HC Deb 11 April 1986 vol 95 cc484-500

'(1) Where a person is to be discharged from a hospital after having received medical treatment for a mental disorder as an inpatient for a continuous period of not less than 6 months ending with the date on which he is to be discharged, then (subject to subsection (3)) the managers of the hospital shall make arrangements for an assesment, before the date of discharge, of the needs of that person for the provision of any services for that person in accordance with any of the welfare enactments in conjunction with—

  1. (a) the local authority for the area in which it appears to the managers that that person is likely to reside after being discharged, and
  2. (b) where that person will be under the age of 19 on that date, the appropriate officer or authority

(2) Where—

  1. (a) a person liable to be detained under the 1983 Act or the 1984 Act is discharged from a hospital in pursuance of an order for his immediate discharge made by a Mental Health Review Tribunal or, in Scotland, by the sheriff, and
  2. (b) he is so discharged after having received medical treatment for mental disorder as an in-patient in a hospital for a continuous period of not less than 6 months ending with the date of his discharge.
then (subject to subsection (3)) the managers of the hospital shall make arrangements for an assessment of the needs of that person in accordance with subsection (1) above as soon as is reasonably practicable.

(3) Nothing in subsection (1) or (2) shall require athe managers of a hospital to make arrangements for an assessment of the needs of a person who has requested that no such arrangements should be made under this section.

(4) In this section— the appropriate officer or authority" means—

  1. (a) where the local authority referred to in subsection (1)(a) is a local education authority, such officer discharging functions of that authority in its capacity as a local education authority as may be appointed by them for the purposes of this section;
  2. (b) where that local authority is not a local education authority, the Inner London Education Authority;
"hospital"—
  1. (a) in relation to England and Wales, means—
    1. (i) a health service hospital within the meaning of the 1977 Act, or
    2. (ii) any accommodation provided by any person pursuant to arrangements made under section 23(1) of that Act (voluntary organisations and other bodies) and used as a hospital; and
  2. (b) in relation to Scotland, means a health service hospital within the meaning of the 1978 Act.
"the managers"—
  1. (a) in relation to—
    1. (i) a health service hospital within the meaning of the 1977 Act (other than a special hospital),
    2. (ii) a health service hospital within the meaning of the 1978 Act (other than a State hospital), or
    3. (iii) any accommodation provided by a local authority and used as a hospital by or on behalf of the Secretary of State under the 1977 Act.
    means the District Health Authority or special health authority, or (as the case may be) the Health Board within the meaning of the 1978 Act, who are responsible for the administration of the hospital;
  2. (b) in relation to a special hospital, means the Secretary of State;
  3. (c) in relation to a State hospital, means a State Hospital Management Committee constituted by the Secretary of State to manage the hospital on his behalf or (where no such committee has been constituted) the Secretary of State; and
  4. (d) in relation to any other hospital, means the person for the time being having the management of the hospital;
"medical treatment"—
  1. (a) in relation to England and Wales, has the meaning given by section 145(1) of the 1983 Act; and
  2. (b) in relation to Scotland, has the meaning given by section 125(1) of the 1984 Act;
Brought up, and read the First time.

Mr. Tom Clarke

I beg to move, That the clause be read a Second time.

Mr. Deputy Speaker

With this it will be convenient to take the following: New clause 6—Persons discharged from hospital—

'(1) Where a person is to be discharged from a hospital after having received medical treatment for mental disorder as an in-patient in a hospital for a continuous period of not less than 6 months ending with the date on which he is to be discharged, then (subject to subsection (3)) the managers of the hospital shall give written notification of that date—

  1. (a) to the local authority for the area in which it appears to the managers that that person is likely to reside after being discharged, and
  2. (b) where that person will be under the age of 19 on that date, to the appropriate officer or authority,
as soon as is reasonably practicable after that date is known to the managers.

(2) Where—

  1. (a) a person liable to be detained under the 1983 Act or the 1984 Act is discharged from a hospital in pursuance of an order for his immediate discharge made by a Mental Health Review Tribunal or, in Scotland, by the sheriff, and
  2. (b) he is so discharged after having received medical treatment for mental disorder as an in-patient in a hospital for a continuous period of not less than 6 months ending with the date of his discharge,
then (subject to subsection (3)) the managers of the hospital shall give written notification of that person's discharge in accordance with paragraphs (a) and (b) of subsection (1) as soon as is reasonably practicable.

(3) Nothing in subsection (1) or (2) shall require the managers of a hospital to give a notification under that subsection in respect of a person who has requested that information about his discharge should not be given under this section.

(4) In this section— the appropriate officer or authority means—

  1. (a) where the local authority referred to in subsection (1) (a) are a local education authority, such officer discharging functions of that authority in its capacity as a local education authority as may be appointed by them for the purposes of this section;
  2. (b) where that local authority are not a local education authority, the Inner London Education Authority;

"hospital"—

  1. (a) in relation to England and Wales, means—
    1. (i) a health service hospital within the meaning of the 1977 Act, or
    2. (ii) any accommodation provided by any person pursuant to arrangements made under section 23(1) of that Act (voluntary organisations and other bodies) and used as a hospital; and
  2. (b) in relation to Scotland, means a health service hospital within the meaning of the 1978 Act;
"the managers"— (a) in relation to—
  1. (i) a health service hospial within the meaning of the 1977 Act (other than a special hospital),
  2. (ii) a health service hospital within the meaning of the 1978 Act (other than a State hospital), or
  3. (iii) any accommodation provided by a local authority and used as a hospital by or on behalf of the Secretary of State under the 1977 Act,
means the District Health Authority or special health authority, or (as the case may be) the Health Board within the meaning of the 1978 Act, who are responsible for the administration of the hospital;
  1. (b) in relation to a special hospital, means the Secretary of State;
  2. (c) in relation to a State hospital, means a State Hospital Management Committee constituted by the Secretary of State to manage the hospital on his behalf or (where no such committee has been constituted) the Secretary of State; and
  3. (d) in relation to any other hospital, means the persons for the time being having the management of the hospital;
"medical treatment"—
  1. (a) in relation to England and Wales, has the meaning given by section 145(1) of the 1983 Act; and
  2. (b) in relation to Scotland, has the meaning given by section 125(1) of the 1984 Act,

New clause 14—Persons discharged from hospital (No. 3)—

'(1) It shall be the duty of the responsible medical officer for any person who has received medical treatment for mental disorder as an in-patient for a period of, or periods totalling not less than, six months in the preceding twelve months or on a regular basis over two years, to prepare a care plan for that person before he is discharged from hospital. Such a care plan shall take into account individual requirements and include as appropriate proposals for medical treatment, day care and accommodation. Such a care plan shall be prepared by the responsible medical officer in consultation with other Health Authority Officers, the local Family Practitioner Committee, the Local Authority and relevant voluntary organisations. No disabled person shall be discharged from hospital until a care plan has been adopted.

(2) The responsible medical officer shall prepare a written statement setting out the care plan and inform the disabled person and, when appointed, his representative of the details of the plan.

(3) If the disabled person or his authorised representative is dissatisfied with any matter set out in the care plan, that person may, within such reasonable period as the authority may allow for the purpose, make further representations to the responsible medical officer.

(4) Where any such representations have been made in accordance with subsection (3) above the responsible medical officer shall reconsider the details of the care plan and inform the disabled person or his authorised representative of his final decision.

(5) In this section—

Amendment No. 4.

Mr. Clarke

New clause 11 deals with an extremely important aspect—the problem of persons leaving hospital. Our objective is to require assessment before discharge from hospital for people who have received in-patient treatment for mental disorder for at least six months. We pursued that matter in Committee. The new clause attempts to reflect some of the responses we received.

The Times of 17 February this year stated: A doctor should not discharge a patient before satisfying himself that there is a satisfactory pattern of living awaiting him … No individual should be discharged into a situation where services do not exist". The author of those words was the Secretary of State for Social Services. My clause, is, therefore, his policy, the policy of the Mental Health Act Commission and everyone's policy, so why not put it on the statute book? I hope that the Minister for Health will accept what we are trying to achieve.

Government new clause 6 merely requires notification by hospitals to the social services as proposed in their consultation paper. The AMA says: Notifying social services departments … is on its own a waste of paper. Both the AMA and the ACC would prefer the assessment to be instigated by the hospital, and that is reflected in new clause 11. I have tried to respond constructively to the suggestions of those who will have to implement the Bill.

The AMA said: Notifying social services departments of impending or actual hospital discharges is, on its own, a waste of paper … We cannot see the Government's proposals as anything other than a token gesture which in some cases will do more harm than good. It would be unfortunate if routine notifications took the place of considered assessments and real attempts to arrange suitable facilities before discharge. The Government should be under no illusions that by its present proposal it is killing off an important aspect of the original Bill.

The Royal College of Psychiatrists wrote to me saying: Psychiatrists will applaud your efforts to obtain adequate community facilities for patients discharged from hospitals and we would wish to support you in this.

New clause 11 follows Government new clause 6 practically verbatim, except that it substitutes "assessing" for "notification". If the hospital is to take the lead responsibility for the assessment in conjunction with the social services, no separate formal notification is required. Because of the Government restrictions elsewhere in the Bill, I have limited the scope of assessments to the "welfare enactments", although other matters, such as housing, will clearly be of prime importance. Because of the general welcome of the principle, I have no doubt that hospitals will seek to broaden the scope of the assessment as appropriate in each case. In this as in other matters we have tried, reluctantly, to accommodate the Government's views.

Mr. Dafydd Wigley (Caernarfon)

Will the hon. Gentleman confirm that, in bringing forward the new clause, he has answered most of the criticisms of those worried by bureaucracy and has retained the core of the argument about assessment? This is a good compromise on which we can all build for the future.

Mr. Clarke

We have tried to do that while conceding the vital principle of arranging for proper assessment before hospital discharge.

I have dropped the 28-day requirement of the original Bill in a further attempt to meet the Government's concerns. I have accepted, with great regret and reluctance, the exclusion of people who have totalled six months' treatment in a year but whose period in hospital has not been continuous. To me, it seems axiomatic that those caught in the revolving door syndrome need the best possible assessment because the support they have had has obviously proved inadequate. If the House accepts the clause, I hope that the Department will suggest to authorities that they can extend the procedures required by the Bill to other patients at their discretion. I am sure that they would wish to do so. There is no substitute for good example, and best practice has its own appeal.

Of course, the authorities are concerned about costs—not so much the cost of assessments, which I think will be on average only one or two a week for each health authority, but the cost of providing community care for mentally ill people where practically nothing exists at present. Ministers have been proclaiming the priority of mental illness for more than 10 years and much of the specific funding from the Department has gone to this sector.

I must admit that, from the publicity Ministers have obtained, I thought that the sums involved were significantly greater than those revealed in a reply to me last Wednesday when the Minister said that the group which causes most concern, the adult mentally ill, had received only £5 million, with another £6 million in the pipeline. Even so, it is difficult to know whether the Department has obtained value for money, and one reason is that authorities are operating in a legislative vacuum. The Mental Health Act 1983 failed to pay more than lip service to the key liaison between authorities over discharge.

10.30 am

On Second Reading I said that the Bill would need to be phased, in consultation with the authorities. The Minister has said that he will not bring parts of the Bill into effect without the necessary resources. I shall refer to that matter generally on Third Reading. Again I am trying hard to accommodate the Minister's position. Where we may differ is in our estimates of the cost and the priority which should be given to disabled people, not in relation to other recipients of the health and social services but other areas of Government expenditure.

On new clause 11, I am fully prepared for implementation to be delayed slightly longer than other clauses in the Bill in order to allow adequate preparation. Of course there is nothing to stop authorities setting up the procedures in advance of a firm target date which I hope will be not later than the financial year 1988–89. However, I think it is right to allow sufficient time for plans for the necessary services to be developed in those areas where the mentally ill are offered next to nothing at present.

This would allow for two full cycles of rate support grant settlement negotiations as well as allocation from joint finance, and so on. I must repeat, however, that I expect the clause to save money in the medium term by significantly reducing hospital readmissions and enabling many ex-patients to achieve eventually stable lives in the community with a minimum of statutory support. The social impact of this change would be immeasurable and immensely worth while. For that reason, we who support the Bill see it as one of our leading priorities and we hope that the Minister for Health will respond in that light.

Mr. Roy Galley (Halifax)

New clause 14 goes a little further in some ways than new clause 11. However, it covers substantially the same ground and it is motivated by the basic conviction that by itself notification will be insufficient in the circumstances which face us. The new clause proposes that individual care plans should be implemented for all the mentally ill and mentally handicapped people who are discharged from hospitals into the community. This was a key recommendation of the Social Services Committee's report on community care. A considerable amount of evidence was given to the Committee—both formal evidence and during visits that were made throughout the country and abroad—to the effect that detailed thought must be given to the arrangements that are made for patients when they are discharged from hospital. The Committee said that the evidence: highlights that sometimes dismal lack of co-operation between the many professions involved in care and treatment of mentally ill people. Evidence was also received of instances where the families of the patients were never informed of their relative's discharge. Insufficient effort would seem to be devoted on occasions to tracking a discharged patient. What is needed is a positive determination to improve the practice on discharges. Parliament laid down, in section 117 of the Mental Health Act 1983, a duty of after-care for detained patients. There is no reason now why a similar regime should not apply to all mental patients, whether statutory or not. That is the kernel of the argument in new clause 14. The success of community care for the mentally ill and the mentally handicapped and the development of new and enlightened policies is vital for us all. There is enormous evidence that the very principle would have a curative effect on many individuals. Therefore, it is important that it should work.

New clause 11 and new clause 14 seek to help the Government to ensure that the community care policy works. It will work only if adequate arrangements are made for those who are discharged from our large institutions. There should be a wide range of opportunities that are geared to the particular needs of each person on discharge. A small, institutionalised form of asylum may be needed, or hospitals, or houses with varying levels of staff support, or a return to the family, or a number of other possibilities.

The clause seeks to provide individual arrangements for those who are discharged, including medical treatment and, where appropriate, day care facilities and accommodation. The clause puts the onus on the responsible medical officer. He is responsible for the oversight of a patient's treatment while he is in hospital. He seems, therefore, to be the right person to have that co-ordinating responsibility.

The new clause says: No disabled person shall be discharged from hospital until a care plan has been adopted. The medical officer would have a duty to liaise with other parts of the health authority and also with the local authority, the relevant voluntary organisation and so on.

New clause 14 would not result in significant open-ended cost implications. The clause provides that people would stay in hospital until appropriate community facilities were available. It tries to deal with the revolving door problem—with those whom the hon. Member for Monklands, West (Mr. Clarke) called "yo-yo" patients. There is no care strategy for them. They may not be long-term inpatients; they keep going into and coming out of hospital. Care planning needs to take that group of people into account.

The wording of the new clause may not be entirely ideal, but when making arrangements for discharge it is necessary that this group should be included. Therefore I urge my right hon. Friend to accept either new clause 11 or new clause 14. It is vital that our community care policies for the mentally ill and the mentally handicapped should work. If they fail, public confidence may be lost and that would lead to pressure to put the policy into reverse. That would not be in the interests of the Government or of the mentally ill and the mentally handicapped. By accepting one or other of these amendments the Government will, I hope, help to buttress a successful policy.

Mr. Lewis Carter-Jones (Eccles)

I agree substantially with what the hon. Member for Halifax (Mr. Galley) has just said. New clause 11 contains the words not less than 6 months. That is merely a guideline. Discharge from long-term hospitals is usually after a much longer period than that. It would be a form of refined cruelty if people who had been in hospital for long periods were to be discharged without their needs having been assessed. This goes to the nub of the matter.

I am certain that the Minister will accept this new clause. It is a wise move. If we are to pursue the policy of bringing these people back into the community, it is, as I said earlier, a form of refined cruelty not to make an assessment of their needs and to provide for those needs. Therefore, I ask both Ministers to accept either new clause 11 or new clause 14. That would make a success of the concept of bringing these people back into the community where they rightly belong.

Mr. Andrew Rowe (Mid-Kent)

I understand why my right hon. Friend should be anxious about the resource implications of what is required. The provisions that have already been made are severely inadequate. However, this is a further example of the tangled web that my right hon. Friend has inherited, for which he is not responsible. He is faced with the difficulty of one pocket of public expenditure suddenly being expected to acept a cost that hitherto has been borne by another pocket of public expenditure. We have to look closely at the extension of joint funding arrangements to enable one element of the caring services to accept a cost which is being saved by another element of the caring services.

Many of the cost implications tend to be exaggerated because, in the past, we have not been sufficiently imaginative to consider alternative ways of handling some of these problems. Many mentally ill patients require, as much as anything, the maintenance of a regular contact with a caring person. Such a person does not need to be highly skilled. The administration of such a service through the local authorities is enormously expensive, no matter how careful the local authority may be in its spending. The administrative costs and the costs of running headquarters are high.

The Community Service Volunteers has helped to sponsor the creation, in Sunderland, of a home help co-operative. It is an imaginative scheme, which should be used on a wider scale. A group of women have set themselves up as a co-operative to provide home help care. They are paid local authority rates but, as they have no overheads, the service costs considerably less than if it were provided directly through the local authority. I believe that there is scope for providing such imaginative support ad I hope that it will be extended. I am aware that the scheme has the support of my right hon. Friend's Department as well as other Government Departments.

It is an imaginative scheme and, if adopted, the cost of providing care in the community, which many patients need to prevent them from going back through the revolving door, could be cut to a point where the anxieties of my right hon. Friend could be minimised.

Mr. Charles Kennedy (Ross, Cromarty and Skye)

I add my name to the long list of people in the House and in the country who have paid tribute to the hon. Member for Monklands, West (Mr. Clarke). He has presented the Bill with characteristic style and detail. On behalf of my colleagues, I support the points which have already been made on new clause 11.

There has been a great deal of public comment—the Minister has also commented on it—on the anxiety concerning resources. It is critical to remember that this new clause concerns assessment and the potential for net savings on existing hospital facilities from a proper assessment of what could and should be made available in the community for patients when they have been discharged.

The new clause should be considered in the context of saving health authority and local authority expenditure in the long term. The demands of patients must be adequately met and there must be proper planning. The hon. Member for Monklands, West sketched out the feasibility of a possible two-year time scale, and that is a sensible plan.

It is important to stress to the Minister that we are all aware that too often community care has been based on the revolving door syndrome. Too often state provision has been inadequate and back-up facilities have not existed in the community. There are genuine difficulties in the community. There is a cycle of hospital admission, discharge and readmission. Anything which helps to overcome that appalling and distressing cycle is surely to be warmly supported. I hope that the Minister will give his warm support to the new clause.

Mr. Patrick Thompson (Norwich, North)

I am grateful for the opportunity to speak in support of new clause 14 which has been explained adequately by my hon. Friend the Member for Halfax (Mr. Galley). I am encouraged by the present atmosphere of general support in the House for the Bill, suitably amended, reaching the statute book. It is a credit to the House and the way in which we approach such a subject.

Recently there was an excellent series of articles in The Times by Marjorie Wallace describing the problems which affect many families whose children become mentally ill. When my hon. Friend the Member for Halifax presented new clause 14 he was considering such cases. Youngsters in a family may be fine and fit for many years but, in their teens, or perhaps later, when they go to university, there is a sudden onset of mental illness which may result in the young person going to hospital. What happens then?

All to often—this process has been described in many articles and papers, so I will not go into detail—these young people are discharged from hospital and are returned to their families. There are often appalling, distressing scenes and the young person may leave the family and become a vagrant. He may return to hospital and be discharged again. The community care, which we all support, does not materialise.

10.45 am

A young person with this type of disability does not know what he wants. He may want to be discharged from hospital but it may not be the right time. For this reason, new clause 14 is pertinent to the problem. There is a great deal of hidden distress in Britain because of that problem.

I strongly emphasise the need for the Government and my right hon. Friend to consider seriously what has been said on new clause 11 and especially new clause 14. I hope that my hon. Friends and Opposition Members will do all that they can to support the principle behind the speech of my hon. Friend the Member for Halifax. We must support principles which are designed to help people, especially young people, in distress.

Mr. Ashley

I commend new clause 11 and the way in which my hon. Friend the Member for Monklands, West (Mr. Clarke) presented it. He did so in the constructive spirit which has animated the debate. I hope that the Minister will feel able to respond to that.

I do not know whether the Minister or other hon. Members have been in hospital. I have a few times and, after a couple of weeks, I have felt disorientated. Of the 15,000 mentally handicapped people who leave hospital, more than 10,000 have been in hospital for two years. One cannot expect them to leave hospital without being in distress; to help them they must be given assessment and resources.

I take issue with my hon. Friend the Member for Eccles (Mr. Carter-Jones). To impose such bad conditions on those people is not refined cruelty but unrefined cruelty. If the clause is accepted—I am sure the Minister will find it constructive—it will help people who ought to be receiving help under existing legislation.

If the Minister can accept the clause, it will be appreciated, and will save him money. It costs £12,000 to keep a person in hospital. The Minister, by accepting the clause, would help the House, himself and the Chancellor of the Exchequer. No one can be more constructive than that.

Mr. Michael Stern (Bristol, North-West)

I should like to add my name to the long list of the those who have congratulated the hon. Member for Monklands, West (Mr. Clarke) on introducing a Bill which will undoubtedly mark significant progress in treatment of and care for, especially, the mentally handicapped. I am most grateful to him for that.

Like many of my colleagues, I accept the need for provision for the assessment of patients who leave hospital after a long stay. It is essential that we go further than the hon. Member for Monklands, West has proposed. May I offer the hon. Gentleman a small warning not to be too prescriptive about the method of assessment? I know from constituency experience that the health authority must often take the lead when providing assessment. That function is usually performed by the authority in which the patient is to live, but it would often be more appropriate if the sending authority did the assessment.

I represent part of the county of Avon—if one accepts that the county of Avon exists—which has for years accepted patients from many parts of the country. It is not known until shortly before they are discharged whether patients still have family connections in those parts of the country from which they came.

As patients leave hospital—there has been a substantial drop in the number of patients in one hospital in my constituency during the past year—the local authority finds itself dealing with not one or five local authorities but nearer 50. That puts a tremendous burden on the health authority in ensuring that patients are provided for unless those other authorities give substantial help. Even then, there is an enormous burden on hospital administration.

A couple who have recently been discharged from a mental hospital are attempting to negotiate with a health authority in the south of England for their brother to stay with them permanently. The difficulties have fallen almost entirely on the local authority because of the distances involved. It has been unable to do much planning of the care that the discharged patient will receive.

I am anxious that we should not, by making prescriptions in the Bill, debar the appropriate method or organisation of assessment from being pursued in what will inevitably be a large number of individual cases with peculiar requirements. I hope that my right hon. Friend the Minister can say to what extent the many forms of assessment currently practised can be encouraged in the Bill.

Mr. Martin Flannery (Sheffield, Hillsborough)

I should like to add my voice to those who have supported my hon. Friend the Member for Monklands, West (Mr. Clarke), whose restrained marshalling of arguments is such a valuable contribution.

I have a major mental hospital in my constituency and I have had contacts with it, although not as many as I would have hoped. I was a head teacher in the area, and it is amazing how one knows what is going on in families when there is mental illness. If families try to look after a sick person and do not receive support, that person will have to go back to hospital depressed and ill once again. It is morally indefensible to let people out of hospital without proper assessment and support. As the hon. Member for Ross, Cromarty and Skye (Mr. Kennedy) said, the melancholy process of coming out of hospital and going back in must be more costly.

My hon. Friend has raised such a fundamental issue that the Bill must go through, especially in view of the large number of the ill and compassionate people who are watching the events in the House today.

Mrs. Edwina Currie (Derbyshire, South)

I too would like to speak briefly on this group of new clauses and the amendment concerning hospital discharge, which has been a matter of considerable concern to many of us, especially those of us who have been involved with administering services in major cities, which have tended to attract people who have been discharged, whether voluntarily or against their will.

I am sorry that I have not been able to take part in debates on the Bill or in the Committee but, like several hon. Members present, those of us who take an interest have been removed from public life, as it were, to serve on the Social Security Bill. I look forward to seeing an end to that as well.

I welcome the thrust of the Bill and greatly hope to see it on the statute book, preferably as soon as possible, but those who are a little cautious have genuine reasons for our concern. Neither the hon. Member for Monklands, West (Mr. Clarke) nor anyone else should imply that we do not care. It is all too easy to write tough legislation, put it on the statute book and then wonder why it is unworkable. It is all too easy to create statutory obligations for local authorities without a thought to the resources that they have to find, and then puzzle about the long list of statutory obligations that local authorities do not carry out. Good will just is not enough.

I am one of those who had to administer previous legislation which had those glaring faults. I think especially of the Chronically Sick and Disabled Persons Act 1970. To make it all work these cautions should be taken into account. A step-by-step approach is more likely to achieve the desired objectives.

I should like to put on record my unconditional admiration of all concerned, especially with regard to the efforts that they have made behind the scenes and in Committee to come to some agreement. I hope from the bottom of my heart that we can achieve our objective today without dividing the House and that we can reach a unanimous view on what we are trying to do. How nice that would be.

New clause 6 is a great practical improvement on the original clause 4. The hon. Member for Monklands, West has said which of the restrictive elements in that clause he has been willing to remove. The 28 days element would have made life just about impossible for everyone in local authorities who tried to administer it.

The Bill that emerged from Committee emphasised social services departments, and so did the hon. Member for Monklands, West when he introduced this debate. It is important that housing should be included because the first thing that a person needs on discharge from hospital is somewhere to live. In that respect, new clauses 11 and 6 are major improvements, because they speak of the local authority rather than just of the local authority social services department. There are local authority departments for whom disabled people may be a much lower priority, who ought to be involved. I am glad that the new clauses make that point.

The hon. Gentleman also said that notifying the social services department is a waste of paper. I understand that he was quoting some of the representations that have been made on the Bill. Surely that is not so. For many of the years in the 1970s we in Birmingham were bedevilled by people on the streets. They had been discharged from hospitals all over the country, especially Scotland, given a train ticket to Birmingham and, in one or two cases, the address of a lodging house, and sent on their way. The local authority, which wanted to assist, was bedevilled by not knowing how many people there were in that position or where they came from.

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Mr. Tom Clarke

The organisation which took the view that it was a waste of paper was saying, in effect, that notification was exclusively a waste of paper and was not meaningful in the absense of full assessment, which is what the new clause seeks to achieve.

Mrs. Currie

I take that point. I would merely say that we do not have any notification at present. Local authorities which have good will, and which in many cases could find the resources to assist, find it extremely difficult to undertake any sort of planning when they do not know with whom they may be dealing. In the cases to which I have referred, people were literally picked out of dustbins. We had no idea from where they came and we were in ignorance of their background. Frequently, they were incapable of giving us that information. That made it extremely difficult to make any sort of arrangements for them. There was no liaison. My judgment at that time was that the health authorities and the hospitals concerned were willing to avoid liaison. They felt that they had done their duty and were content to send people on their way. That was wrong.

I shall direct a few remarks to my hon. Friend the Member for Halifax (Mr. Galley) and comment on the excellent way in which he introduced new clause 14. My hon. Friend said that notification is not enough, and that is right. However, as long as we do not have notification, we should welcome moves in that direction. I suspect that if my right hon. Friend the Minister for Health had introduced a small Bill containing all the clauses that he is keen to support this morning, we would all have welcomed it as an example of some progress being made in helping the disabled.

I am worried about new clause 14—my hon. Friend the Member for Halifax knows that I have the greatest sympathy for it, having served with him on the Select Committee on Social Services—because of the power that is proposed within it and the command that is given over resources. I suspect that we shall end up by taking power out of the hands of elected representatives, where it should remain.

As the clause stands, an enormous amount of effort could be put into writing perfection into all care plans and producing exactly what would be required for every year of discharge of a disabled person's lifetime, only to find that resources are not available to do what is required. Alternatively, the committees involved might direct priorities elsewhere. When I had responsibilities for these matters in Birmingham, I can remember being asked on one occasion whether I would be prepared to release resources for much favoured plans to help redevelop the centre of the city to save it from dereliction. I took the view that those plans were rather more important than other considerations. We hoped to maintain the rate basis of the city and so produce resources in future to assist the disabled and everyone else we wanted to help. If we write perfection into all care plans, they may end up on the shelf, in common with much other planning. The law would be complied with, but that would not be good enough. That would not be sufficient.

When a local authority knows that a person is coming out of hospital, the planning process should start. We should write into law the liaison that should take place between the authorities concerned. That is the bedrock of getting any decent discharge plan going. That is the sine quo non. Unfortunately, that is not set out in the law, The Bill, with wise amendments, will give considerable assistance to the disabled and I hope that we shall see it make progress today.

Mr. Alfred Morris

I rise to endorse new clause 11 from the Opposition Front Bench. I am pleased to do so because it is an important new clause which merits the support of right hon. and hon. Members on both sides of the House.

Ministers in successive Governments have for years pressed for joint planning and joint assessment of residents who are being considered for planned discharge from hospital. That being so, and in the light of the successful use of joint funding and other resource allocation changes to facilitate such collaboration, it is surely untenable to object to procedures which require hospitals to give reasonable notice to the local authority—so that timely and proper assessment can take place—when they propose to discharge a patient.

I have known many cases where people have had to be swiftly readmitted to hospital because there was no knowledge by the local authority of their discharge from hospital. That can be costly as well as inhumane. My hon. Friend the Member for Monklands, West (Mr. Clarke) was eminently right to say that there could be savings in the medium term. There will be cost implications in the short term entirely due to the poor level of services for the mentally ill at present. In many authorities the level of services, as I am sure the Minister for Health will agree, is regrettably very low indeed.

There is an important gap that the clause seeks to fill and it deserves the support of both sides of the House. I hope that we shall not have to divide to ensure that the clause is added to the Bill.

Mr. Hayhoe

We have had a useful short debate in which many helpful suggestions have been made, some of which have gone rather wider than the legislative detail that is before us. Perhaps it would not be appropriate for me to respond to many of these suggestions, and I am not sure that I would be able to do so without considerably more research. I can assure those who have contributed to the debate that their contributions will be considered carefully, including their suggestions that certain ideas should be more widely adopted.

I welcome the general support that has emerged from this short debate for the broad thrust of the community care concept of moving people, wherever appropriate, out of institutional care into the more dignified, the more human and the more—

Mr. Laurie Pavitt (Brent, South)

Therapeutic?

Mr. Hayhoe

Yes—therapeutic atmosphere. That is the word that I was after. It is a move that improves their own physical standards. One sees remarkable improvements in people as a result of moving them from institutions into the community. That is in no way to criticise those who contribute to the running of our large institutions. I would not wish to do other than pay tribute to them. I do not believe that in commending community care we are seeking to deny the great dedication that comes from the majority of those who work in the institutions.

Mr. Pavitt

Give 'em the money, Barney.

Mr. Hayhoe

I think that it will be useful for the record to make it clear that clause 4 as it stands would place a duty on hospital managers to inform the relevant social services department of the date of discharge—at least 28 days in advance—of any person who had received treatment for mental disorder as an inpatient for periods totalling six months or more in the preceding 12 months period. Notification would be subject to the patient's consent. Social services departments, on receipt of this information, would undertake an assessment of that person's needs within 28 days.

These provisions arouse concern within the Government although the intention behind the clause was very much in line with their general philosophy of community care, which the Government have been promoting in various ways. It seeks to enshrine in legislation what is already accepted good practice. But it would introduce procedures that are unnecessarily prescriptive and would cause problems in practice. It would place the responsibility for assessment of patients about to be discharged from psychiatric hospitals in all cases on social services departments. It is right that social services should contribute to assessments, but hospital authorities with current responsibility for the patient should normally be in the lead. There would be great difficulties if the hospital authorities were not very much involved.

A minimum period of 28 days for notifying social services of a patient's discharge would, as my hon. Friend the Member for Derbyshire, South (Mrs. Currie) said, impose unacceptable administrative constraint on both health and local authorities. The formula for adding up periods of short-term care in hospital would cause problems. It is not uncommon for people with mental disorder to spend frequent short spells as inpatients. The notification process could be triggered off unnecessarily at frequent intervals.

The Government's new clause 6 would require hospital managers, unless the patient objects, to inform the appropriate local authority—social services department, or, in the case of people under 19, local authority—of the expected date of discharge of an inpatient who had been receiving treatment for a mental disorder for a continuous period of at least six months, as soon as it is reasonably practicable to do so. It would require hospital managers, in the case of a mental health review tribunal directing the immediate discharge of such a patient, to inform the local authority that discharge had taken place, provided the patient does not object.

There are two alternatives to the Government's new clause 6. I shall briefly deal with new clause 14 proposed by my hon. Friend the Member for Halifax (Mr. Galley). The new clause would require the responsible medical officer to prepare a care plan before discharge for any person who had

received medical treatment for mental disorder as an in-patient for a period, of or periods totalling not less than, six months in the preceding twelve months or on a regular basis over two years. The care plan would have to be prepared in consultation with other health authority officers, the local family practitioner committee, the local authority and relevant voluntary organisations. No disabled person could be discharged from hospital until a care plan had been adopted. The new clause further provides for a statement of the care plan to be provided to the disabled person or his authorised representative and for representations about the content of the care plan to be made to the responsible medical officer.

It is not clear from the clause as drafted precisely what is meant by a care plan, although I took note of the comments made by my hon. Friend the Member for Halifax and the support given to him by my hon. Friend the Member for Norwich, North (Mr. Thompson). Presumably, as I understand it, it would be a detailed programme tailor-made to the individual person and designed with particular treatment objectives in mind. However, the production of a plan is only the first step, as all of us realise. As a plan, it means very little. The treatments or activities have to be delivered, the results monitored and the plan updated to take account of the success or failure and the need to set new goals. The whole process is resource-intensive. Even at the level which may be envisaged by my hon. Friend the Member for Halifax of producing a statement of the main elements of care which will be provided in the community, it has to be said that people's needs change and are particularly likely to change after discharge from hospital into a new environment. Those were the very points made by the right hon. Member for Stoke-on-Trent, South (Mr. Ashley). A detailed plan produced before discharge could be of short-lived validity. It could also introduce inflexibility whereas the authorities responsible for the care of the mentally disordered person after discharge should be sensitive to changes in the person's needs and react accordingly. The machinery envisaged is rather bureaucratic.

The provision that no disabled person shall be discharged from hospital until a care plan has been adopted would conflict with the right of voluntary patients to discharge themselves whenever they like, and with the implementation of a decision of a mental health review tribunal to order an immediate discharge. Therefore, there are technical problems and other difficulties associated with the clause as drafted and suggested by my hon. Friend.

11.15 am

In his comments my hon. Friend the Member for Halifax made it clear that if he could not have new clause 14 he would like new clause 11 rather than the Government's new clause 6. Therefore, I shall deal with new clause 11 which has been proposed by the promoter of the Bill. It follows the basic structure of the Government's proposed new clause 6. I am grateful to the hon. Member for Monklands, West (Mr. Clarke) for building upon that. It would certainly avoid some of the objectionable features of clause 4, which I have pointed out to the House. In particular, the 28-day minimum period for notification disappears as does the formula for adding up periods of short term care in hospital. New clause 11 would place a duty upon hospital managers, when someone is being discharged from hospital after having received continuous treatment as an inpatient for a continuous period of at least six months, to make arrangements with the relevant local authority for an assessment of the patient's needs. The assessment would have to be made before the date of discharge except in the case of patients who are discharged immediately by a mental health review tribunal, in which case the arrangements would have to be made as soon as is practicable.

There are some difficulties with this clause. I would be less than frank with the House if I did not acknowledge that. It fails to make clear what the extent and the duty would be of hospital managers when a local authority failed to participate in the arrangements for an assessment. What will happen if the local authorities social services department is unco-operative? That is not clear in the present formulation. Clearly, hospital authorities have no power to direct local authorities to participate in the assessment of needs.

Similarly, the clause fails to make clear what responsibility, if any, would fall on a local education authority in respect of persons under 19 years of age as they have no responsibility for welfare enactments within the terms of the Bill. I am advised that, in any event, those under 19 years of age in hospital would have already been the subject of a statement of special education needs as provided for under the new clauses we have just discussed and new clause 12, which we have accepted. In other words, there is a technical problem. By requiring hospital managers to make arrangements for an assessment it would give them a wider responsibility than would be placed on them under the Government's new clause 6. That is the thrust of what the hon. Member for Monklands, West is doing in commending his new clause to the House.

I am very sympathetic and I want to respond positively and constructively to what the hon. Gentleman and both sides of the House have put to me. I believe that there will need to be some further discussion with the local authorities, and especially with the health authorities because there is a new provision for them. Therefore, in the time available it has not been possible to have the proper level of consultation required.

It has been acknowledged that there are resource implications for this. I have noted the, I hope not optimistic, comments about the initial savings which are available, if not in the short term, at least in the medium and long term. I suppose, having once been a Treasury Minister, one has a certain training to recognise that jam tomorrow is something which never quite seems to come, whereas costs today are very much always on one's desk. I do not want to be unduly controversial on this matter. I have made the Government's position on resources absolutely clear. If this leads to a reduction of duplication, of course, it is something which all of us welcome because, whatever our arguments across the Floor of the House on the amount of resources that ought to be and can be made available, we will all agree that the resources which are available should be used effectively and efficiently to help the individuals concerned. Therefore, I certainly do not oppose the adoption of the new clause proposed by the promoter of the Bill. In those circumstances, I would not propose to move new clause 6.

Question put and agreed to.

Clause read a Second time, and added to the Bill.

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