Drug and Alcohol Abuse

HL Deb 14 April 1993 vol 544 cc1068-99

3.4 p.m.

Lord McNair rose to call attention to the social and legal implications of drug and alcohol abuse and to the case for increased facilities for residential care; and to move for Papers.

The noble Lord said: My Lords, I am grateful for the opportunity to discuss this serious matter and I hope that the effect of the debate will be to clarify some of the issues relating to drug and alcohol abuse and to make some progress towards resolving them. I included in the title reference to provision for residential care. Although such public provision is something of which I have neither much knowledge nor experience, there are many in your Lordships' House who do. I am glad to see that some of those are speaking today.

Before I start perhaps I may ask whether anyone else saw a small article in yesterday's Independent? If any other speaker intended to refer to it, I apologise for getting in first. It states: 13 April 1816 Samuel Taylor Coleridge writes to James Gillman, a surgeon, accepting treatment for his opium addiction: 'No sixty hours have yet passed without my having taken Laudanum, tho' for the past week comparatively trifling doses. I have full belief that your anxiety will not extend beyond the first week, and for the first week I shall not, I must not be permitted to leave your house, unless I should walk out with you. Delicately or indelicately, this must be done; and the servant must receive an absolute command from you on no account to fetch anything for me. The stimulus of conversation suspends the terror that haunts my mind; but when I am alone, the horrors I have suffered from Laudanum, the degradation, the blighted utility, almost overwhelm me"'. It appears that little has changed.

When we talk about drug and alcohol abuse we use language in a curious way because it is the person's body and his mind, and in fact his whole being, that are abused by the consumption of the substance. We regard the substance with differing degrees of seriousness depending on several factors: the effect on the person's behaviour; the degree of addiction and the speed with which addiction sets in; the legal background against which consumption takes place; the commercial environment in which the substance is used. For example, does it generate tax revenue? Is it available only on the black market? We consider also the toxic or health-threatening properties of the substance, current medical prescribing practice and what is regarded as acceptable in the culture.

I want to try to illuminate a little the world of the addict. In doing so I must confess that I have never had a drug or alcohol problem myself so that my interest is in a sense vicarious and my experience is a retelling of the experiences of professionals in the field and of former addicts whom I know.

I should like to spend some time on the problem of methadone. This is a synthetic opiate which was first developed by German chemists during the Second World War when Germany was unable to obtain supplies of either morphine or heroin to use as painkillers for their wounded. But its use as a substitute for heroin follows a pattern of unsuccessful substitution which started when morphine was first used to try to cure alcoholism. The resulting morphine addiction was then treated by substituting diamor-phine or heroin, which is a derivative, like morphine, of opium. Heroin addiction was fuelled by illicit supplies of heroin from Asia and by changing cultural attitudes and the lifestyles of young peoples' role models in the entertainment world.

Methadone is prescribed as a substitute for heroin. It is listed in MIMS as a painkiller, but a GP friend of mine told me that it is only ever used as a heroin substitute. I feel therefore that it would be useful to examine the effects of the drug and the results of the present prescribing regime. It is available both as a linctus and as injectables in ampoule form. It is wholly synthetic so that third world production and smuggling is not a problem, although there is a well established black market in prescribed methadone.

There is one major problem with substituting methadone for heroin. It is much more addictive than heroin and much more difficult to come off. While that is obviously good for the shareholders of Wellcome, the manufacturers, it is a disaster for thousands of heroin addicts who are persuaded to change from heroin to methadone. In the words of one former addict, "Methadone is less vicious but subtly more evil and destructive, both mentally and physically". That is from someone who has used both and who was reassured for years that methadone was harmless.

The same doctor explained to him that as he could no longer use the veins in his arms for injecting, he should inject it into the femoral vein, in the groin—a counsel of despair if ever there was one. It not infrequently happens that people who do this, and who lack adequate anatomical knowledge, manage to inject into the femoral artery, with disastrous results. That, of course, applies whatever substance is injected. Methadone, however, has many physical as well as mental effects, despite the doctors' reassurances. These include bloating of the torso, wasting of the muscles and heart irregularities.

Perhaps at this point I should go into detail about a particularly unpleasant aspect of the addiction industry. I recently discussed with former addicts their experiences of the methadone prescribing practice of certain doctors outside the NHS who are often located in Harley Street or thereabouts. I must stress that what I am about to say applies only to a few unscrupulous doctors. I do not include the sincere pioneers of maintenance prescribing, who are not motivated by profit, even if they are misguided. We calculated the throughput of patients at one surgery on the basis of an average of 10 minutes per patient —there is always a queue—and multiplied that by the average cost of a prescription and the number of patients that a doctor could see in a day. It should be borne in mind that these doctors do not actually have to handle the drugs. They are, if you like, well paid agents for the manufacturers. The prescription for which addicts pay the doctor is simply a permit to go to their chemist and pay two or three times as much as the prescription cost for the actual drugs.

We calculated that these practitioners are earning at the rate of about £300,000 a year. No doubt if questioned they would plead pitifully that the rents in Harley Street or Wimpole Street are so high, and so on. No doubt this would also be the reason given for their induction procedures and the reluctance to countenance a reduction in the amount of the addict's prescription, which is something that addicts have found. Apart from compliance with the regulations, their main concern when first consulted by a new patient is whether he or she can pay for the prescription on a regular basis. For those addicts who are able to maintain their employment, a job reference will suffice. For others, a bank statement is required. I should add here that it is usually the doctors working within the NHS who try to persuade the addicts to reduce their consumption.

I should be grateful if the Minister would tell the House—I have given her notice of this question— what has been the total volume of methadone prescribed each year for the past two years both inside and outside the NHS. I sincerely hope that the Minister will listen carefully to my criticisms of government policy regarding methadone and realise that they are based on the experiences of both former addicts and professionals in the field.

I conclude what I have to say about methadone with this. To encourage someone to change from heroin to methadone is to play upon that person the cruelest practical joke imaginable. Withdrawal from heroin takes three or four days. It may include involuntary muscle spasms and cramps, insomnia and nervousness. But methadone withdrawal can take weeks, during which time the person may experience diarrhoea, back pain, extremely severe abdominal pain and cramps, hot and cold flushes, insomnia, sweating and a deep pain in the bones. This has been described by some as a sensation that their bones are deteriorating. I hope that the Government will swiftly reverse this policy of substituting methadone for heroin. If maintenance prescribing is deemed necessary, then in my view it is better to maintain people on heroin.

There is another very serious situation about which little is spoken. This is the problem of tranquilliser addiction. It is estimated that 2 per cent. of the adult population takes tranquillisers regularly. The majority of people taking tranquillisers regularly would experience serious withdrawal symptoms if they stopped taking them.

Benzodiazepines are drugs of addiction par excellence and the body rapidly acclimatises to them so that progressively larger and larger doses are required not just to maintain the status quo but to prevent the onset of extremely unpleasant withdrawal symptoms even at the regular dose. These consist of a long list of very nasty physical and mental sensations. Stopping taking benzodiazepines brings on severe, intense and seemingly endless withdrawals. The reason why not much is heard of this problem is the incapacitating nature of the suffering. People suffering tranquilliser withdrawals are socially paralysed. They are often too terrified even to pick up the phone or write a letter. Their world seems to come crashing down on them. Thoughts of death and suicide haunt them. It is well nigh impossible for people in this state to link up with other sufferers to form common interest or pressure groups, so millions suffer in silence. But their suffering is real and the dangers of regular tranquilliser use should be more widely known. Will the Minister tell the House what research the Government have undertaken into this problem and what is the latest advice to doctors? I also have another suggestion which could be put in place in the case of suicides. I should like to see a recording of the prescribed drugs which the person who had committed suicide had been taking in the period leading up to his death.

I should now like to turn to the drug situation in prisons. Because of the unusual economic situation in prisons the inmates have come up with novel means of economic survival. Prisoners divide into those who use drugs and those who want nothing to do with them. However, drugs as well as cigarettes and even phone cards are used as currency in the prisoners' economic system. But, for whatever reason and in whatever way, drugs are freely available in prison. It has even been put to me that the prison authorities prefer to have a certain amount of opiates circulating because it reduces tension. I was told that the atmosphere gets very tense if they are not available.

I suggest that intervention with drug and alcohol rehabilitation in prisons is essential to break the vicious circle of drug induced crime. I know from reading Addiction Counselling World that some initiatives are currently being tried, and I welcome that. This should be a major focus of government policy in the prisons. If you think of the cost of a drug habit as being £500 per week, then in the space of a year the person has to come by a total of £26,000. And this will be repeated year after year. Effective drug rehabilitation, as described in the same publication, at a cost of about £7,000 to £10,000 per person then looks like a worthwhile investment. The cost would be less in prisons because accommodation is already provided.

It is worth noting that any drug is taken initially to produce a positive pleasurable effect. As with alcohol, the drug taker may come to depend on some other property of the drug—for example, anxiety reduction —and may then continue to take it in order to eliminate some negative effect; for example, depress-sion or the onset of withdrawal symptoms. Recognition of this change is often the event that prompts the drug user to seek help. Withdrawal, or "cold turkey", is greatly feared by addicts who, if they have not experienced it themselves, will certainly have discussed it with other addicts. I remember a meeting of the All-Party Group on Drug Misuse at which Dr. John Marks from Liverpool stated that addicts did not want to come off drugs and that they either grew out of their addiction or died, so either way they ceased to be a problem. The noble Lord, Lord Mancroft, and others at that meeting took exception to that callous and self-serving attitude, and former addicts to whom I have spoken all say that deep down all addicts do in fact want to get off drugs.

Something else has come to my attention which I should like the Department of Health to consider carefully. I believe I am right in saying that all currently available syringes have stamped on them a kind of government health warning to the effect that they should not be re-used. But they still can be re-used by anyone who decides to do so. I know of at least one perfectly practical design, with which I have no financial connection—I expect there are more—for a syringe that is impossible to re-use although it functions normally when used the first time. This is such an eminently sensible idea that I cannot imagine why it was not implemented when re-use of syringes first became a problem. It is something I intend to take up with the Department of Health though I do not expect a full answer when the Minister winds up the debate.

I feel very strongly that the Government should give equal emphasis to educational approaches to prevent children becoming involved with drugs in the first place as they do to the rehabilitation services side of the problem. Last time we debated this subject I spoke about TACADE, the Advisory Council on Alcohol and Drug Education. The noble Lord, Lord Russell of Liverpool, spoke about life education centres. I believe that the noble Baroness, Lady Masham of Ilton, will say something about TACADE today. I hope that I do not steal her thunder.

The activities of those two organisations seem to me to complement each other very well. Life education centres have 12 mobile audio-visual demonstration units which tour the country giving a lively presentation of the effects of different kinds of substance abuse and kindle in their young audience a sense of wonder at the way in which their bodies work and an awareness of their own uniqueness. Understanding the mechanisms of peer group pressures, they are better able to resist offers of drugs, alcohol and cigarettes. I have seen one of their mobile units in operation and was very impressed.

I must congratulate the Department of Health on its decision to give TACADE the Section 64 core funding for which it has been asking for the past three years. This funding, modest though welcome, is a recognition of the major contribution that TACADE has made to the educational life of the country. An evaluation of its programme, Skills for the Primary School Child, will be published this summer. However, indications from schools suggest that this programme is having an important, positive effect on the moral outlook of primary school children who are exposed to it. This takes the form of marked reductions in bullying and truancy and improvements in general behaviour, communication skills and the ability to form satisfactory relationships with others.

However, I should like to add a note of caution as regards the programme. It works best when and where it is applied fully after staff have been properly trained to deliver it. That is because the teachers need to understand fully the principles behind the programme and to reflect on their own attitudes and social skills.

The decline of moral values and the reduction in community spirit have been commented on by many people, including the Secretary of State for Education. Skills for the Primary School Child helps greatly to produce the attitudes which collectively make up those desirable attributes and produce the behaviour we want from our children; and it is in childhood that we need to learn to be good and kind, to respect others and to respect ourselves.

Traditional values were, it must be said, often enforced by a measure of fear, whereas now we need to inculcate positive values on the basis of an understanding that respecting others and oneself makes for a happy life. When society is falling apart all around them, it is doubly necessary to have a part of the school curriculum that makes it possible for children to learn how to grow into emotionally mature people. In that way, they will experience the natural high that is our birthright and will more easily resist the temptation to use drugs and abuse alcohol. I beg to move for Papers.

3.22 p.m.

Lord Mancroft

My Lords, we should be grateful to the noble Lord, Lord McNair, not only for putting the Motion down on the Order Paper but for using words which allow us to have a wide-ranging debate with a focus within it. There are tremendous legal and social implications. There are legal implications because there are social implications. The social implications connected with the misuse of drugs and alcohol in this country are because we, as a society, quite rightly came to the conclusion that excessive use of alcohol, or indeed any use of illicit drugs, is bad in two ways: it is bad for an individual's health; and it is bad for society as a whole. Both factors are very true. It is because such use is bad for society as a whole and because it is injurious to personal health that we have sought various methods to prevent it. That is where the legal implications come in. We have made it difficult to sell alcohol in the same way that one would sell other products. One sells alcohol through licensed premises and off-licences. That is a method of control.

We control other drugs too. I refer to "other drugs" because alcohol is a drug; it happens to be a rather popular social recreational drug which is an inherent part of western society. However, it is nevertheless a narcotic drug and a very poisonous one at that. Drugs such as cannabis, cocaine and heroin are controlled in another way. In this country we do not make them illegal for the most part; we control them. We have a Misuse of Drugs Act which seeks to prevent ordinary people from using those drugs. One can only obtain drugs such as heroin through a doctor and for very few medical reasons. But heroin is a very useful carefully prescribed medical drug. I have referred to one of the ways in which we control drugs in this country.

We have sanctions for people who do not stick to those rules. If, against our law, people wish to import drugs in large quantities into this country we pour an enormous amount of money into Customs to prevent them from doing that. We have the police to prevent people from possessing, buying or selling drugs or driving cars under the influence of drugs. An enormous amount of police time is taken up in trying to ensure that people keep those laws; on the whole they do not seem to.

We have courts. We take people before the courts if they break those rules and the police catch them. Forty thousand people were taken to the courts last year for the possession of drugs. Only about 1,200 of those 40,000 actually went to prison, and that is probably not a bad thing because there are far more drugs in prison. The noble Lord, Lord McNair, touched upon the issue. The figures vary slightly depending upon whom one listens to, but the 1989 survey indicated that 43 per cent. of male prisoners had used drugs before and during the time they were in prison. Therefore, perhaps prison is not a good place in which to put people with drug problems.

We have another method of control: we tell doctors that they must inform the Home Office if they know that any of their patients use drugs. There are about 20,000 people on that list at present. The figure has increased 74 per cent. from 1987 to 1991, which is the latest figure that I have. The Home Office admits quite openly that probably only one-fifth of those who are addicted to drugs are on that list. The others escape merely because they give false names to the doctors or because the doctors do not choose to register them. I do not believe that the Home Office tries that hard to make sure that the list is accurate. Even accepting those figures, we must assume that there are at least 100,000 addicts in this country. That is what the Home Office believes. I ask noble Lords to remember that figure.

In connection with the law and the courts, we have a variety of other methods to try to stop people taking drugs. They are not always very satisfactory. It appears that most of those who are in prison for a variety of drug offences come out and reoffend. Taking drugs and possessing them is not the only reason for appearing before the courts. Of those who appear before the London magistrates, 83 per cent. have a drink or drug problem as a contributory factor in their offence. Although under the latest Criminal Justice Act there is a treatment provision, it is not often used because there are few treatment facilities to which one can send those people. They come out and reoffend. To keep allowing people to go round and round the system is very expensive. According to the Home Office the cost of drug-related street crime in the Metropolitan Police area currently runs at £1,850 million every single year: it costs you and me £1.85 billion as a result of people stealing to acquire illegal drugs. I am a simpleton in these matters, but my view is that that is an unacceptable figure. We should not accept it, yet we do. Year after year we allow that figure, and it is rising.

I stated that the Home Office admits to 100,000 addicts. Perhaps I may quote from an article in the Evening Standard of 25th January 1993 which states: Figures released last week reveal that Customs officers confiscated a record £545 million worth of drugs last year". I do not know about other noble Lords but I do not believe that 100,000 people can afford to buy £545 million worth of drugs, in particular when we know that if a person steals a cassette player out of a car he will sell it for only £5. We do not need to do much mathematics to realise that to produce that figure an awful lot more than 100,000 people must be taking drugs. The article continues: still the number of users and seizures by drug squads grows. Consequently, says Commander John O'Connor, the best way to tackle the problem is to reduce demand … In North America, the strategy of the Seventies and Eighties appeared to be to attack the source. But government-backed programmes of crop destruction have had little impact on the tide … that has saturated the US market". In other words, we cannot control the supply, but we can try to control demand. There are two ways in which we can do that. The first is the prevention/education route, and the other is the treatment route. The noble Lord, Lord McNair, mentioned the two best organisations in the area of prevention and education: TACADE and the Life Education Centres. I. am sorry that the noble Lord, Lord Russell of Liverpool, is not in his place to talk about the Life Education Centres because he knows a great deal more about them than me. Those organisations are very effective. As the noble Lord, Lord McNair, said, they teach children to think positively about their health and about what they do with their bodies and minds but—and there is a really big "but" in this— there is no practical evidence that drug prevention in this way works. Just because one teaches people that drugs are not a good thing, it does not mean that they grow up not to take them. All the evidence points to the fact that they do. People cannot learn not to take drugs in the same way that they learn French irregular verbs. Drug taking is partly learned behaviour and the people from whom children learn it are the adults around them—their parents, teachers, and adult family friends. That is where people learn how to take drugs, and that is where we must stop them.

What we do know is that treatment works. If I say that with a certain amount of pique, it is because earlier this year we had European Drug Prevention Week which the Department of Health spent more than £250,000 publicising—I know that because I was told by the company that the department hired to publicise the event—when everybody in the indepen-dent sector told the department that it would not work. Indeed, the previous week the department reversed the community care proposals which allowed treatment to be properly funded. That galls slightly. In fact, that galls a great deal because treatment does work. We know that it works and we can show that it works. However, it only works if it is good treatment in much the same way as a good mechanic will mend one's car but, my God, a bad mechanic will ruin it. We need to make sure that we have some better mechanics.

Therefore, I welcome the report that I read in the Daily Telegraph last week that the Minister responsible, Dr. Mawhinney, has started a study into the way in which we treat drug and alcohol addiction in this country. That must be good. The whole row over community care and its funding took place because social services departments do not want the drug addicts and the alcoholics and neither do the health authorities. For 20 years they were bounced between one and the other, falling between two stools, with the result that this country still has only about 2,000 in-patient beds. America has one such bed for every 2,000 per head of population, whereas in this country we still have only one bed for every 220,000 per head of population. We cannot allow that to continue because it is too expensive to leave those people untreated. We must change that.

There will, of course, be endless debates about whether we should prescribe methadone. The noble Lord, Lord McNair, described it carefully. I have severe doubts about methadone. It has a role, but only a very limited one. There is no doubt that the noble Lord is right that methadone is massively over-prescribed. It is very expensive and extremely dangerous. We need to think about it carefully. One does not swop somebody from one drug to another. It is not a good thing to do. It is possible to persuade people to stop drug use and to abstain. One could say to an addict when he comes through the door, "Listen old boy, we have two choices for you: either you can go next door and we can give you some stuff to keep you level and everything will he hunky-dory, or you can go into an abstinence programme which will he hard work and unpleasant". But what will be his reaction? He will say, "Thanks very much, guy, I think I'll have the drug". We should not give people who are weak and vulnerable such decisions to make because they are not in the right frame of mind for making them.

We do not need more huge amounts of public money, but we do need the money which is currently being spent to be spent properly. As yet, there are no qualifications for drug counsellors in this country and we have no registration of facilities. The existing facilities are registered either as nursing homes or psychiatric hospitals—and they are neither. Although psychiatrists seem to play an increasing role in this area—wrongly, in my view—we must remember that very nearly 100 years ago Sigmund Freud wrote that alcoholism is not a psychiatric illness. It is very important that we get these people off the psychiatrist's couch where no good is done them but where an awful lot of money is wasted.

It is true that there are not enough treatment beds. We need far more. Not only that, we need out-patient treatment; but we will not get that until we have good in-patient treatments. It is no good the Government saying, "It is up to the market and the treatment providers" when the treatment providers do not have enough money from the local authorities to provide the treatment. The Government must give a lead in helping these places to get going. They must give a lead in ensuring that they are properly registered and that they receive the correct amount of money and in ensuring that there are proper outcome studies to see how they work, to fine-tune them and to improve them.

The noble Lord, Lord McNair, mentioned treatment in prison. He was talking about the remarkable Addictive Diseases Trust programme at Downview Prison. Fourteen patients can be treated at any one time which is the equivalent of 120 each year. The cost of treating those equals the cost to the Home Office of one prisoner returning to the prison. Therefore, if only one of the patients being treated in any one month stays off drugs and does not come back to prison, that pays for the cost of the whole programme. That is cost-effective. That is the way in which we want to run treatment. That is the way in which it should be run.

In the remaining minute left to me, perhaps I may conclude by saying that it is very important to realise that historic attempts to control the supply of drugs have failed, will continue to fail, and will fail at an ever faster rate because drugs are entering this country ever more rapidly. Therefore, we should review the money that is spent on Customs and on the crop replacement schemes, which have proved absolutely useless. We must review the law, the way in which we control drugs, and the role of the courts and the prison system in drug control generally. We must not expect education and prevention to provide all the answers, although we do need to keep trying in that area. We do need to concentrate on treatment and to do so now, and hard. We need to combine drug and alcohol treatments. We do not need two sets of civil servants and two sets of experts. We should combine them.

There is an answer to the drug problem—and that answer is treatment. It is good, effective, cost-effective, in-patient treatment, followed by out-patient treat-ment. It does not require more money; it just requires a little bit of thought.

3.37 p.m.

Lord Ennals

My Lords, I, too, should like to thank the noble Lord, Lord McNair, for introducing the debate. That would be so even if the debate had provided only an opportunity for the noble Lord, Lord Mancroft, to make the excellent speech that he has just given. I found myself in profound agreement with much of what he said, especially with the view that treatment works. There is now a great body of experience which is perhaps at risk for financial reasons, but I shall come to that. I agree that drug and alcohol addiction is not a psychiatric problem. To confuse mental illness with alcoholism and drug addiction is not to understand the nature of mental illness or the other problems of addiction that this debate is all about.

The debate is well timed, coming just two weeks after local authorities have taken over their new responsibilities for community care. That care includes the two forms of abuse we are considering. Unlike the noble Lord, Lord McNair, who opened the debate, I want to concentrate on residential care, including treatment, and some of the related legal problems—not because I do not think that many of the other problems are important, but because the noble Lord has cast the debate so wide that it enables us to concentrate on other issues which seem more important to some of us.

The debate on community care, both nationally and locally, has concentrated on the largest groups for which local authorities have responsibility. I am thinking of the elderly, in particular the very elderly who need so much more care, including nursing care and appropriate housing care. The groups include also the disabled, those with some form of mental illness, and those with learning difficulties. I suppose that those categories will receive more attention from local authorities having responsibilities which they did not have previously rather than the care and treatment of those with drug and alcohol abuse problems.

It is my view—I have expressed it before in the presence of the Minister—that the local authorities have been funded inadequately by the Department of Health to the tune of £200 million or £250 million a year. What the figure is, and how right we are, as opposed to the Government's view, will be discovered in time. It may be discovered due to inadequate community care. I hope that that will not be the case. But we must watch the matter carefully. A big responsibility is rightly being put on the local authorities.

Today we are considering, or arguing, the case for one of the categories for which local authorities are responsible —those suffering from drug or alcohol abuse. It is interesting to consider the numbers. I was glad to hear the noble Lord, Lord Mancroft, deal with the figures. He asked a question. It is one that I wish to put in a positive way. What is the Government's assessment of the numbers with which we are dealing? The noble Lord, Lord Mancroft, mentioned 100,000. Is that a fair estimate? It is important that we should have the answer when we look at the inadequate number of residential treatment centres which are run mainly by voluntary organisations. As he said, the figure given may be far lower. But it is obviously increasing greatly.

As a junior Minister in the Home Office with responsibility, among others, for this problem—admittedly, it was the 1960s—I was horrified to discover that there were 4,700 registered addicts. I said then that whatever the number of registered addicts it would be a drop in the ocean. My first question is: what sort of numbers are we dealing with? To what extent are they increasing? Perhaps the Minister will say why they are increasing. For local authorities assuming these responsibilities, they are largely new problems.

Many will remember the progress of the National Health Service and Community Care Bill through this place. We passed an amendment about the ring-fencing of community care. Ministers in another place then made a change which did not touch upon the generality of community care but upon the aspect of drug and alcohol abuse. Mr. Kenneth Clarke, the then Secretary of State, tabled an amendment to the Bill which provided for the earmarking of cash for local authorities to be given only to drug and alcohol projects. He said that money would be ring-fenced and local authorities would be able to spend it only on grants to such bodies. That was a clear statement upon which voluntary organisations operated from then on.

On the same day, Virginia Bottomley, then Minister of State for Health, said: Specific grants shall be available for those who are drug addicts or alcoholics". However, in October 1992 charities learned that ring-fencing had been abandoned. None of us should under estimate the importance of the decision the Government took not to ring-fence those sums that local authorities needed to provide the services about which we are talking today.

I wish to say a word about the London-based Alcohol Recovery Project which is seeking leave—or was two months ago—for a judicial review of the policy after a High Court judge accepted that Mrs. Bottomley may have acted unfairly when she reversed government policies to guarantee funding for voluntary drug and alcohol projects. I am afraid that I do not know the outcome of the case: I hope that the Minister will tell me. If everyone else here knows, I apologise for my ignorance. Mr. Justice Auld said that he was troubled that the reversal of policy had prejudiced the Alcohol Recovery Project financially because it had relied upon the word of Mrs. Bottomley and her predecessor that money for the projects would he ring-fenced or safeguarded. The judge agreed that the review should be arranged urgently after the Queen's Counsel appearing for the Department of Health said: The timetable targeted of April 1, 1993, (for the introduction of the new policy) will be put in jeopardy if there remains a degree of uncertainty". I take another example. The problem of homeless people is still growing. The new community care arrangements may lead to an increase in the number of homeless people—I shall be interested to know whether the Government expect that to be the case —many of whom have drink and drug-related problems. They may have other social problems that explain their homelessness, but the fact that they are homeless has been established clearly. I was presiding recently at a conference in the Queen Elizabeth Conference Centre at which a Minister was speaking. It was a conference organised by Telethon and Centrepoint, Soho. It was considering the problem of young homeless people, many of whom had drug and alcohol-related problems. We were looking at the unsatisfactory way in which during the first 12 months of the implementation of the Children Act local authorities had been able to meet the needs of those homeless people. It would be helpful to know the Minister's view on that matter.

I understand—this was referred to by the noble Lord, Lord Mancroft—that there is to be a review of alcohol and drug treatment. I understand, as he said, that it is to be carried out by Dr. Brian Mawhinney who is worried that policies have grown in a haphazard fashion with no overall strategy. It is interesting to hear a Minister make that announcement about what his Government have been up to. It may be that it is an important survey to carry out at this time. I hope that there will be close co-operation and consultation with the local authorities and the voluntary organisations which have far more information about these issues than the statutory bodies themselves. It has often been bad and sad that the voluntary organisations have been told what is to affect them and have not been consulted adequately about what government policy should be. It is said that an independent, outside figure is expected to be asked to head the review. It will be charged with assessing the clinical effectiveness of the various drug and alcohol treatments and rehabilitation facilities.

I hope that the terms of reference will include sustaining the residential treatment centres which both the noble Lord, Lord Mancroft, and I have emphasised are important, not just because of the experience that they have built up, which can be passed on to others, but because of the grave risk they now face. I hope that the noble Baroness, Lady Masham, will say something about her experience in the field. That includes an experience, which I share, of Phoenix House. Not long ago, as many as half of those treatment centres were expecting that they might have to close their doors because the local authorities will be, as they see it, giving a high priority to the care of the elderly and the other groups to which I have referred; the mentally ill and those with learning difficulties. As they have not yet had any experience of funding drug and alcohol abuse centres they might receive low priority and therefore suffer. I hope that the Minister will tell us what action has been taken in recent months to ensure that such dangerous results do not occur.

Sometimes one welcomes reviews but sometimes one is suspicious of them. I am often suspicious of the Government, every time they want to save money, deciding to have a review and calling it by any name other than "How we shall save money". When debating the Unstarred Question later this evening we shall discuss ways of changing the powers which doctors have for treating patients and for including the best treatments. A review has drawn the conclusion that there is a great deal of money to be saved. I hope that the forthcoming review, which is to be carried out by the department, will not have the same purpose. I heard on the "Today" programme that there is to be a new review into mental health. I do not know whether it will again take in the experience of the voluntary agencies—I must declare my interest as president of MIND—but I hope that there will be the fullest consultation because, frankly, the Government's record on consultation is not good.

I hope that in reply the Minister will find time to comment on the Mawhinney inquiry and on the mental health inquiry. Presumably that will not exclude the subjects that we are discussing today. I repeat my thanks to the noble Lord, Lord McNair, for introducing the debate and I look forward with great interest to hearing the information which the Minister will give in reply.

3.52 p.m.

Baroness Masham of Ilton

My Lords, I too wish to thank the noble Lord, Lord McNair, for giving us the opportunity to discuss this important subject. There is on today's Order Paper two debates on drugs; this, the first, is on the abuse of drugs and the second, the Unstarred Question, is on limiting some useful medications. Both debates are associated with The Health of the Nation but in different ways. I felt that I should say a few words in both debates as anxieties need to be aired. It is hoped that the Government will take note.

There is no doubt in my mind that people abuse their bodies not only with drugs and alcohol but with tobacco, which I also include as a drug of abuse and addiction. All those contribute to much ill health and I congratulate the Government on their White Paper, The Health of the Nation. Drugs, alcohol and smoking abuse are all contributory factors in the priority targets of the White Paper; those are coronary heart disease and strokes, cancers, mental illness, HIV/AIDS and sexual health, and accidents.

There is also a connection between alcohol, drugs and despair. At the root of abuse is an existential void, due to the absence of values and lack of self-confidence. This is a world problem but as we move into Europe anxieties about the adverse effects of alcohol consumption and the harm to European economic and social integration are expressed in the report of a working group of the World Health Organisation. Will the Minister tell the House today what the ministerial group is doing about the problem? What are its recommendations?

The report states that awareness of alcohol-related problems is greater at national level than at Community level and for most European countries integration will imply the relaxation of alcohol controls, lower taxes and more alcohol available on the market. Many of the control measures now in force will have to be lifted since they discriminate against foreign beverages.

Alcohol is particularly difficult because it is legal. Does the Minister believe that GPs have enough training about the problems and does she believe that some GPs perceive questions about alcohol as being embarrassing and intruding upon patients' privacy? Does the Minister agree that there is a problem of alcoholism among GPs? With so much emphasis on primary health care I wish to ask the Minister whether she discusses these problems with the medical colleges and the BMA.

In the North the spread of drug abuse came later than in the South. However, now the increase in crime is very evident and the public are most anxious especially at the growth in crime among young people. Some time ago a group of parents from Glasgow came to your Lordships' House to make some of us aware of the terrible problems that they were having in trying to keep their children away from drugs. One example they gave was of old-age pensioners who are prescribed free sleeping pills and tranquillisers and who sell them to children who mix the drugs and inject themselves. Such problems cannot be tackled by parents alone. They need the support of the health authorities, the social services, the probation service, the education authorities, the police and the voluntary agencies, which understand the problems. It was very disappointing when the Government rejected the amendment which I moved in the previous education Bill to make "life" skills a mandatory part of the school curriculum. That would have given emphasis to the vital need.

It was also worrying when last year the Government stopped the pump-priming grant for the provision of health education drug co-ordinators. Those posts were an important link between health and education and with so many changes in the health service that seemed the very worst time to be removing the security provided by the co-ordinators. No doubt the small-time local pushers who target young people are laughing.

On 3rd April this year The Times featured an article on a drug smuggler who stole a woman's identity. There were two pictures of a Nigerian woman who hijacked the life of Susan Cole, a blond young woman, in order to smuggle cocaine into Britain. Is it not time that everybody possessed an identity card with a photograph in order to stop such things happening? Many people working in security jobs now have such cards, but we are not facing up to the ever-growing dangers of drug smuggling which end up with the devastating results of drug abuse within families.

I turn now to the problems facing residential care houses dealing with drug and alcohol rehabilitation. I have heard from those running a small house in the New Forest which takes 20 adults and six children. Priority is given to Wessex residents but only about 10 per cent. are from Wessex. The largest proportion comes from London, with several people from Liverpool and Glasgow, among other areas. During the run-up to 1st April and care in the community, those running the centre became increasingly alarmed by the changes being made; that is, the changes in funding and in attitudes. They have been told that many London authorities will no longer be funding people wishing to enter a rehabilitation house outside London. That is just one example of the new policy.

There appears also to be an increase in the prescribing of methadone without the previous programme of dose reduction and eventual drug-free status. Does that mean that care in the community, in so far as it affects drug users, is coming to mean giving unlimited methadone but with no encouragement to give up drugs? Could that be seen as a cheaper option than residential care? I have heard that methadone addiction is more difficult to remedy than heroin addiction, as was said by the noble Lord, Lord McNair. Therefore, in the long run it may lead to increased drug abuse, increased crime to fund it, and the whole community paying dearly.

Obtaining sufficient funds has always been an uphill struggle for rehabilitation houses as drug users do not receive a good press. The young people who go to the home which I mentioned and to similar homes —many of whom are seriously deprived and some are parents with their young children—are not simply helped to break the drug-taking habit which has disrupted their lives but are trained in the many skills, both educational and "life", to enable them to return to the community as useful citizens and not as criminals.

It costs only £227 per week to keep a young person off the streets, not committing crimes and not going to prison and also learning how to improve his or her life for the future. Those who go with children are shown how to become better parents. All are shown how to live together in harmony. That home does not know how it will survive in the future. Is it not wise to have a choice of homes, because different people respond to different methods of treatment? It is possible that some of the best homes will have to close.

Last year with some colleagues from Parliament I visited prisoners held in police cells here in London. Having seen with my own eyes a seriously alcoholic prisoner, I asked the doctor who was processing him through the system what would become of him. The doctor said, "If I could have one thing, it would be some secure detox centres to send people like him for treatment". The prisoner wished to try to reform but without facilities he will stay at risk to himself and others, going in and out of the prison system.

For many years I have been associated with Phoenix House, which has several drug rehabilitation and re-entry houses throughout England. Phoenix House has tackled that most difficult problem for years and has found a much better way of treatment than incarcerating people in prison who will not have faced up to their addiction while in prison but may have helped to spread both drugs and HIV to other prisoners within the system.

The major current concern as predicted by Phoenix House is the fate of those people leaving custody. Last year nearly 75 per cent. of the residents of Phoenix House came through the criminal justice system and it is by no means clear who is responsible for funding such people. An example is a man referred to Phoenix House nine months ago from a prison in Kent. He was sentenced four years ago from Lewisham and stayed in a total of four or five prisons across the country throughout the time of his sentence. The Parole Board agreed to parole him on the basis that he had a clear desire to leave prison and go to Phoenix House. Understandably, Kent is reluctant to pay for the funding, given that the man's only reason for being in Kent was because of a Home Office prison transfer. Lewisham is reluctant to fund him because four years out of the borough is a long time. It is probably worried about the precedent which that may set so early on in the light of the Act. The ridiculous position may arise where the man elects to remain in custody while that problem is being sorted out despite a release date having been identified for this week.

There is still no clear guidance from the Department of Health or indeed the Home Office despite the repeated requests for clarification on that issue. Perhaps the Minister will be able to do something about that. Unless government departments work closely in co-operation over these matters, the uncertainty will continue. That is neither cost effective for the taxpayer nor beneficial for the rehabilitation of the individual. The community care legislation may mean that a significant number of referrals will be made through the criminal justice system.

Last week's Yorkshire Post had the headline: Prisoners try to stay in jail because of drug supplies". The article said that drug use in Britain's first private jail is rife. That is the Wolds remand prison at Everthorpe, North Humberside. It is rather worrying that that institution has not allowed the board of visitors from Wetherby young offenders institution, which is nearby, to visit, after two requests.

Members of the board of visitors are appointed by the Secretary of State and the Home Office. Several members of the Wetherby board of visitors are magistrates and the board members are responsible members of society. They are interested only in the well-being of the inmates and the institution. They were interested to visit the Wolds, as they are interested to visit other penal establishments. Perhaps the Minister will ask why the Wetherby board of visitors has not been made welcome. I should like to know also whether the Home Office will inquire into the alleged drug problem. Perhaps the Minister will pass on that request and reply to me by letter.

Unless all interested departments, agencies and individuals pull together to promote education against drug and alcohol abuse, there will not be the united front so desperately needed for good healthy living instead of the depressing deprivations of the drug culture.

4.5 p.m.

Lord Rea

My Lords, I thank the noble Lord, Lord McNair, for raising this vitally important topic. I believe that I should refer to the remarks made by the noble Baroness, Lady Masham. It is my great pleasure to congratulate her today because a little mole tells me that it is her birthday.

The noble Baroness is right to say that GPs have not been adequately trained in the past to deal with the problems of drug and alcohol abuse. That problem is now being addressed. The Royal College of General Practitioners is fully aware of that need, as are academic departments of general practice dealing with the training of undergraduate medical students throughout the country. In my practice we try hard to collaborate with the local drug treatment unit and alcohol advisory unit attached to University College Hospital, Middlesex.

There is a difficulty as regards training GPs throughout the country because to do the job properly it is necessary to collaborate with other counselling services in the local community. All too often they do not exist for GPs to collaborate with. That is particularly so with regard to out patient treatment units for people with drug problems.

As the noble Lord, Lord Mancroft, pointed out, there is little doubt that both alcohol and drug abuse is increasing in this country but there is also little doubt that both are more common in societies under stress. People turn to drugs and excessive use of alcohol to escape from uncomfortable feelings. Young people in Britain feel that they are rejected and unwanted by society. That applies to all unemployed people. Those who become addicted from all walks of life are of a more dependent personality than those who can drink appropriate amounts at appropriate times or use drugs occasionally or "recreationally" —I like that word. However, where there is mass unhappiness, more people turn to those means of relief and become enmeshed in what is a way of life with its own imperatives and values. Instead of developing skills which are of use to the whole of society, their ingenuity is devoted to outwitting that society because they feel that they are outside it—and with good reason.

I shall not describe the health impact of the misuse of these substances in any great detail. Suffice it to say that addiction to some drugs is fatal. Heroin has a mortality rate of 10 per cent. during a phase of addiction. However, unless an overdose is taken it is not the drug itself which kills; it is the way in which it is used that makes it so deadly. The problem is that street heroin is of variable strength and purity. The 10 or so recent deaths in the King's Cross district seem to have occurred—and this was described in the Independent newspaper article referred to by the noble Lord, Lord McNair—because a batch of unexpectedly high strength of heroin was sold on the street. Another explanation is that it had been cut or mixed—that is, diluted—with a poisonous substance as yet unidentified.

I saw three drug addicts in my surgery this morning. One of them said, "Some of the stuff they mix with heroin is lethal. I wouldn't be surprised if they didn't put some strychnine in this, or that someone had a wish to get rid of someone that they sold the drug to". I am not at all sure that that is not possible. However, in this particular case I think that it was an unexpectedly strong preparation of heroin that was the cause of the trouble.

Of course, as all noble Lords know, HIV infection and AIDS have now to be added to the dangers of the use of injected drugs.

The direct damage to health caused by excessive alcohol consumption is quite well known, but the indirect damage is more costly to the nation and to the National Health Service. Serious road accidents apart, many hospital admissions are due in part to the poor nutrition and self-neglect that are associated with alcohol abuse. One study found that 25 per cent. of acute admissions were at least in part alcohol related. While saying that, I do not deny—in fact, I fully accept—all the evidence which shows that light to moderate alcohol consumption is actually beneficial to health, particularly in relation to heart disease.

However, as other speakers have outlined, the social consequences far outweigh the damage to physical health. In the case of drug abuse the result is petty crime. The noble Lord, Lord Mancroft, repeated the figure that he gave us a year or so back of £1.8 billion worth of goods that are stolen by drug users to finance their habit. That is in the metropolitan area alone, and drugs are used all over the country. On the other hand, more often than not alcohol plays a part in violent crime and serious road accidents. However, more serious even than that is the damage it inflicts on family life, with harm possibly showing itself in the next generation.

What are we doing about all that? Action to prevent the problem needs to be considered first. I am following something along the lines of the noble Lord, Lord Mancroft. Primary prevention—to remove the underlying cause—is the basic need. Here the Government seem quite helpless. There are many steps that could be taken to give the youth of this country a greater sense that they are valued. If jobs cannot be created overnight, training courses could be extended and improved. Much more could be done to ensure that the courses lead to real jobs afterwards. I do not accept that because there is a recession the Government can sit by making only token and ineffectual gestures which sometimes serve only to increase the cynicism of youth—and of all unemployed people in Britain. All other methods to prevent drug and alcohol abuse are doomed to work against the current as long as a large proportion of the population has so little hope.

As the noble Lord, Lord Mancroft, pointed out, a great deal of time, money and ingenuity is devoted to trying to stop drug imports getting through, with much congratulation when a big haul is unearthed. But the ingenuity of the traffickers is very effective, and the sheer volume is such that far more always gets through than is discovered.

Much thought is also given to reducing demand, first by health education. However, most workers in the drugs field feel that the money spent on big advertising campaigns has been wasted and could have been better employed in the provision of more and better treatment and rehabilitation centres. (If I say on each occasion that the noble Lord, Lord Mancroft, has said what I am saying my speech will be rather longer than I mean it to be. But I thoroughly concur with many—although not all—of the views that he holds.) However, that is not to say that carefully targeted health education in schools, for instance, cannot be effective; but there has been remarkably little evaluation of the effect of any health education activities. I know that it is an extremely difficult area to tackle, but I wonder whether the noble Baroness, in her reply, can point to any research which has demonstrated that health education in the drugs and alcohol field actually works to reduce demand in any location where it is given.

That brings me to the second part of the Motion moved by the noble Lord, Lord McNair: what do we do about those in our midst who are afflicted? After all, they are the ones who are giving us a headache. Drug and alcohol treatment centres nearly all work on the principle of helping users to give up their habit smoothly, but nearly all have a very high relapse rate. There is often too high an expectation of success by the staff and a false optimism on the part of the users who may agree to treatment for a variety of reasons before they are really motivated to give up and to become abstinent.

Cynics may say that addicts often come off drugs or alcohol finally without help—they just grit their teeth and give themselves the cold turkey treatment, with the suffering that that entails. But I do not take such a Spartan view. There are drug users and alcoholics who, with much patience, can be helped. While they are being counselled (and in the case of drug users being given substitute drugs to relieve them of the necessity to raise £100 daily to finance their habit) the harm that they do to the rest of the community is much reduced.

The clinic run by Dr. John Marks in Liverpool (which has already been referred to) recognises that most addicts cannot give up until the right moment for them, which may be several years ahead. They receive maintenance treatment meanwhile, sometimes methadone; but in that clinic not only methadone. I agree with some of the worries expressed by the noble Lord, Lord McNair, about methadone. But I do not think it is quite as bad as he made out. In fact, while people are receiving it as maintenance treatment, many car radios and television sets are saved from being stolen.

As a result of the policy of Dr. John Marks's clinic, he has a much higher final success rate than most units, with the added advantage that the crime rate in Liverpool around his clinic has actually come down against the national trend of increasing crime, despite the area being one of the most deprived in the country. I do not think that the noble Lord, Lord McNair, is right to say that he has a callous approach. Far from it: I think that Dr. Marks actually has a much more realistic and effective approach. Indeed, if one talks to him one realises that he is not in the least callous; in fact, he is an extremely caring man.

Finally, I should like to talk about residential centres as they are referred to in the title of the Motion and other speakers have mentioned them. There is a proportion of alcoholics and drug abusers whose lifestyle is so chaotic that they cannot cope with out-patient treatment. They need to get away from their family or environmental setting to be able to start their rehabilitation. Some are sent to the centres by court order. If they can tolerate the regime they often make great progress only to relapse on or shortly after returning home—to the same circumstances from which they came. Several admissions may often be needed. That is why it is the most costly form of rehabilitation. Because of the relapse rate, there is some doubt as to whether residential centres are cost-effective. However, against that it should be remembered that those who go to the centres are often the most intractable cases who cause the most damage in the community, either by stealing goods from other people or by harm to their own families.

Several noble Lords have mentioned the financial difficulties which these centres are already experiencing and which they will certainly experience more and more this year. I wish to ask the noble Baroness, perhaps as a parting shot, if she will state whether, as has been suggested in some quarters, the Government feel that these units, which are nearly all run by the voluntary sector, are not cost-effective. Does she still think that they have a definite role in helping to curb the suffering of their clients and the communities in which they live? If so, I hope she will be able to reassure us that a satisfactory method of funding these residential units will be found and applied soon, before they start closing, as they surely will if this funding does not materialise.

4.20 p.m.

The Viscount of Falkland

My Lords, I thank my noble friend Lord McNair for tabling this debate today and for providing such a wide Motion. I cannot say that I looked forward to the debate. It is my intention to concentrate on the alcohol part of the Motion, and I have learnt over the eight or nine years that I have spent in your Lordships' House that one has to walk rather a tightrope when speaking about alcohol problems in order not to clear the Chamber. I shall try to avoid talking about the evils of drink. I have always tried to avoid doing so.

One must nevertheless face the fact that there has always been a sizeable drink problem in this country. In most of the developed countries of the world there is a sizeable alcohol problem of one type or another. As regards the developing countries, it seems that the quicker they develop the more their alcohol problems increase. No one can say precisely why that is so. Alcohol is a socially acceptable mood-changing substance. On the good side it gives people a lot of comfort and happiness. It is used to celebrate events and to toast people. It is consumed on people's birthdays. At this stage I join in the good wishes paid to the noble Baroness, Lady Masham of Ilton, on her birthday which falls today. I thank her for the tireless work she does in this area.

A sum in excess of £50 million is spent on drink per day in this country. However, that is not really the problem. In France people spend double that amount per day on drink. Our actual consumption of raw alcohol is relatively modest. It is the pattern of abuse of alcohol in this country which is worrying. A number of important changes have occurred in recent times. The most helpful change—a cultural change —is in the attitude towards drink and driving. When I was a young man it was considered part of one's training to drink too much and to drive. One was considered rather a Jack-the-lad if one did so successfully. Nowadays I look back with horror at the experiences I had as a young man. I am glad that most people now accept that it is extremely dangerous to drink and drive. Young people in particular have been made aware of the rapid effect that drink can have on their handling of cars and other machinery. As a motor cyclist I know that it is almost impossible to ride a motor cycle with a feeling of security even after one drink. I am happy to say that few motor cyclists drink and ride.

A phrase that sticks with me was that uttered by the noble Lord, Lord Mancroft, when he said that treatment works. That is the truest statement I have heard today and in my opinion the most important aspect of our debate. Treatment works for those who abuse drugs and for those who abuse alcohol. Those who abuse both kinds of mood-changing substances are treated in approximately the same way. Enormous steps have been taken in the development of treatment which works quickly and which has a permanent effect. However, problems arise with the diagnosis of people in the first place and the ability to get them into treatment. When I first became involved in the matter it struck me that there was probably more argument, discussion and jealousy in the caring professions than in any other area apart from academia. I was amazed to discover the number of people involved in the field of alcohol abuse or the treatment of it who were not speaking to one another.

In preparation for the debate I rang the director of policy of a local authority. The authority has an important treatment centre within its boundaries and is making great efforts to make the new community care legislation work amid all the difficulties that that entails. The director said that one of his main problems was to obtain a common attitude within his local authority as regards the treatment of alcoholics and drug addicts. He said that there was a difference of philosophy among various people acting within that area. The matter has been highlighted by other noble Lords who have mentioned GPs who often face the difficult task—one must acknowledge that it is difficult—of dealing with a patient who appears to be anxious and depressed and who shows no outward signs of being a misuser either of drugs or of alcohol. The GP then prescribes certain drugs to deal with the perceived anxiety and depression.

Recently a study was conducted in Ireland in a home for women alcoholics. The study showed that 94 women had been at first diagnosed as clinically depressed and had been treated. It was subsequently discovered, when they were treated, that only one of the 94 was clinically depressed. I am not saying that would happen here but I have consulted specialists this morning and they tell me that that is the problem they face.

One of the problems in this area is the conventional wisdom that detoxification and medical intervention are acceptable but counselling is not. There is a distinct resistance on the part of some people in the medical profession and some psychiatrists to counselling. It appears they object to any moral content in the counselling. That also applies to what one might call the primary care agencies. Social workers are often loath to deal with what they perceive and know to be an alcohol problem in this way. They use various terms to describe what they face; for example, role legitimacy and role adequacy. Some noble Lords may understand those terms better than I. As I understand it, they mean that if one is a social worker and one drinks, one feels it is improper to bring judgment to bear on someone who is clearly abusing drink and one avoids doing so.

Women drinkers give rise to particular concern. There has been a marked rise in drinking among women, mostly among women who have been the victims of a family break-up. They may have been abandoned or divorced and seem to turn to drink as a means of enhancing the feeling of their own identity which they have lost. They have lost their sense of identity as wives or mothers. Increasing numbers of young women in the age group 25 to 40, many of them successful, are independent and competing in a man's world. Often they drink as part of that lifestyle without realising the difficulties which they face because of their physical inability as women to tolerate the same amount of alcohol as men.

Another important problem which needs to be addressed seriously is the increase in criminal behaviour among juveniles. It is not possible to say exactly how many under age children are drinking but it is a large number. A recent study of children of secondary school age showed that at least 90,000 children in that age group are drinking more than the amounts prescribed in respect of the public at large, namely 14 units for a female and 21 units for a male. That is a serious figure. It does not take into account those who have not yet reached that dangerous level of intake. It is often reported that some children arrive in classrooms suffering from the effects of drink or even drunk. The link between criminal behaviour and drink is clear. It is a problem which all those involved with law enforcement and social work have to deal with every day.

It is unnecessary to complain again about the community care legislation, disappointed though we were that the ring-fencing of funds for care related to drug and alcohol problems was moved into the general area of local authority control. There has been an indication that there will be helpful and serious monitoring. I am fearful that while that monitoring is taking place many residential homes will close. I am afraid that it will be too late to save a number of them.

The fact that many people suffering from these problems are often hostile to the moral content of counselling within the residential environment is a further disadvantage. We shall have to address that problem later because I am sure that it will be raised as a result of the monitoring process.

It is not helpful to continue the endless debate about the distinction between heavy social drinkers and alcoholics. Such a distinction is meaningless. We all know people who abuse drink. We all know people who are clearly alcoholics. There are many people with problems, many of them helpless and vulnerable. The Government are making the right noises. I hope that in her summing up the noble Baroness will be able to give us some encouragement to believe that this enormously difficult problem will be approached and dealt with more successfully than in the past.

4.34 p.m.

Lord Desai

My Lords, I join other noble Lords in thanking the noble Lord, Lord McNair, for giving us this opportunity for a wide-ranging debate on the subject before the House. I also join other noble Lords in congratulating the noble Baroness, Lady Masham, on her birthday.

Because the Motion has been formulated so broadly, and following so many good speeches, I shall take the opportunity to devote the first half of my speech to the broad social and legal implications of drug and alcohol abuse and then move on to the more particular and urgent problem of residential care. It may be helpful to start with the example which the noble Viscount, Lord Falkland, gave concerning the way in which legal changes can make actions which were not previously criminal illegal or decriminalise acts which were previously thought to be criminal. A good example is drinking and driving. Something which was socially acceptable, if not boasted about, was made criminal by a careful law which no subsequent government have repealed. Tight enforcement of that law has now produced a fundamental change in social attitudes towards drinking and driving. Therefore, activities which were not previously criminal can be criminalised if we consider them to be harmful. Similarly, activities which were previously thought to be criminal can be decrimi-nalised, as in the case of homosexual behaviour among consenting adults. Therefore, we have to distinguish between what is physically and socially harmful, whether or not it is illegal, and activities which can be made legal or illegal in line with current convention and practice.

I do not propose that we ought to change the law in any of these matters, but I should like the Government at some stage to take a broader look at activities relating to the possession and use of drugs which are currently criminal offences and consider whether there are aspects which could be decrimi-nalised and which it would not be desirable to decriminalise. I believe that that is a question which ought to be brought out into the open.

I have no views on the matter and we have no policy on the subject, but the question of drug abuse and crime is important. If, for example, we decided that smoking would be banned because it was individually and socially harmful or we decided that the drinking of alcohol would be banned except under prescription for health reasons, we would have a very different society. I do not advocate such changes, but in the United States, for example, the debate about passive smoking has altered certain forms of behaviour.

Therefore, when we discuss the social and legal implications of drug and alcohol abuse we should remember that the context can change rapidly and can be made to change rapidly. What we call a crime today we may not call a crime tomorrow, and we may make certain activities criminal. Therefore, perhaps at some stage we should have a more wide-ranging debate on or an inquiry into the social and legal implications of drug and alcohol abuse. We have not had such a debate recently.

That leads me to the interesting question of the extent of alcohol and drug abuse which the noble Lord, Lord Mancroft, raised in his interesting speech. He said that figures relating to the number of drug addicts admitted by the Home Office (100,000) and the value of drugs seized by Customs (roughly £0.5 billion) do not accurately reflect the extent of the problem. The inquiry announced by a Minister in another place will not cover that aspect, but we ought to take up the question.

As a statistician I imagine that those figures are both serious underestimates. The figures for the number of admitted drug addicts, the amount of drugs seized and the amount stolen by drug addicts are all serious underestimates, in differing proportions. For our own information we should take up the question of how many drug addicts there are in society and what that is costing society.

I believe that the economics of the matter should be looked at in a much broader way, as the noble Lord, Lord Mancroft, said. It is not just narrowly the amount of money which we spend on drug and alcohol abuse as part of a certain budget, but also the ramifications in the Home Office budget; the unreported thefts; the unreported costs of drug and alcohol abuse visited upon citizens who are mugged or have something stolen from them. Those are additional costs and we ought to ask ourselves whether there are better ways of treatment and of implementing or changing the law which will minimise the current heavy costs on people. We may not call it drug abuse but crime or theft, yet it may all be interlinked.

The true cost-effectiveness of treatment of one form or another—it may be prevention or effective counselling rather than treatment—ought not to be looked at in the narrow economic sense of costs per bed but of costs saved by preventing the return of one person to drug addiction. Again, the noble Lord, Lord Mancroft, pointed that out.

In that regard we could justify a much more carefully worked out and better resourced programme to do something about drug and alcohol abuse than we have had so far. I agree that it may be difficult to alter the supply of drugs, except for synthetic drugs like methadone, which was mentioned by the noble Lord, Lord McNair. I assume that most other drugs are imported because they are not home-produced. If that is the case, it would be difficult to affect the supply of those drugs. One should try to do one's best about the demand for them, but that is not easy in the short run. It is difficult to alter people's habits in the short run.

We may try to concentrate on preventing people from entering the phase of becoming drug or alcohol abusers, but it is difficult to diminish the demand from people already addicted because the drugs are habit-forming. However, it may be possible by treatment to prevent people returning to being drug abusers. That is the way the Government ought to move, looking at the effectiveness of the money spent on drug and alcohol abuse.

The second part of the Motion calls attention, to the case for increased facilities for residential care". I particularly thank the noble Lord, Lord McNair, for including that because, as many noble Lords have pointed out, the situation is now that residential care facilities are under great threat. I honestly believe that this was not intended by the Government. There was no knowingly evil intention on their part. However, the fact that the ring-fencing on drug and alcohol abuse has been dropped has raised serious anxiety in the minds of the people who are active in the field.

I am involved in one drug intervention agency, City Roads, so I must declare an interest. People who work in the area are dedicated. They work under the most difficult circumstances, in jobs which are not badly paid but are certainly not well paid. The social value of what they do far exceeds the income they receive and they work very hard. There is serious anxiety among them, as was shown by a survey conducted by Alcohol Concern and SCODA. Many agencies feel that they are likely to have to shut down because of the change in the rules for funding. That may be alarmist but I should like to know the Government's assessment of the situation.

Given that there is this feeling, are the Government doing anything urgently to avoid the situation where the few residential care facilities that we have are shut down? They are inadequate, as the noble Lord, Lord Mancroft, pointed out, in relation to those in the United States. Once the facilities are shut down they will be difficult to re-open because people's acquired skills in the field will be lost. They will find jobs elsewhere and soon the skills will not be available.

From that point of view, yes, I should like increased facilities for residential care. But right now what are the Government doing to prevent the erosion of facilities for residential care, which is likely given the change in the rules? I have been out of the country for two weeks and a revolution may have happened in the meantime in those matters, but I should like to know what is going on. I should also like to know whether there is any prospect of an increase in resources in the field. Such funding as is available is not good enough. The rise in the figures for crime and drug abuse, which are not unconnected with the problem, make me feel that perhaps more resources devoted to residential care may be a better crime-fighting tactic than firmer policing, which is not to be sneezed at. I should like to know from the noble Baroness the Government's latest position on the matter.

Given that local authorities have not had adequate time to prepare their programmes, with the change in the rules which came rather late, and given that often drug and alcohol abusers do not have priority in the local authority's mind —there certainly is not a strong lobby on their side—to obtain resources from the local authority budget, will the Government consider issuing directives rather than just guidelines? Those would tell the local authority how to assess and meet needs as they arise. Currently the problem is very serious. I concede that there is no intention on the part of the Government to affect the sector adversely, but we may be doing so unintentionally. I should like us to avoid the unintended consequences of a late change in policy. I wish that the Minister would give me some hope when she replies. I thank all noble Lords for the excellent debate and look forward to the reply from the Minister.

4.47 p.m.

Baroness Cumberlege

My Lords, I too should like to thank the noble Lord, Lord McNair, for initiating this debate and enabling people with enormous knowledge and expertise on the subject to express their views in your Lordships' House and for me to have the opportunity to restate the Government's commitment in this important area.

There is a great deal of common ground between noble Lords, particularly those who have spoken today, and the Government. I should like to start by stressing the very high priority which the Government have in tackling the problems associated with the misuse of alcohol and drugs. We recognise the terrible loss and waste of young lives which can occur when young people succumb to these temptations, particularly drug abuse, and the misery and anguish it causes not only to misusers but to their families and friends, diminishing society as a whole. Prevention is always better than cure, but when prevention fails then residential treatment and rehabilitation play an important part; but it is only a part, and over the years the Government have evolved a comprehensive strategy to tackle alcohol and drug misuse.

The drugs strategy involves co-ordinated action on five main fronts: first, to improve international co-operation in order to reduce supplies from abroad; secondly, to increase the effectiveness of police and Customs enforcement; thirdly, to maintain effective deterrents and tight domestic controls; fourthly, to develop prevention publicity and education; and last, but not least, to improve treatment and rehabilitation.

My noble friend Lord Mancroft mentioned the range of sanctions employed to control drugs. He urged us to accept the supply but reduce the demand. I fear that that is a counsel of despair and I think that it is right that we should also try to reduce the supply so far as possible.

Indeed, we have introduced tough penalties to deter drug traffickers and dealers, including a maximum penalty of life imprisonment for supplying or having possession with intent to supply Class A substances such as heroin, and 14 years for a substance such as cannabis. Drug trafficking is an international problem and has been described as the biggest commercial and criminal business in the world. Enforcement is a key component and the latest statistics show that the number of people dealt with for drugs offences rose to 54,000 in 1991: an increase of 3,600 over the previous year. That gives some encouragement to those determined to contain and eventually to conquer this serious crime.

Alcohol is a different matter and noble Lords will know that its consumption in sensible quantities and in appropriate circumstances provides many people with enjoyment. I share that view, expressed also by the noble Viscount, Lord Falkland; indeed I am prompted at this moment to drink a toast to the noble Baroness, Lady Masham, on her birthday —alas, on the Front Bench I have only water.

Although drinking can be pleasurable, in excess it can cause not only harm to health—progressively increasing the risk of raised blood pressure and strokes, and other conditions such as cancers and liver cirrhosis—but alcohol consumption on inappropriate occasions can lead to accidents, particularly on the roads, and to reduced concentration and efficiency at work. Heavy drinking is also often associated with violent and sexual crimes, family break-up and disorderly behaviour.

The White Paper The Health of the Nation reflects the importance the Government attach to tackling health problems associated with both alcohol and drug misuse, and includes targets for both. The White Paper also emphasises that government, at both national and local level, has a role to play in ensuring that there continues to be a comprehensive range of services to meet the needs of alcohol and drug misusers.

It is against that background that the future of residential treatment and rehabilitation needs to be seen. There are at present around 2,000 places in residential centres, very nearly all of them provided by the independent sector. I can assure the noble Lords, Lord Rea, and Lord Desai, that the Government recognise and value the contribution which they and non-residential centres make, and are committed to developing further services for people with alcohol and drug problems.

In 1991 we introduced a specific grant which enables local authorities to make payments to voluntary organisations. In the three years since its introduction the grant has supported a wide range of services. For example, The Richmond Fellowship has now received three years' support for the development of services for women substance misusers and their pre-school children. Turning Point, whose Griffin project was opened in September 1992 by the Princess of Wales, received a grant of £160,000 to provide a service for drug misusers who are HIV positive.

The noble Lord, Lord McNair, specifically mentioned the work of TACADE. As he indicated, it is a very effective and valuable organisation, one of many which are supported by the Government. With regard to the importance of drugs education in schools, the noble Lord may be interested to know that the Advisory Council on the Misuse of Drugs will shortly publish a report on drugs education in schools to which the Government will give careful consideration.

I turn now to the specific grant. In the two years of the grant, £3.5 million was provided by the Department of Health and other local sources provided a further £1.5 million; 176 awards were made, and over £2 million was spent on residential care. The rest was allocated to non-residential services, either to increase the effectiveness of the residential services or for training.

In the current year the grant has been increased by 9 per cent., with £2.3 million to be provided by the Department of Health. Residential services will continue to receive £1.6 million, but the scope of the grant has been widened to ensure that adequate and suitable community-based services will also be available for those drug misusers who do not need residential care.

The community care arrangements, introduced this month, ensure that local authorities will have the lead responsibility for the assessment of people who may be in need of care and, where appropriate, to make arrangements and pay for the social care costs. The network of residential services will therefore need to be responsive to local needs. A total of £565 million has been transferred to local authorities, ring-fenced for the implementation of community care.

I know that the noble Lord, Lord Ennals, has frequently sparred on the subject of ring-fencing. His view is that there should be a specific sum of money. But the Government decided not to ring-fence funds solely for drugs and alcohol abuse, but to ring-fence a total amount for community care. That view and decision were supported by the judicial review which took place. The application of that judicial review was dismissed. The court upheld the action of the Secretary of State to ring-fence the entire sum of money. The £565 million includes resources for the purchase of services for alcohol and drug misusers. As the noble Lord, Lord Ennals, suggests, the Government recognise that alcohol and drug misusers have not traditionally looked to statutory bodies for help; many will have no settled address and may lead transient lifestyles. I hope that I can reassure him and the noble Baroness, Lady Masham of Ilton, when I say that we have now issued special guidance to local authorities which encourages them to make sure that eligibility criteria and assessment procedures are sensitive to the particular needs of alcohol and drug misusers, including those recently released from prison.

At our request, the Local Government Drugs Forum has been working with the local authority associations to draw up advice on "fast track" assessments, which will ensure that people in urgent need of care, whether living in their home area, away from home, or without settled accommodation, and for whom a delay may result in increased harm to them or their families, receive a rapid response to their needs. The advice to local authorities was issued by the Local Government Drugs Forum at the end of March.

I can reassure the noble Lord, Lord Desai, and other noble Lords, that the Government have also listened to the concerns expressed by those in the independent sector who provide services. Due to the relatively short length of stay in alcohol and drug rehabilitation and residential homes, any changes in referral patterns or delays as the new community care arrangements settle down could have a disproportionate effect on those services. We have therefore decided to establish special monitoring arrangements through Goldsmith's College to identify local authority referral patterns, and occupancy levels in residential homes.

The noble Lords, Lord McNair and Lord Ennals, my noble friend Lord Mancroft, and the noble Baroness, Lady Masham of Ilton, raised reservations about the use of methadone. I understand those reservations. Abstinence must remain our ultimate goal in drug treatment. But prescribing substitute drugs such as methadone can be a useful tool in helping to change the behaviour of some drug misusers. The aim is to reduce the injecting substances which, as the noble Lord, Lord Rea, suggested, puts users at risk of acquiring HIV and spreading it among drug users, and from them to the wider population. Provision of methadone should be part of a planned programme of treatment.

The noble Lord asked how much methadone is prescribed. Approximately 300 million milligrammes of oral methadone was prescribed by regional health and family health service authorities in 1991–92. Around 1 million ampoules of methadone was also prescribed. He also asked for the cost of the prescription. The cost of methadone prescribed in 1991–92 was £4.4 million. That sum will be increased by the usual prescribing costs, which include the time of the doctor and the relevant fees. Figures for 1992–93 are not yet available.

Concerning the leakage of methadone into the black market, figures of police drug seizures show that very little methadone is seized. The view of the Home Office drugs inspectorate is that leakage is small. Methadone mixture is not generally considered by drug misusers to be a particularly attractive street drug.

The noble Lord, Lord McNair, asked what advice is given to doctors on prescribing tranquillisers. Advice to doctors encourages them to limit the prescribing of tranquillisers to short periods to arrest acute symptoms. Guidelines on clinical management of drug misuse have been issued to all doctors, covering treatment and management of misuse of all drugs.

I am pleased that the intention of my honourable friend the Minister to carry out a comprehensive review has been welcomed in your Lordships' House. I am sure that he will consider the views expressed, including those of the noble Lord, Lord Desai. The details of the review have not yet been finalised but I shall ensure that your Lordships are kept informed as the proposals develop.

With regard to the first ever national survey of mental illness in Britain, announced today, field work on the survey will start a week today to try to discover the true extent of psychiatric illness among the adult population. Among other things, it will try to measure the smoking, drinking and drug-taking habits of people with mental illness.

The noble Lords, Lord Ennals and Lord Desai, asked how many drug addicts there were. It is difficult to assess the scale of a problem which is essentially an illegal activity. The Home Office addicts index, to which the noble Lord, Lord Ennals, referred, currently shows about 20,000 addicts registered. That index relies on the notification by doctors of people who attend their clinics and who they consider are dependent on a range of controlled drugs. Clearly, therefore, it is an underestimate of the true numbers of addicts, many of whom will not have seen a doctor and may not be in touch with any services.

As I said, drug misuse is an illegal and clandestine activity. We need more information. The results of a large-scale Home Office survey will be published later this year and will give us a better feel for the scale of misuse.

The noble Baroness, Lady Masham, advocated a range of treatment options to meet the needs of alcohol and drug misusers. There is a wide range of treatment options available. Under the community care arrangements, local authorities are responsible for assessing individual needs and drawing up packages of care to meet the needs of each individual person. Local authorities will be free to purchase that care from whichever service provider is most suitable. The noble Baroness also suggested that identity cards would be of use. That issue has been considered several times in recent years. However, it has been recognised that it would be enormously expensive to set up and maintain a viable system. The noble Baroness asked a series of questions, many of them very detailed and important. I shall write to her in reply.

The noble Viscount, Lord Falkland, questioned the value of publicity campaigns. National publicity campaigns can be effective in drawing public awareness to the problems of drug misuse. However, since 1991–92 the Department of Health has shifted the emphasis away from major national campaigns to encourage regional campaigns, which can better target local problems.

I shall quickly mention in this context the Home Office drug abuse prevention initiative. It is now established in 20 areas in England, Scotland and Wales, where there is considered to be a substantial risk from the threat of drug misuse. In each location there is a team helping to reinforce, harness and stimulate community action against drugs. An important element of the initiative is that the effectiveness of the prevention programmes being put in place is closely monitored and they are assessed to see what lessons can be learned.

In conclusion, the Government attach a high priority to the provision of suitable services within community care for alcohol and drug misusers. Local authority representatives made clear that they share the view of the Government and your Lordships' House that those services should receive a high priority. There is therefore every reason to expect local authorities to meet their responsibilities for that important client group. We remain confident that local authority commitment and the special measures that we have put in place will ensure that the valuable network of both residential and non-residential services will continue to develop.

5.4 p.m.

Lord McNair

My Lords, we have had an interesting and very wide-ranging debate. I know that your Lordships are anxious for the business to proceed and I shall not keep the House for very long. I am grateful to all those who have spoken.

I agree with the noble Lord, Lord Mancroft, that treatment works. Moreover, it is relatively easy to measure the effectiveness of treatment programmes. The successful participant, marked out by previous court and hospital appearances, does not reoffend or fall sick.

I feel that the noble Lord was less than fair to education for prevention. Life education centres are carrying out both independent and in-house outcome surveys. The problem is that such surveys take a long time. It is argued that someone who has reached the age of 21 and not yet taken drugs probably will not take them; but proof of the effectiveness of prevention programmes will take 10 to 15 years to appear. The evaluation of TACADE's primary schools programme, to which I referred, will be interesting. As I tried to point out, if it affects positively a cluster of related behaviours and shows that the children who benefit from such a programme are in their lives winning socially and academically and developing high self-esteem, it can be inferred that such children are less likely to become involved in substance abuse, in which the most significant personality trait is low self-esteem.

I was interested to hear of the review of treatment services planned by the Minister of State, Dr. Brian Mawhinney. I hope that the reservations expressed by the noble Lord, Lord Ennals, are not justified, although I share his suspicions. It was also interesting to hear several speakers emphasise that alcohol and drug addiction in themselves are not mental illnesses and do not benefit from the intervention of psychiatrists.

I thank all noble Lords who have taken part in the debate and beg leave to withdraw the Motion.

Motion for Papers, by leave, withdrawn.