic recovery from an obvious effect—that is, the detoxification, the drying out of the alcoholic. Secondly, that there is the requirement for custodial or at least close treatment for a certain amount of time. But, thirdly—and this is the point which seems to me to be relevant to this particular debate—if the man or woman who has been detoxified—dried out—and who has recovered in health and wellbeing in some kind of hostel and who otherwise would have no normal kind of social life to which to return, is thereafter exposed to the world as it is, it is highly unlikely that the third stage of that process of reclamation will be achieved; even if it is temporarily achieved, it will be quickly forgotten.

The point of the argument is that a return to the community—as has already been advertised so often in your Lordships' House this afternoon—the requirement of seeking to recover these disabled people within the framework of the normal society from which they have become estranged, is of the utmost importance. Therefore, I totally agree with those declarations of intent, that community care, or recovery within the community, belongs in particular to this area of disablement which we call alcoholism.

But how do we do it? The community as it stands, or as it exists, is an amorphous body until it is broken up into its constituent parts and it is dealt with in particular categories. That is obviously true in the realm of the alcoholic. He requires some kind of protective housing if he is to be reclaimed. That protective housing must not be within a custodial environment which precludes freedom of activity, but it must be within the kind of environment in which he can quickly seek and find the kind of aid which he needs.

So I come to the practical considerations. I regard it as a major tragedy, all the worse because of increasing unemployment, that there are temptations and predispositions to intemperence in the beginning, drunkenness to go on with, and lastly alcoholism and the spirit drinker. I find this an increasing menace. Once upon a time in the hostels over which I had some charge, you could generally regard an alcoholic as getting a job within six weeks. That day has gone. The temptation—particularly among those who are younger—is an ever-increasing one, promoted or at least accentuated by indolence and inability to contribute anything to the society in which they live.

I would plead with the Government not to curtail the kind of services, in money in particular, which can keep alive voluntary associations—such as I could categorise, but I shall not—for if they do not, then I heartily agree with my noble friend, who spoke so convincingly about the perils that await a Government which, with a short-term concern for the maintenance of a particular monetary policy, fail to see that the long-term emergence of such a policy can not only mean a more costly but an even more dangerous and more desolate society than the one in which we now live.

I believe that there are two areas of concern, and when I have said this I shall sit down. There is the area in which the local authority should accept in greater degree its own responsibility for setting up some of those organisations which can at least give an opportunity to the recovered or semi-recovered alcoholic to take his place again in the normal society from which he has been estranged. But I would make a final plea for that particular contribution which enlightened and sensible organisations can provide as the bell-wether of what later perhaps could be a reformed and totally efficient welfare service.

I include my next remarks because I think that they are due to the Minister. I know how ineffective and sometimes how sentimental local efforts on a voluntary basis can become, but I would commend to the Minister the ever-increasing knowledge in the voluntary sphere about the particular problem of alcoholism and to place it under consideration for a practical solution or for an increased contribution of aid seems to me to be the height of civilised behaviour and, above all, one of the greatest safeguards for some kind of future in which the aid for the disabled will no longer be required, for so few will be disabled.

7.28 p.m.

The Countess of Loudoun

My Lords, when the idea of discharging mental patients into the community was decided on a few years ago, it being a very new idea at that time, not enough thought was given to the follow-through by the community services, with the result that was a near-disaster. Many ex-patients found themselves much worse off in the community than they had been in the long-stay wards of mental institutions. Yes, they were provided with shelter, but that in itself would not solve their difficulties. For a return to normality they needed the availability of good daycare, access to work and the support of friends and neighbours, this latter in an uncaring and often hostile community.

Therefore, the whole subject has had to be thoroughly investigated, which has inevitably caused some delays and disappointments. However, this must be preferable to running the higher risks of relapse and readmission. MIND's "Home from Hospital" campaign was launched at the end of April 1976 with the aim of increasing the amount of accommodation in the community for former psychatric patients. Since the start of this campaign, which was financed by a very welcome grant of £20,000 from the DHSS plus a contribution from MIND itself, MIND's local associations for mental health have opened, or are planning to open, another 70 hostels and group homes providing places for 300 former hospital patients.

Thanks to the two Granada television programmes appealing to the public for offers of accommodation, 1,250 replies were received and a further 123 definite placements have been arranged by social workers, hospitals, and voluntary workers as a direct result. A large number of psychatric hospitals have assessed the numbers of patients who could leave now if they had somewhere to go. There is a marked increase in the number of patients discharged into sheltered accommodation of various kinds, many hospitals having their own well advanced resettlement schemes. But this increase in the discharge rate is likely to slow down, due to the present cutbacks in hospital expenditure.

To me the most exciting development has been the co-operation between MIND and the housing corporations, resulting in a sharp increase in the number of projects jointly organised by them. At least eight new schemes are in an advanced state of planning and many more schemes, using rehabilitated property, can be expected this year. With good press coverage, regional television and radio, plus two major conferences, many of those concerned in aspects of rehabilitation have been able to come together and share their knowledge and work out co-ordinated plans. This includes not only accommodation in the community but also work rehabilitation for those considered suitable for training or retraining, as the case may be. There are bound to be some severely handicapped patients for whom any work rehabilitation must, of necessity, be on humanitarian grounds alone; that is, to give them something to do.

Over the years we have had several committees and their reports. The Piercey Report in 1956, which stressed the need for organised rehabilitation, the establishment of regional rehabilitation units, and special training for doctors in the field. These recommendations remain largely unimplemented. Eighteen years later a sub-committee of the Standing Medical Advisory Committee was set up under the chairmanship of Sir Ronald Tunbridge to look into the same question and make recommendations. Having explored available rehabilitation facilities, the committee concluded that insufficient attention was paid to the problems, and this when employment prospects in the 1960s were relatively good, which is clearly no longer the case today. The Tunbridge Report recommendations for an integrated district service, based on every district general hospital, have not materialised, though there are a few rehabilitation units existing, but these are based on psychiatric hospitals.

The Government have set up a number of resettlement services. The Employment Services Agency runs 26 employment rehabilitation centres providing 2,500 places. Each year an average of 13,000 people pass through these centres. There are specially trained disablement resettlement officers to provide a service for people suffering all forms of serious handicap or disability, whether or not they choose to register as disabled. These officers are mostly based at local employment offices, although a few large psychiatric hospitals now have their own. It is the responsibility of these officers to put people forward for sheltered employment, either with Remploy or in schemes run by local authorities or voluntary organisations. So a great deal is being done already, but it is vital that we keep up the momentum.

To sum up, we must learn by our mistakes. Adequate housing in the community is a priority, but it must be with the full co-operation and backing of the social services. But we should make quite sure that any psychiatric patient discharged into the community is ready for his new life, trained for it to the best of our ability, and can look forward to a useful and satisfying life in the future.

7.35 p.m.

Baroness Faithfull

My Lords, I apologise for intervening when my name is not on the list. I did in fact put it in but I was rather late. I, with others, should like to congratulate the noble Earl for bringing this matter before your Lordships' House today. Briefly, I should like to talk about whose is the responsibility. Where does the buck lie in the question of after-care of the mentally ill and the mentally handicapped? The Department of Health and Social Security published in February a document called Care in Action. This document is a handbook of policy and priorities for the health and personal social services in England.

The book lays down certain principles. The principles are prevention; cost-effective community care; domiciliary care; planning collaboration and joint funding; the relationship between the statutory and the voluntary bodies; and the use of volunteers. They have laid down priority sectors of the community. Those priority sectors are elderly people, especially the most vulnerable and frail; mentally ill people; mentally handicapped people; physically and sensorially handicapped people; and in the Health Service the maternity services and neo-natal care; primary care services; and services relating to the care of young children at risk and the treatment of juvenile offenders. So the Government have given a lead to local authorities as to where they think their priorities lie. I personally think that there are one or two important sectors left out, but for the purposes of this debate let us take note that mentally ill and mentally handicapped people are considered, and advised to be, a priority.

There are various difficulties here. First, does the responsibility lie at central Government level or at local government level? What is the interaction and the inter-relationship between the two? May I first of all say that I wish to ask the Minister whether there is any possibility of calling a conference of the statutory and voluntary bodies on their relationship one to the other. The noble Lord, Lord Lloyd, talked about money for the Richmond Fellowship, and many other noble Lords have talked about the need for grants. We are in a dilemma in the relationship between the voluntary sector and the statutory sector.

In Care in Action, the handbook from the Department of Health and Social Security, it is advised that there should be this partnership. But as I understand it, it is not only in the area of mental health but in all areas that local authorities have used voluntary organisations to very good purpose, and have worked in partnership with them. They now find themselves cut back in certain areas by their own local authorities, and therefore although needing services of the voluntary organisations they are not using the services of the voluntary organisations. That means that the partnership is falling because there is not the money being paid to the voluntary organisations. Therefore, there is a dilemma here. I have found it in other fields, and particularly in the field of the care of children. I wonder whether the time has not come for there to be a clearly defined policy concerning the relationship between the local authorities, the voluntary organisations and the central Government departments.

The Government accepted the Jay Report, which was concerned with the care of the mentally handicapped, including of course the after-care of the mentally handicapped if they had been in a custodial setting. Although the recommendations of the Jay Committee have been accepted, so far as I know no practical steps have been taken to implement them, particularly in the sphere of training, although one must pay tribute to the Secretary of State and the Department of Health and Social Security for having set up the Berkeley Committee to look into the training of social workers—this will interest the noble Lord, Lord Winstanley—and to consider the generic or specialist element. I am not sure—the noble Lord, Lord Winstanley, will know this better than I—about the training of nurses in the mental health field in the community. Certainly in my area training has been given to nurses who work with families in the community.

As for provision for the mentally ill discharged from hospital, I agree with noble Lords who have pointed out how few local authorities have set up a service in this respect and have not created good safeguards for patients who are discharged. For the mentally ill and, indeed, for the mentally handicapped, there cannot be just one facility; there must be a wide range of facilities to meet the wide range of needs of the mentally ill discharged from hospital. Again, whatever the Government may do and recommend, the responsibility lies at local level. One wonders whether there should be a procedure of joint planning at local level as between the Health Service, the local authority and the voluntary organisations. I appreciate that many local authorities have such a committee and joint planning, but I wonder whether such joint local committes of the three sectors have done enough to make known to the public the needs of the mentally ill and mentally handicapped.

The question of the implementation of the recommendations of the Butler Committee has been mentioned. We are all disturbed by conditions in our prisons, and we are deeply disturbed about the question of patients in prisons who could better be cared for and and helped in secure units attached to hospitals. The noble Baroness, Lady Masham of Ilton, has already spoken about children. I would only add in that context that many parents would be able to help their children coming out of hospital, or perhaps even help to prevent them going in, if they were helped at an early stage and if there were earlier assessment.

I call for a much more practical and structured approach at local level between the Health Service, the social services and the voluntary services—I would also include the volunteers, who are slightly different from the voluntary services—and I call on the Minister to make clear the relationship on a financial basis between the voluntary organisations and the statutory services. At the end of the day it is good practice and sensitivity to the needs of people that will bring about the change we want to see, but there must be a proper structure to achieve that.

7.45 p.m.

Lord Wallace of Coslany

My Lords, I was very glad indeed that the noble Baroness, Lady Faithfull, decided to take part in the debate. When I tell her about the excitement there was behind the scenes when it was discovered that her name was not down among the list of speakers, she will realise how pleased we always are to have her take part in a debate such as this, so much do we appreciate her expertise. The House will not wish me to be too long at this somewhat late hour. I do not pretend to speak as an expert on this subject, because I am not, although I have listened to experts in this debate. The House will be grateful to my noble friend Lord Longford for his initiative in tabling such an important Question. He and others have put forward thought-provoking proposals, and while I am sure the noble Lord, Lord Cullen of Ashbourne, will do so when he speaks, I wish to thank all noble Lords who have taken part, including one noble Lord the elevation of whom I am not sure is material or spiritual.

I must be frank straight away and tell the House that this subject deserves and needs a full-scale debate, for we have the problems of dealing with not only the after-care of the mentally sick but also the needs of the mentally handicapped. I support the call of my noble friend Lord Longford for an inquiry and I support the call of the noble Baroness, Lady Faithfull, for greater co-ordination. The trouble with inquiries is that, although they eventually take place and are finalised and issue reports, seldom is action taken on their reports, when action is what we need.

Many years ago the subject of mental illness was brushed under the carpet. With the passage of time there has been a change in the attitude of society to some extent, but more needs to be done to educate the public and secure the co-operation of local and national authorities, a point which has been emphasised by many speakers in this debate. We must face the fact that there are thousands of patients in mental hospitals who could leave if accommodation outside and after-care facilities were available, and I understand the official estimate of such cases is 20,000, but I stand to be corrected.

In the meantime, these people, many of them long-stay patients, have become, or are becoming, institutionalised, and facing the outside world can be a terrifying prospect, however much skilled care and attention they may receive in hospital. It is a fact that some have been released without proper accommodation or after-care, and many are sleeping rough, moving from one night shelter to another, and in some cases finishing up in prison. There is no humanity in releasing people under such circumstances and conditions. True, I am talking about a minority, but such a state of affairs does exist and must not be allowed to exist much longer. Thanks are indeed due to the voluntary bodies and to some understanding local authorities, so that there is a brighter picture for some others.

Some years ago, when I was the Member of Parliament for Norwich North, I visited a road in which the old houses had been restored in a joint effort by the city council and a voluntary organisation. Two of the houses had been diverted as accommodation for discharged female former mental patients. The accommodation was cosy, bright and cheerful. I stopped for tea and had a chat with the residents and their resident companion, a former nurse at their old hospital. All were happy and cheerful. Cinema and theatre visits were organised, as were shopping expeditions, all carefully designed to get them used to the outside world before going their various ways. That sort of preparation is vitally important. That is ideal, provided that there exists a continuing form of aftercare. I shall never forget that experience because it was a practical example of what can be done and is being done in some cases. It is true that such facilities exist elsewhere, but they are far too few to meet the existing need, which is considerable.

There is also the question of delay in the provision of psychiatric units in general hospitals. A psychiatric unit is planned at a general hospital for the building of which I have spent the greater part of my public life fighting. The unit is planned, but when is it to be built?—probably not in my lifetime, because there is always the question of who is to find the money. Such provision has been a casualty of succeeding economy campaigns—and I am not throwing the blame on one side or the other.

The noble Countess, Lady Loudoun, referred to the MIND campaign, which started in April 1976. It was a magnificent effort, and similar efforts by MIND are continuing. The noble Countess also referred to the Granada Television appeal, which attracted 1,250 responses. The media can be a very important factor in tackling this problem, provided that it is properly used. Perhaps we can indulge in a campaign, possibly with the Government's co-operation, to organise programmes to bring home to the people of this country the needs that arise from this problem. One concentrates on MIND because it has sold itself fairly well in regard to its campaign, but of course it is not the only voluntary organisation operating in this field. Although the organisations are doing a fine job, they will be the first to admit that an enormous field has yet to be covered.

The noble Countess, Lady Loudoun, spoke, too, about the co-operation involving the Housing Corporation and the MIND campaign. That is the kind of thing that is needed. Yesterday at Question Time—I see present the noble Baroness who asked the Question—information was given regarding housing accommodation that has been empty for over 12 months. It is estimated that 20,000 units are empty. Will the Government drive home to local authorities the urgent need for some of these units to be adapted for use by patients discharged from psychiatric hospitals? The accommodation is there. I have seen with my own eyes old houses converted to meet the needs to which I have referred. Is it too much to ask for this, even in a period of severe financial restraint?

As has already been said, cut-backs in public expenditure, locally and nationally, are not helping in regard to housing, and grants to voluntary bodies tend to be reduced. It seems to me that the main source of inspiration and action in this vital field comes from the voluntary organisations. It is true that there have been committee reports and recommendations, but so far there has been no positive system of integrated rehabilitation schemes. Perhaps I am cynical, but that seems to be the usual fate of recommendations and reports following inquiries.

There is need for more employment training, but with unemployment at today's levels, even if an adequate system existed, chances of employment would be somewhat remote. I make no party point when I remind your Lordships that unemployment is on a large scale. I had personal experience of unemployment as a youth and again, later, when married. I know of the extreme mental strain that unemployment can cause. It is little wonder that some people, not perhaps morally fortified, and without any idealism behind them, become mentally sick and break down. That, in turn, can lead to alcoholism, if they can afford to drink, and this can be dangerous in the extreme. One need stroll only from here to Charing Cross station to see some of the results of that kind of predicament. This trend must be carefully watched, particularly among young people. We must shake ourselves into reality. I know from personal experience of the dangers that can arise from unemployment.

Finally, I turn to the needs of the mentally handicapped—not much mention has been made of this aspect of the matter—and I shall confine my remarks to children. Very close to my home in Sidcup is a school for mentally-handicapped children. It is a fine, purpose-built building, in beautiful surroundings, and it has a dedicated staff and helpers doing a magnificent job. I often meet the children from the school in groups, carrying out little shopping expeditions, and it is obvious that they are devoted to their teachers and helpers. The school was originally started in temporary premises—the local labour hall, by chance—and it is now doing a fine job, the success of which is, as I know, reflected in a happier and useful home life for some of those involved; and later in some cases employment can be found. The school is well supported by parents and voluntary organisations. That is the ideal situation.

On 20th March, while waiting for Gardeners' World (one of my favourite television programmes, as your Lordships will probably expect) I casually watched the Oxford Road Show. Being an old square, I found most of it beyond my comprehension, but I was jolted into grave concern and alarm when before an audience of young teenagers the subject of the care of mentally-handicapped children was raised during the serious spot in the programme. The item dealt with schools for the mentally-handicapped. It was stated quite categorically that less than 50 per cent. of local authorities were carrying out their responsibilities in this field. It was stated that under the Education Act 1944 such children have the right to stay at special schools until the age of 19, if necessary. It was also stated that some local authorities—Oxford and Hampshire were quoted—are breaking the law, robbing children of their statutory right. Will the Government confirm or deny that that situation exists?

To return to the main theme of the debate, I would say that it appears to me that the bulk of the work in after-care is carried out by voluntary organisations. It is true that grants are made by central Government and local authorities, but in the present economic climate the grants have been cut and will continue to be cut. The noble Baroness, Lady Faithfull, spoke about co-ordination. I would ask: what system of co-ordination exists among Government departments, local authorities and voluntary organisations? I might be wrong, but the present system seems to me to be patchy in the extreme. I hope that the Government spokesman, the noble Lord, Lord Cullen of Ashbourne, will be able to put our minds at rest. Like the noble Baroness, Lady Faithfull, I should like to see the various bodies get together to tackle the problem through co-ordination, frame the guidelines, and get on with the job.

This is not a problem to be ignored after a short debate in your Lordships' House. It is a tremendous social problem, and we must deal with it. It is our responsibility. This is, after all, the International Year of the Disabled. When I was in Hong Kong on a mission with a number of Members of Parliament I was given a tie, on which were the words, "The International Year of the Disabled". I was asked to wear the tie to show that the organisers there intended to put in 100 per cent. effort for the Inter-national Year of the Disabled. I wonder whether we in Britain could do the same? The question of the after-care of the mentally sick and the mentally handicapped is one that is overdue for energetic and positive action. We all agree about that. But is it just talk, or is there to be action? We cannot afford any longer to neglect our responsibilities. This debate, short as it is, is bound to be a challenge to the nation's conscience, and I hope that we shall indeed, in the not too distant future, have a wider debate and some demonstration on all sides that we really mean business in this tremendous problem, to which there can be a solution.

Baroness Faithfull

My Lords, before the noble Lord sits down, may I be permitted to ask him a question? Did I understand him to say that Oxford were not carrying out their legal responsibilities with regard to the mentally handicapped child? This is not my experience.

Lord Wallace of Coslany

My Lords, I am only quoting the statement made in the programme, "The Oxford Road Show". I do not recommend it; it is mainly pop stuff, and, really, my mind does not go as far as that. But it said that two areas were not carrying out their legal responsibilities. This refers, I rather gather, to the facility of remaining until the age of 19 in handicapped schools; but they quoted Oxfordshire and Hampshire. I can only quote what they said, and that is the position so far as I know.

8.2 p.m.

Lord Cullen of Ashbourne

My Lords, I think we have had a most interesting debate, and I hope the noble Earl is pleased with it. We have heard from so many people with such great knowledge that I think it has been very valuable indeed. The noble Lord, Lord Winstanley, said that he suffered from too much knowledge on this subject. I am afraid I am the reverse, and all I shall be able to do is to give what I have been told by the department is the Government's line, and their views on these matters. I shall not be able to answer all the questions, but as soon as I can I shall certainly see that they are answered.

Before responding to the points which have been raised, some of which I shall try to answer, I wish to say that the Government welcome this opportunity to draw attention to what is a very important question; and I am grateful to the noble Earl for having given me the opportunity to set some comments within the framework of a more general statement of the Government's policies and intentions in relation to the development of services for the mentally ill. I should also like to thank the noble Earl for having postponed the debate from last Thursday, when we would have started at about half-past nine at night. Today has been a great improvement.

My Lords, the word "after-care" first appears in the National Health Service Act 1946. Section 28 said: A local authority may with the approval of the Minister, and to such extent as the Minister may direct shall, make arrangements for the purpose of the prevention of illness, the care of persons suffering from illness or mental defectiveness, or the after-care of such persons…". So this was a power, and the Minister could, if he wished, direct that it should be a duty. But no such direction was made until after the passage of the Mental Health Act 1959. This enumerated the purposes for which care and after-care arrangements could be made, including, for example, among such purposes, the provision of residential accommodation and the provision of day centres; and under directions issued by the then Minister in August 1959, the provision of both residential accommodation and day centres became a duty. This statutory duty laid on local health authorities became in 1974, under a new direction, a duty of the local social services authority, and this it still remains, My noble friend Lord Lloyd referred to this in what he called his second maiden speech.

However, the duty is expressed in fairly general terms, and gives local individual authorities discretion to determine the needs of their own localities for the amount of such provision that is necessary. This is a sensible arrangement, since the needs of individual localities are bound to differ, as many noble Lords have said today, and to be affected by other forms of provision which are available.

Paralleling the development of legislation between 1946 and 1981 there has been a revolution in the practice of psychiatry and in therapeutic and rehabilitative techniques. There has been the "open door" movement, the new psychotropic drugs, the therapeutic community and an emphasis on the hospital as one component part of a wider community mental health service. There has also been a reversal of institutional attitudes, linked to a positive stress on the restoration of social skills. All these developments have led to a transformation of both the size and character of the in-patient population. This has led in consequence to major changes in the pattern of discharges and in the practice of after-care.

My Lords, 35 years ago many patients would have been detained under compulsory powers and would have spent many months or years in hospitals before returning, if returning at all, to the community. Today, the average patient enters hospital voluntarily on an informal basis and returns far more rapidly to life in the community outside hospital. I should like to quote two figures to illustrate the magnitude of the change. First, about 90 per cent. of first admissions in 1979 were discharged within three months of admission; secondly, at the end of December 1979 there were, as has already been mentioned, 76,000 patients in mental hospitals and units in England, compared with 143,000 on the same date in 1954. That factor was mentioned by the noble Lord, Lord Richardson.

These changes have a direct bearing on the task of after-care. It has expanded from a voluntary activity of the old local health authorities to become an important part of the work of both health and social service authorities. Together they have to plan and provide a whole range of specialised services and facilities on behalf of the discharged patient. To the skills of the medical profession are allied those of psychologists, occupational therapists, social workers, community psychiatric nurses, the staff of industrial therapy units, disablement resettlement officers and many others—not forgetting the members of the primary health team.

My Lords, what is the task? Before going on to describe particular elements in that task and to reply to some of the points which have been made, I should like to suggest to your Lordships very briefly the extended nature of the task itself. This will make clear why we share the view of the noble Earl that what he calls "mental after-care" and what we would prefer to call more generally "community psychiatric care", is crucial to our mental health services.

In 1946, when the National Health Service Act was passed, after-care for mental illness seemed like an optional extra for the local health authorities of that time. Not only were many fewer people discharged annually, but the assumption then was that if they were discharged it was because they had recovered. People who still needed care would stay in hospital. In addition, people who had no home, or no home that would take them, often stayed in hospital. So it is not surprising that the number of in-patients continued to rise.

But the new philosophy, symbolised by the Mental Health Act 1959, implied three new major and very long-term tasks for us. The first, which rightly received much attention in the 1960s and 1970s, is to meet the needs of those who have recovered but who have no home: patients who have been described as being trapped in hospital. This task has been tackled in one mental illness hospital after another, and today we can say that we have nearly dealt with the backlog. Most of the non-patients responsibility for whom we inherited from the past have now left the mental illness hospitals. Many factors have helped. Nearly all patients were changed to an informal status after the passage of the 1959 Act and in the favourable employment situation of the 'sixties many in-patients were able to make an initial trial of the outside world in employment.

Later the position on employment declined, but there was an improvement of the housing situation. And let us not forget the benefits of our social security system which ensures that no patient is now trapped in hospital merely because of lack of a personal income. So now there are only a few people in this position to be dealt with each year. These recovered patients who need a new home may need considerable help to get them started, but once they have found their place they may need no further help.

But there is a second task, for a group which today makes greater demands on community services. These are the people who have a home, but are still suffering from some degree of mental illness. Today we appreciate that for many such people care in the community will be better for their mental health than continuing in-patient care. And almost everybody who spoke today underlined this. But this depends on their receiving the right care. And I think we also see, better than even 10 years ago, that this care may be needed for many years. Few people now believe that mental illness will go away if we stop locking people up. There is evidence, both from this country and from other countries, to disprove that. So this group are going to need not only transitional care in picking up life again, but continuing care from both health and social services, just as they would once have received continuous support in hospital. But in the community they can receive it in a more flexible way, so that they resume control of their own lives to the fullest possible extent.

Many of these people with some continuing disablement are living in family homes, and so a large part of the burden of continuing care will fall on relatives. So our third task is supporting both the patients and relatives of this group of people—people who have returned to their ordinary lives, but continue to have special needs.

Fourthly, a fairly small group numerically have continuing psychiatric needs and also have no homes. The fourth task for health and social services is, therefore, a double task of providing for members of this group both the homes and the support they need to live in them.

For completeness perhaps I should mention two more groups. First, we must not let our concern for after-care obscure the fact that there are a few for whom continuing care can best be provided within the hospital. They will, therefore, remain as long-stay in-patients. Another much larger group will not require "after-care" in the traditional sense, because they never become in-patients, as psychiatrists are finding ways to treat more people without in-patient care. These people form an important part of the demand for the range of community care services which we try to make available.

I turn to some of the points made by noble Lords. Some of them I shall answer in general form and others more particularly. On the subject of residential accommodation, the 1975 White Paper recognised the need for a range of accommodation which could cater for short-term and longer-term needs. The White Paper guidelines on "desirable provision" were flexible. They differentiated between areas of high and more average need. For an area of average need the minimum suggested is 19 places per 100,000 population in long- and short-term accommodation taken together. Applying this to England, the possible need is approximately 8,830 places. Taking account of additional requirements in some of the "high need" areas, a figure of 10,000 places might be a reasonable "round figure" target.

The Department has figures for accommodation in local authorities' own premises, both staffed and un-staffed. There are also figures for places made available to local authorities by voluntary organisations and by private organisations. Adding these together, the total number of available places has risen from 3,322 in 1973 to 5,604 in 1980. We can add to these the number of adults known to be in private lodgings arranged and supervised by social services departments. These have risen from 551 in 1975 to about 800 in 1980. Altogether, the figures for residential places and supervised lodgings in 1980 totalled about 6,400.

To some extent those figures underestimate the total available accommodation. There has been an un- quantified but significant growth in the provision of group homes. Voluntary organisations, we know, have been particularly active in promoting their development. One of the particular merits of group homes is that they merge imperceptibly into normal residence in the community and statistical returns do not necessarily "pick them up". Indeed, some former hospital patients originally classified as "group home residents" change over to having their own direct tenancies with the housing authority. Of course, national figures will conceal substantial local variations, and needs will be much higher in some areas than in others. Nevertheless, it is clear that there has been steady progress in the development of a wide range of residential accommodation for the after-care of the mentally-ill. According to the latest figures progress has been maintained. In 1979–80 expenditure on residential care increased by about 10 per cent. in real terms.

To turn to day care, the total number of day hospital places has increased rapidly from 10,206 in 1975 to 12,947 in 1978. Although this is still far short of the White Paper target of 35 places per 100,000 population for in-patients attending day hospital plus a further 30 places per 100,000 population for day-patients, at the present rate of growth the target should be reached by the mid 1990s. The growth in day centres provided by local authorities in England has been slower than hoped for, but places in day centres specifically for the mentally ill, together with places made available by voluntary and other organisations and including a proportion of places for the mentally ill in so-called "mixed centres", have risen from 5,374 in 1973 to 7,740 in 1980. This is still far short of the White Paper guideline of 27,810. There are, however, currently some doubts about the validity of the White Paper figures, and I will turn to this in a moment.

Not only is it evident that the figures conceal considerable local variations, but it is clear that the practice of day care varies widely. There is a fairly general view that not all clients require day-care on a five-day week basis. Some clients, depending on the degree of disability, may be supported on a one-plus day-a-week basis, or by even less frequent contact. There is, therefore, no exact correspondence between the number of places in day centres and the number of clients receiving active support and help from the centres. Much depends on local policies and on the way in which day care is integrated into the overall network of health and personal social services in any given area.

It may be that the fixed White Paper guideline should be replaced by a range of guidelines which discriminate between high need and low need localities—as the White Paper did for residential accommodation. It may also be better to think in terms of combined total for day hospital and day centre places. This does not imply that the two are interchangeable. There are some functions that seem clearly more appropriate to a day hospital, and some that seem clearly more appropriate to a day centre. But there is a fairly large intermediate area of tasks which it seems likely can equally be undertaken by a day centre or by a suitable peripheral day hospital. There is also some evidence to suggest that the combined guidelines for day hospital and day centre places may be too high. The guideline figure perhaps more nearly represents the number of people to be supported at any one time rather than the number of places required. There have been many references to the voluntary sector. There have been suggestions—I think, not in the House today—that the Government are inclined to rely too much on the voluntary sector.

The Government do not see this as a question of "either/or" but of "both/and". There has long been a vigorous tradition of voluntary service in this country and the major voluntary organisations in the field of mental health. The Mental After-care Association, MIND, the Guidepost Trust, the Richmond Fellowship and many others, provide important services which contribute significantly to the range of facilities available for the care in the community of those disabled by or recovering from mental illness. We also recognise the great value of the voluntary sector's ability to use its freedom to innovate and pioneer. Voluntary organisations can direct their attention to the margins more easily than statutory bodies. They can identify needs which are not easily categorised and which do not fit into neat compartments. They can pioneer and innovate new methods of help and new patterns of service. This is why the Government believe in partnership and close co-ordination between the voluntary a statutory sectors.

My noble friend Lady Faithfull asked about the position of the co-ordination between the voluntary and the statutory sectors. I shall write to her about that. It is certainly the earnest wish of the Government that the maximum amount of co-ordination should develop. There are one or two points that I should make clear. First, despite all the economies that local authorities have had to make, Care in Action shows in England total grants by local authorities to voluntary organisations in the personal social services sector rose between 1978–79 and 1979–80 by 8 per cent. in real terms.

Secondly, between 1975–76 and 1979–80 the mentally ill fared relatively better than other client groups. Local authority grants increased by no fewer than 58 per cent. in real terms. Thirdly, the amount allocated by the DHSS for grants to voluntary bodies has increased by approximately 75 per cent. in real terms between 1975–76 and 1979–80 to almost £6 million at 1979–80 out-turn prices. Not only has the total increased but the share of the total allocation to voluntary organisations concerned with mental health has risen to almost 10 per cent.

The Government's intention is that grants for voluntary bodies will continue to be maintained in real terms. On the question of fees paid by local authorities to voluntary organisations for places taken up in facilities provided by voluntary organisations there is in the available figures no evidence that these have been declining either in cash terms or real terms. The most recent years for which figures are available are 1978–79 and 1979–80. Between these two years payments by local authorities to voluntary organisations actually rose in real terms by 5 per cent. So the figures do not show any downward trend in the total of local authority grants to voluntary bodies or any reluctance to make use of the facilities that they have developed.

Regarding the future, Care in Action commends the closest possible collaboration between the voluntary and statutory sectors. I note with pleasure the local authority associations and the National Council for Voluntary Organisations have established a joint working party to prepare guidelines on working relationships between social services authorities and voluntary organisations. This is, I think, a useful and constructive initiative.

I have left until last the question of joint finance which is a particularly relevant source of funding for mental after-care enabling as it does transfer of resources between health and local authorities. At constant prices (November 1979) joint finance has grown from £30 million in 1977–78 to £54 million in 1980–81. Further real term growth is planned; £56 million in 1981–82 and £58 million in 1982–83. The rules governing the application of joint finance have already been significantly relaxed; but the suggestion of transferring cash with patients to local authority personal social services is currently under consideration by the DHSS in a wider context.

Various methods have been suggested, including attaching grants to patients or places in residential accommodation or centres. As to the meeting of the cost of such grants, it has been suggested that the cash might be found by the consequential closure of hospital wards. As announced in Care in Action, the Secretary of State for Social Services hopes to issue a consultative document later this year and views will be canvassed on a wide range of options.

The noble Lord, Lord Winstanley, asked me about the grant for MIND. This was only submitted to the DHSS Ministers and officials a few weeks ago. The sum involved last year was £275,000. MIND is seeking a major increase. There are standing arrangements for continuing payment of the grant while the new level of grant is under consideration. These were exercised last year when the grant took 21 weeks in negotiation. But I am happy to say the outcome was an increase of £25,000 for MIND on that occasion. I am happy to reassure the noble Lord, Lord Richardson, that the experimental hostel wards and hospital hostels (as they are sometimes called) are seen by the department as important initiatives and their development is being very carefully studied and evaluated.

The noble Baroness, Lady Masham of Ilton, mentioned the subject of anorexia nervosa. The Government are aware that there is evidence that this distressing condition may have become more common in the past decade, especially among adolescent girls and young women. Treatment is normally regarded as best provided within the comprehensive range of mental health services. Some recent comparative research on a variety of treatment methods may yield useful results in identifying improved methods of treatment. I shall be writing further to the noble Baroness.

In conclusion, I believe the debate has illustrated that we need a wide range of residential accommodation and a variety of other supporting services. Some people need only brief help in re-establishing their ordinary lives. Some will need a permanent helping hand in coping with their ordinary lives, while others will need to build a new life, with which they will need continuing support. If this last group are to achieve a quality of life better than that of the traditional long-stay patient, much skill will be needed. The supporting and care services and facilities will need to be carefully deployed so that each individual is rehabilitated to the highest possible level.

It is the most severely disabled patient who represents the greatest coallenge to the new pattern of services set out in the 1975 White Paper. There is little doubt that the average short-stay patient benefits from the new, district-based psychiatric services; he or she benefits from the developing multi-disciplinary therapeutic teams and from the flexible network of services, which enable him to get the treatment he needs with the minimum of disruption to his ordinary life. On the face of it, it is good that the number of chronic long-stay in-patients has fallen, but we must satisfy ourselves that we are meeting the needs of the patient who is now remaining in the community but who has chronic disabilities; this point has been made very strongly by several noble Lords today.

The challenge as we abandon old patterns of care is to be sure that the new network of services which the patient needs is fully established and readily accessible—otherwise there is an unacceptable dilemma: the patient may be discharbed or may discharge himself into the community although nobody has arranged suitable facilities for his continuing care and support; or he may stay in hospital, not because he needs in-patient treatment but simply because there are no suitable facilities for him outside. Both are unacceptable and the Government policy is to ensure that the National Heatlh Service, and local authorities in partnership with voluntary organisations, plan and develop networks of community care which are comprehensive yet flexible and responsive to the needs of the individual patient.

In particular we must concentrate more care on those with long-term needs. I commend to the noble Lords the recently published report by the Multi-Disciplinary Working Party on Rehabilitation set up by the Royal College of Psychiatrists, under the title Psychiatric Rehabilitation in the 1980s, which was referred to by the noble Lord, Lord Richardson. This report makes very clear that rehabilitation is for everyone and not just for those who are obliging enough to get better. Every patient with chronic disabilities needs the help of a district rehabilitation team.

I have already suggested that as a generic term community psychiatric care may be better than mental after-care. It brings out more clearly that this is a task in its own right and not just something which is tacked on to in-patient treatment, which not everybody needs. Looking at this slightly wider spectrum, how is our network of community care growing? I will conclude by bringing together a few of the most significant figures. Residential places are up from 3,332 in 1973 to 5,604 in 1980; day hospital places are up from 10,200 in 1975 to 13,000 in 1978; local authority day centre places are up in number from 5,374 in 1973 to 7,740 in 1980.

The number of nurses in community psychiatric services is up to 2,000 and a service is provided in nearly every health district. The total of local authority grants to voluntary organisations is up by 8 per cent. in real terms in 1979–80, and grants specifically for the mentally ill are up by 58 per cent. in real terms over the five years to 1979–80. In the light of these figures and although I know that your Lordships would like us to be going much faster than we are, as we would ourselves, I can give the noble Lord some measure of reassurance. Despite present difficulties the network is growing—unevenly but quite widely. With regard to the importance of the sort of care provided, I agree with what the noble Earl and noble Lords have said. We welcome the inquiry that the noble Lord is about to undertake and hope that we shall be returning to this subject after he has made his investigation.

I would thank the noble Earl for having raised this subject today, and I hope that this Question has done something to increase general understanding of the importance of this subject and that it has all been worthwhile.

Lord Taylor of Gryfe

My Lords, the noble Lord, Lord Cullen of Ashbourne, has of course spoken on behalf of the Department of Health and Social Security, whose responsibilities are for England and Wales. May I suggest to him that the concern that has been expressed this afternoon is equally applicable to Scotland? can I have the noble Lord's assurance that the content of this excellent debate will be conveyed to his right honourable friend the Secretary of State?

Lord Cullen of Ashbourne

Certainly, I guarantee to do that.