Community Care

HC Deb 26 June 1989 vol 155 cc704-55

Mr. Speaker

I must announce to the House that I have selected the amendment in the name of the Prime Minister.

Mr. Tim Rathbone (Lewes)

On a point of order, Mr. Speaker. Have the Government given you notice of any intention to announce today what they intend to do to mark the United Nations designated International Day against Drug Abuse and Trafficking? If not, and as there is a full string of the Leader of the House, the Chief Whip and the Secretary of State for Health presently on the Front Bench, perhaps they could incorporate that information in the reply to the debate.

Mr. Speaker

That is a matter for the Front Bench. The hon. Member for Workington (Mr. Campbell-Savours) drew attention to matters contained in early-day motions, and that might be an admirable subject.

3.41 pm

Mr. Robin Cook (Livingston)

I beg to move, That this House condemns the continuing failure of Her Majesty's Government to ensure that community services are expanded at a rate which matches the closure of mental health hospitals or the growth in the population of the very elderly; expresses concern that the sole focus on the acute sector of the White Paper Working for Patients will further divert resources from chronic care; regrets that, in the year since Ministers received the Griffiths Report on Community Care, they have failed to respond to a single recommendation; accepts its central conclusion that social service authorities should be the lead agency for community care; and rejects proposals that would confine local authorities to being purchasers rather than providers of services for the elderly and handicapped in their communities. The whole House will know that, more than one year ago, Sir Roy Griffiths presented a blueprint to rationalise and develop care in the community. The Government's enthusiasm both for that problem and for Sir Roy's solution can be gauged by the fact that they chose to publish his report on the day after Budget day in 1988, which made sure that it never disturbed the conscience of a single sub-editor.

Last week we passed another milestone in the history of the Griffiths report, because as of then, Ministers have spent longer ruminating over their response to Griffiths than it took Sir Roy to research, write and print the entire report. There is a stark contrast to that delay. In the same period that Ministers sat on Sir Roy's recommendations, the Secretary of State found the time to write a White Paper that turns upside down the entire acute sector of the National Health Service. It was published at the end of January, consultation on it finished four months later, and we are threatened with a Bill on that White Paper in five months' time.

The contrast between the breakneck pace of the Government's White Paper and the tardy progress in response to the Griffiths report is that no one wants the Secretary of State to force through his eccentric plans for our hospitals—even his Back Benchers are now praying that it will fade away and stop terrifying them in their constituencies—while everyone involved in delivering community care has pleaded with the Secretary of State to respond positively to the Griffiths report.

I understand that the House will not hear the Secretary of State's response today—[HON. MEMBERS: "Why not?"] He has been kind enough to write to me to apologise because he will not be taking part in the debate. I understand that the Government will be represented in both the opening and closing of the debate by the Parliamentary Under-Secretary, whose name unfortunately does not even appear on the Government's amendment. Of course, I welcome the Under-Secretary to our debate. He is a gentleman of both courtesy and candour. I shall not try to get him into trouble with his superiors by arguing whether in those qualities he compares favourably or not with them. It is not a criticism of the Parliamentary Under-Secretary when I say that the House might have expected the Secretary of State to participate in this debate.

The Secretary of State for Health (Mr. Kenneth Clarke)

I am grateful to the hon. Gentleman for giving way, but I am surprised that he has raised this point. He shadows no fewer than two Departments of State and invariably participates in every debate on any subject arising from either Department. If he were a football player, he would be described as a greedy player. I believe that there are members of his team who are more than competent, but he often seems unwilling to give them an airing. My hon. friend the Parliamentary Under-Secretary of State is extremely competent to answer the hon. Gentleman's attacks on this or any other subject, particularly when the hon. Gentleman has chosen to raise a subject which he knows perfectly well will be addressed in a few weeks' time when there is to be a statement on the Griffiths report.

Mr. Cook

As I understand the Secretary of State's intervention, he is explaining why the Parliamentary Under-Secretary should be Secretary of State rather than himself. He chose to refer to my experience of Supply day debates. I have been to the House of Commons Library and checked on the 54 Supply day debates which have been held since the last general election. Of those 54 motions tabled by the Labour party, on only seven out of the 54 occasions, were the debates not replied to by a Cabinet member. Of those seven, there was only one occasion on which the speech from the Government Bench was made by a Parliamentary Under-Secretary rather than a Minister of State; that was when, unfortunately, the Minister of State, Agriculture, Fisheries and Food was taken ill in Brussels and replaced by a Parliamentary Secretary. Although the House may not have fully appreciated his speech, we well understood why the Parliamentary Secretary made it.

The clear conclusion is that the only time when a healthy team of Ministers has left a Parliamentary Under-Secretary to reply to the debate is when the topic under discussion was care in the community. Those outside the House who are concerned about community care and try to make it work, will note that this demonstrates where community care comes in terms of this Government's priorities. Unfortunately, outsiders reading this debate will feel particularly aggrieved as they struggle to maintain services for community care which are in constant danger of being washed away by an ever-rising tide of need.

Since the publication of the Griffiths report, another 40,000 elderly people have been added to the total number of those aged over 85. I recently received a parliamentary answer which showed how the provisions to support those people living at home have failed to keep pace with the increase in numbers. The number of those attending day hospitals per thousand of elderly over 75 has fallen from 552 in 1983 to 498 in 1987. That is a 10 per cent. drop, although such provision can be vital in enabling the elderly to be supported when living at home.

At least central Government can choose how many resources they put into the problem. Local authorities, when providing their services, find that they are ground between the lower millstone of ever-rising demand and the upper millstone of ever-decreasing resources. Sir Roy Griffiths states: many social services departments and voluntary groups grappling with the problems at local level certainly felt that the Israelites faced with the requirement to make bricks without straw had a comparatively routine task. Those people left to take the strain are those officially designated informal carers, by which is normally meant the nearest available female relative. In reality, they provide the great bulk of care in the community. It is an outrage that we leave them to get on with it with minimal support. Nursing is a skilled job. Those in the profession receive three years' training and are then expected to work eight-hour shifts at a stretch. Time and again we ask informal carers to provide 24-hour constant nursing without training, respite or help, and often without sleep. It is hardly surprising that study after study shows that people left in constant attendance without a break are in poorer physical and mental health than the rest of the population.

One development since the Griffiths report clearly shows the Government's indifference to these carers. In April last year, people caring for a disabled relative were the only group on long-term supplementary benefit who received no premium on transfer to income support. As a result, 150,000 carers found that they were £5 a week worse off in entitlement. We owe this group an immense debt; to reward that debt by cutting still further an income that is already pathetic beggars belief.

What makes the Government's meanness towards relatives who care for the elderly at home all the more unjust is the Government's willingness to tolerate dramatic rises in payments of social security to the proprietors of private homes. In 1980, the Government made social security payable to cover residential fees of private and voluntary homes, and presumably intended thereby to stimulate the private sector in residential care. That, certainly, was the dramatic effect.

Unfortunately, as happens so often when the Government are faced with the financial consequences of their own policies, they then rebelled at the bill. In 1985, they stopped paying the fees and imposed a national limit on each category. I have received figures in parliamentary answers which show that the limits on these categories have been lowered in real terms since their introduction in 1985. For elderly people in nursing homes, the money has fallen from £199 to £190 a week; for the mentally ill, it has fallen from £211 to £195; for the mentally handicapped, it has fallen from £234 to £205. The cost of such homes, however, is not falling in real terms: it is rising. In between, a real gap is emerging between what they charge and what the social security system will pay, with the result that a growing number of elderly and handicapped people cannot meet their bills and face the real risk of being put out on the street.

We condemn the Government's irresponsible policy of allowing this sector to grow unplanned and uncontrolled. Some, at least, of the payments that go to elderly people in residential care could have been used to sustain them in the community if local authorities had been given half the resources that the Government are willing to pay the proprietors of private homes. Having created this problem, Ministers cannot justify the cynical response of capping expenditure and leaving vulnerable and elderly patients to face the consequences of being unable to pay their bills.

From the elderly, I turn to services for those decanted from mental health hospitals, where we find the same picture of rising demand overwhelming inadequate provision. The Government have certainly pursued a vigorous programme of hospital closures, nowhere more markedly than in the case of mental health hospitals. The closure programme has been so rapid that Ministers seem to have difficulty keeping abreast of it. Last year I tabled a parliamentary Question inviting Ministers to list the mental health hospitals for which there were no closure plans. A subsequent survey of the list published in Hansard discovered that it included four mental health hospitals which had already closed at the time of the answer and two others which closed during the time that it took to carry out the survey. When I wrote to Ministers drawing their attention to this inaccuracy, I received a letter which had the breath to advise me: the majority of the information in the reply was correct. Apparently it is sufficient for Ministers these days to aim at only a pass mark in a parliamentary answer.

Since then, I have received figures which confirm how badly the expansion of community care has failed to match the contraction of institutional care. Between 1979 and 1986, 28,500 long-stay patients were discharged from mental health hospitals into the community. In that same period, only 2,230 extra places were provided in day centres for the mentally ill. In other words, fewer than one in 10 of those discharged to the community had the opportunity of a place which could provide them with support and the opportunity of comfort. One can, of course, find excellent cases of an integrated range of community care facilities right across the country, from Dorset to Lambeth. It is all the more lamentable that, given those illustrations of what is possible, the majority of cases fall so far short.

A number of studies now confirm that, for most of those leaving care in an institution, care in the community is a myth. For starters, if the statutory authorities are going to deliver care in the community, they must know where to find the former patients who will receive that care. One study of 50 patients discharged from Claybury mental hospitals could trace only 26. Of those 26 who were traced, only six had a place at any day centure. A study of 150 patients discharged from mental hospitals in Essex could trace only 100. Two thirds of those traced had received no help since leaving hospital.

That is not just a problem for the authorities: it is a source of distress for the relatives. A son—perhaps even a wife—may have a serious mental health condition, but his parents may not know where he is—whether he is in accommodation, whether he is being fed or whether he is going through an acute episode or is in a stable condition.

The reality is that, although we may not know where any one patient might be, we have an accurate idea of where they turn up. Hon. Members can find some of them under railway arches within strolling distance of the House. One medical study of the homeless who attended the Crisis at Christmas venue last year discovered that more than half of them had a history of psychotic disorder, and one third displayed psychotic symptoms that very night; yet two thirds of them had no contact with any medical centre.

They also turn up in our remand centres, because it is more convenient for our society to label their behaviour as criminal than to respond to their medical or social needs. At the time of the Rampton disorders, I tabled a parliamentary Question to the Government, from the answer to which I discovered that one in six of those who were inmates at the Rampton remand centre at the time were formerly in-patients at psychiatric hospitals. As Dr. Kilgour, the director of medical services of Her Majesty's prisons, has said: My colleagues and I find ourselves having to handle people who are inappropriately committed to custodial sentence due, to put it bluntly, to the failure of the community to provide suitable facilities for them. I read in The Daily Telegraph last week that this problem has now surfaced in the consciousness of the Prime Minister. Confronted with the closure of Friern Barnet hospital in her constituency, the Prime Minister has ordered plans for further hospital closures to be frozen. I am glad that someone in the Government has recognised the problem, but that emphatically cannot be a permanent solution. Many of our present stock of mental health hospitals were built by the Victorians. Some of them were built as the local poorhouses—places of punishment and detention rather than of medical treatment. The solution is not to perpetuate those conditions indefinitely, but to make a reality of community care by providing the services that are needed to support the patients who leave the hospitals—to provide them with small-scale residential communities, with day hospitals and drop-in centres, and with sheltered employment opportunities, because many of those leaving hospital want to work.

This morning, West Lothian Poverty Action Forum in my constituency published an excellent report that allows claimants to speak in their own voices. I was much struck by the observation of one disabled claimant about the trap in which he found himself. He had no experience; therefore he could get no job. He could get no job; therefore, he could obtain no experience. Only community provision can help him to break out of that trap.

That brings me back to the Government's failure to respond to Sir Roy's recommendations to improve care in the community. There are plenty of reasons why we should treat the report with caution. Indeed, if I suspected that that was why the Government were taking so long to respond to the report, I would treat the delay with more understanding and tolerance. Sir Roy's report contains no commitment to extra resources to make community care work. There is nothing about enabling users to participate in the planning of services or to contribute to the management of those services when they are up and running. For all the rhetoric about consumerism in the report, Sir Roy has produced a design intended to improve lines of managerial accountability, not to make the services accountable to the users.

Mr. Peter Thurnham (Bolton, North-East)

The hon. Gentleman has criticised the Government for the length of time in responding to the Griffiths report. As I understand it, the Labour party policy review did not agree with Griffiths, in so far as Griffiths calls for local authorities to be more the organisers and purchasers of services instead of the providers. Why is the Labour party so keen on the local authority being the provider? Is that because of the continued obeisance of the Labour party to the trade unions?

Mr. Cook

It is true that one reason why the Labour party remains committed to public provision is that public provision overwhelmingly provides better working conditions for those who provide the service. We do not believe that a caring and compassionate service can be provided for those in need if it is based on the exploitation of the workers in the service.

It is certainly not the case that we have failed to respond to Griffiths. We have produced major documents in response to the Griffiths report. We have differences with Griffiths. We believe that in many respects he was in error partly because of the remit that he was given by Treasury Ministers and that that explains why he was unable to recommend extra resources. We believe that it is inexcusable that the Government will not tell us whether they agree with Griffiths and, if they fail to agree with him, what they will put in place of Griffiths.

The hon. Member for Bolton, North-East (Mr. Thurnham) has put his finger on the major reason why Ministers have been delaying a response to Griffiths. That has not happened because Griffiths failed to recommend extra resources—that must commend the report, rather than be a handicap in the Government's eyes. Ministers have behaved like paralysed rabbits for the past year as a result of the sheer horror that they must feel at Griffiths's central recommendation. As the hon. Member for Bolton, North-East said, the central recommendation is that if we are serious about care in the community, more responsibility and control of resources will have to be given to local authorities which provide the services in the community. That message is as welcome to No. 10 as telling the Prime Minister that Labour has a 14-point lead in the opinion polls.

The Prime Minister has presided over a sustained strategy of undermining local government, which has abolished the local authorities which she liked least, which has cribbed and confined with restrictions the right to express political opinions of those local authorities which remain, and which is currently compelling the authorities to hand over many of their services to private contractors.

After a decade of running down local government, the Prime Minister and her Ministers have received a report which advises them that, in this matter at least, they cannot do without local government. It tells them that, if they are serious about caring for the elderly and providing for the mentally ill and mentally handicapped, they need local government. Rumours are surfacing in the press that a compromise has been worked out in the Cabinet and that local authorities will be designated as the lead agencies in community care, but that they are to be denied any opportunity to demonstrate leadership because they will be stripped of all responsibility for direct provision of services.

The Adam Smith Institute recently threw a party to celebrate its 100th proposal to be accepted by the Government. It has produced a document along the lines that I have just described. It justifies preventing local authorities from making direct provision on the following grounds: Government's priority should be to encourage the growth of the private sector. No initiative by Government should undermine that independent sector or attempt to compete with it. There is a remarkable double standard there. Local authorities are to be obliged to put all their services out to competitive tendering, but the private sector is protected from competition by the local authority. Given the Adam Smith solution to the Hong Kong problem, we should all be grateful that it is not proposing that we should sweep up the mentally ill and put them down on the Mull of Kintyre.

It cannot be emphasised too strongly that local authorities are the largest single providers of residential and domiciliary care; they understand the needs of people requiring community care; that they have acquired unrivalled experience and professional skills in running community care; and that it would be pure ideological vandalism to break up that service—and we shall fight any proposals to do so.

In the meantime, scandalous examples of the failure of community care continue to accumulate. I mentioned that former patients can be found in hostels for the homeless and in remand centres. Tragically, they also turn up as the subjects of inquests, such as that currently being held into the death of Beverley Lewis. Deaf, blind and handicapped from rubella, and unable to demand help herself, she starved to death in the community in the year since Griffiths. Tragic though her case is, it does not compare with the much greater scandal of the delay and indifference with which Ministers treated Griffiths over that same year. We have already lost a whole year. It is because we believe that there is no more time to lose that we shall vote tonight for an urgent response from the Government.

4.5 pm

The Parliamentary Under-Secretary of State for Health (Mr. Roger Freeman)

I beg to move, to leave out from "House" to the end of the Question and add instead thereof: commends the Government's record on the development and funding of community services for all people in need of care; reaffirms its support for the policy of community care; believes that it will be complemented and strengthened by the proposals contained in the Government's White Paper, 'Working for Patients'; and looks forward to an announcement of the Government's conclusions on Sir Roy Griffiths' report, 'Community Care: Agenda for Action', in the near future. I am grateful to the hon. Member for Livingston (Mr. Cook) for making out an excellent case for my early preferment. However, I do not believe that his recommendation will be entirely productive.

I apologise for the absence of my hon. Friend the Minister of State, Department of Health, who is chairing a conference of the Council of Europe in Strasbourg, which is an important and long-standing engagement. My response will be as brief as possible, because I know that many right hon. and hon. Members wish to speak. If I catch your eye later, Mr. Speaker, and with the leave of the House, I shall seek to answer some of the questions that will arise.

What do we mean by care in the community? For the mentally ill and the mentally handicapped, we mean providing care away from the large, isolated and inhumane Victorian institutions that for so long have been the hallmark of institutional care. That policy has existed for 20 years, shared with differential rates of fervour by right hon. and hon. Members on both sides of the House. We want to move away from a regime that involves long-stay facilities, hostels, houses—[Interruption.] Perhaps the hon. Member for Peckham (Ms. Harman) will pay me the courtesy, as she usually does, of listening to my arguments—

Mr. Nigel Griffiths (Edinburgh, South)

It is not worth it.

Mr. Freeman

The hon. Gentleman's remark is a little premature. If he will listen to what I have to say, I shall do him the courtesy of listening to his contribution.

We want to move away from a regime of institutional care in isolated, Victorian institutions to a system whereby we provide a range of facilities much closer to the community.

We want to enable more elderly people to stay in their own homes for as long as possible before institutional care becomes necessary and unavoidable. I quote from the report of the Public Accounts Committee laid on 25 April 1988, which I am sure the hon. Member for Livingston read: We draw attention to the fact that up to 23 per cent. of claimants"— that is claimants of income support— entering residential homes could have stayed in their own homes for longer periods had appropriate community support services been made available. Although not all right hon. and hon. Members may agree with that figure, I am sure that they accept the broad thrust of the Committee's argument.

The Government want to ensure that a greater proportion of the elderly can stay in their own homes for as long as possible, and we fully appreciate that that requires proper domiciliary support. If the elderly are allowed to remain in their own homes they retain their dignity and independence, and are closer to their friends and families. It is a more effective use of taxpayers' money to care for the elderly in their own homes, which is where they want to receive care, rather than in institutions.

Dame Elaine Kellett-Bowman (Lancaster)

Is my hon. Friend aware that the Lancaster health authority was the first in the country to provide round-the-clock nursing care for those who stay in their own homes? We have two large institutions, and we pioneered the kind of service to which my hon. Friend has referred.

Mr. Freeman

My hon. Friend is right, and I pay tribute to Lancaster. There are many examples of excellent community care facilities, although I regret to say that there are also many areas where they are not excellent. I shall deal with that a little later.

Ms. Harriet Harman (Peckham)

I support what the Minister has said about the importance of people being able to stay independent in their own homes. Does he not recognise, however, that one of the recruiting sergeants for residential care—both public and, increasingly, private—is the present difficulty of obtaining home helps and meals on wheels, compared with 10 years ago? Local authority social service and voluntary sector provision have not kept pace with the growing number of people who need such services.

Mr. Freeman

One of the challenges in any review of community care provision is the need to look carefully at how taxpayers' money is spent. I agree that there is a strong case for using taxpayers' money for the care of the elderly in their own homes—and the hon. Lady listed a range of services—rather than in hospital, if they are cured, or in nursing or residential homes. There must be a case for providing proper support for those who wish to stay in their own homes.

What was Sir Roy asked to do in his report? He was not asked, as the hon. Member for Livingston (Mr. Cook) said, to consider the level of resources; he was asked to consider how we should decide which elderly and handicapped people should be cared for in the community, what help should be provided and who should make the necessary judgment. What did he suggest? As we all know, he suggested that the social services authorities should have prime responsibility for assessing and arranging, although they should not necessarily have monopoly in the provision of services. As my hon. Friend the Member for Bolton, North-East (Mr. Thurnham) said in an intervention, Sir Roy recommended a range of provision.

The Government will be making a statement about our response to the Griffiths report before the summer recess, but there will also be a debate in Government time at a suitable point thereafter. A substantial amount of time has been devoted to considering the implications of the report, and I remind the House that different Departments are involved: the Department of the Environment, the Department of Social Security, the Treasury and, of course, the Department of Health. It is very complicated to work through all the implications, and it would be much better to get the analysis right than to rush it.

The hon. Member for Livingston said that this was the third debate on community care in seven months. It will probably be the last occasion for the Government to listen to comments and advice from the House before we announce our conclusions.

Mr. John Battle (Leeds, West)

The Minister has given the impression that existing facilities and services were being supported. Is not the Treasury at this very moment discussing with the Department of the Environment reductions in local authority provision, which means that next year authorities will not be able to spend as much on home and meals at home for the elderly? While we are discussing the matter, the service is being reduced. Is that not the reality?

Mr. Freeman

No, it is not the reality. If the hon. Gentleman will be patient, I shall deal shortly with social services provision and the resources devoted to local authorities.

I am puzzled by the Opposition motion. It expresses concern that the sole focus on the acute sector of the White Paper Working for Patients will further divert resources from chronic care". The hon. Member for Livingston has obviously given some careful thought to the wording of the motion. Provision for care in the community was deliberately omitted from the White Paper. We wanted sufficient time in which to prepare a proper response. That will come shortly. There are two reasons why the hon. Member for Livingston needs further time in which to reflect on the phrasing of an appropriate motion. He knows that the White Paper "Working for Patients" does not have as its sole focus acute care. Many of the proposals concern primary care.

The responsibility for providing a comprehensive range of health services for all people, including those in the community—the elderly, the mentally handicapped and the mentally ill—will rest firmly under our proposals with the district health authority. It will be the purchaser of care. Who that care is provided for will depend on a variety of circumstances. The district health authority will be responsible for the balance and range of services that are required and for the care of everyone, including those in the community. By definition, a community health service must be provided locally. The district health authority will have the primary responsibility for ensuring that it is provided.

Ms. Hilary Armstrong (Durham, North-West)

The Government say that they have not yet responded to Griffiths because they are considering the whole range of responses and want to consider them all carefully. Why, therefore, have the Government not held a debate so that hon. Members could give their responses to Griffiths, which could also be considered by the Government?

Mr. Freeman

We are having a debate on Griffiths today.

Ms. Armstrong

But in our time.

Mr. Freeman

I have already said that when the Government respond to the Griffiths report there will, at a suitable time, be a debate in Government time.

Mr. Tim Devlin (Stockton, South)

Will my hon. Friend remind hon. Members how many debates we have had on the subject in the last two years?

Mr. Freeman

I have already said that this is the third debate within six months.

The hon. Member for Livingston implied that the Treasury was cutting the resources that are made available to local authorities. He should know that personal social services are provided through the local authority. Expenditure in real terms on personal social services increased by 25 per cent. between 1980 and 1989. The provision for personal social services in 1989–90 has increased by 10 per cent. in cash terms. National Health Service provision for community heath services, such as district nurses, health visitors, chiropody, occupational therapy and community psychiatric nurses increased by 27 per cent. in real terms between 1979–80 and 1986–87. There has been real growth in the amount of resources devoted to community health services. Income support for the elderly in residential and nursing homes has increased substantially, to approximately £1 billion of taxpayers' money.

Mr. Tony Worthington (Clydebank and Milngavie)

Unlike many of my colleagues, I think that the Government have responded to the Griffiths report. They have done so by setting up a structure in "Working for Patients" that makes community care very difficult indeed. The assumption is that most health care is of the "wheel them in horizontal and wheel them out vertical" kind, rather than of a continuing nature, which is what is required by many patients. Is the Minister able to say how many times mental health is mentioned in "Working for Patients"?

Mr. Freeman

I hope that I have made it plan that "Working for Patients" was directed at reforms in primary care and the hospital service and that we shall he responding shortly as to community care for the mentally ill, handicapped and elderly. The district health authorities will be responsible for ensuring that there is a complete range of provision for all those patients.

Turning to mental illness, the hon. Member for Livingston was perfectly fair on the House, and I agree with him, about the rundown in the number of beds in mental hospitals. Between 1977 and 1987, patient numbers have reduced from some 84,000 to some 60,000—a reduction of about 24,000. Over the same 10 years, local authorities and the Health Service have provided about 11,000 places. Day hospital places have increased by 5,000 to 18,000, residential places have increased by 4,000 to 9,000 and places at day centres have increased by 2.000 to 6,000. Between 1981 and 1986, the number of community psychiatric nurses doubled.

Hon. Members who contribute to the debate will share the hon. Gentleman's concern and mine that in the past there has not been adequate provision for those discharged from large psychiatric hospitals. There is no question about that. However, I must make two points. First, any discharge from a mental institution, in the past, or today, is a clinical decision and is not taken by administrators or politicians. Secondly, some of those patients go home where they are properly cared for. Nevertheless, the hon. Gentleman made a fair point. I agree with him that the provision of facilities in the community is not uniformly adequate and in the past some authorities have discharged patients from mental hospitals without ensuring that there was proper and adequate care. That is one issue that we shall address in our response to Griffiths.

I shall make one final point about hospital closures. At a recent Question Time, my hon. Friend the Member for Macclesfield (Mr. Winterton) asked me a question, and perhaps my answer was not as clear as it should have been. Let me make it quite plain that we have pursued the policy, and shall continue to pursue it with great vigour, of ensuring that a hospital closes only as a consequence of adequate facilities being available in the community and not for financial reasons. I give the House that very clear assurance.

Mr. Chris Mullin (Sunderland, South)

In my constituency there is a large psychiatric hospital from which large numbers of people have been discharged. As any hon. Member in that position will know, one receives a constant stream of complaints from neighbours, relatives, staff who work in the hospital or patients themselves that people are being discharged into the community for financial reasons. The most extreme case that has come to my notice involved three people who were discharged into the community, and two of them committed suicide.

Mr. Freeman

I want to make it quite plain that discharge from psychiatric hospitals is a matter of clinical judgment. It is not for administrators, politicians or ministerial judgment. Hospitals will not close for financial reasons. In future, hospitals will close only when we are satisfied that there are adequate facilities in the community. That has been Government policy. I am not announcing or stating new policy, I am simply emphasising existing policy.

Mr. Nicholas Winterton (Macclesfield)

Is my hon. Friend aware that considerable pressure is being brought by managers on consultants to discharge patients because they want to empty the hospital to realise its capital value for development? I hope that my right hon. and learned Friend the Secretary of State for Health and my hon. Friend the Minister—I know that my hon. Friend is deeply committed to the problems of the mentally handicapped, mentally ill and elderly—are aware that great pressure is being brought on consultants which inevitably could affect their clinical decisions.

Mr. Freeman

I do not deny that that pressure exists. Intelligent ways to ensure the release now of the capital value of sites that are under-utilised are already being pursued in the Health Service. Before a hospital is closed, residential facilities must already be in place. I draw my hon. Friend's attention to the practice in the Oxford and East Anglian regions, which have excellent bridging finance schemes, and the practice in Yorkshire—

Ms. Harman

Not enough is done.

Mr. Freeman

The bridging schemes work well in the Oxford and East Anglian regions; perhaps other regions should learn lessons from them. In Yorkshire, where only part of the mental hospital site which I have in mind is used, there has been an imaginative sale and lease-back of facilities, so that all the present patients are properly cared for in existing facilities but substantial capital is released now to construct new facilities. Other measures which the Government have under consideration must await the response to the Griffiths report.

Mr. Tom Clarke (Monklands, West)

We know of the importance of the timetable as we discussed these matters. I should like to ask the Minister, as we do not have the benefit of hearing from the Secretary of State for Health, about the press reports last week that the famous committee E, which is apparently considering this matter, received evidence. As the Secretary of State is here, perhaps he will take the opportunity to try to catch your eye, Mr. Speaker. I am sure that no one would object. Is it true that the Adam Smith Institute has submitted a paper to that committee and that it will submit a revised paper in two weeks' time?

Mr. Freeman

The newspaper reports are inaccurate.

Ms. Harman

In what respect?

Mr. Freeman

The hon. Member for Monklands, West (Mr. Clarke) asked me whether there was a moratorium on the closure of hospitals. I have told him that those newspaper reports are inaccurate. I have described the Government's policy on mental hospitals. When the hon. Gentleman has a chance to contribute in greater detail, I shall be happy to respond.

Mrs. Alice Mahon (Halifax)

My hon. Friend the Member for Livingston (Mr. Cook) referred to mentally ill people who are languishing in prison and on remand. Does the hon. Gentleman have plans to monitor how many people who previously had serious psychiatric disorders are in prison? What does he intend to do to ensure that this tragic business stops once and for all?

Mr. Freeman

The Home Office has commissioned a study of all patients in remand centres and long-stay prisons to ascertain how many are suffering from a form of mental illness. As I am sure the hon. Lady knows, the estimates of prisoners who have some form of mental illness range from 3 per cent. to 30 per cent. Undoubtedly, a number of prisoners in the prison service should not be in prisons but should be either in special hospitals or in mental institutions with some form of security. We are working closely with the Home Office to ascertain the numbers and to work out how initially those people can avoid the criminal system and how those who go through it can be moved, with proper security, to mental institutions.

We have already laid it down that by 1991 all district health authorities should have comprehensive care programmes for the mentally ill. We shall issue guidelines shortly to those health authorities to show how they should put those care programmes in place and what form they should take. The Royal College of Psychiatrists is drawing up guidelines on standards to assess patients before discharge and to ensure that there is proper follow-up thereafter. I assure the House that, when my right hon. and learned Friend the Secretary of State for Health and his Cabinet colleagues are reaching a conclusion on the Griffiths report, they will cover the important aspect of mental illness.

Mr. Nigel Griffiths

Does the hon. Gentleman realise that comprehensive care programmes and plans are not worth the paper they are written on if they are not backed up by comprehensive funding? Does he realise that the constituents who write to me are caught between the Scylla of seeing their relatives in mental hospitals with declining levels of care and others under increasing pressure as funding becomes tighter and the Charybdis of having their relatives in the community, with cuts in the number of home helps, meals-on-wheels services and in the general level of funding and provision in the community? We want to see some action on finance, not merely vague programmes.

Mr. Freeman

I shall deal with the elderly shortly. I commend the arrangements that Oxford region has put in place to transfer capital and revenue funding from large hospitals that are slowly being run down into proper provision, facilities and staffing in the community for mentally handicapped people. We should like such a model to be applied throughout the Health Service.

Between 1976 and 1986 there was a fall of 15,000 in the number of mentally handicapped patients being cared for in larger institutions. All those patients have returned to the community. Some have returned to their homes, but about 8,000 are using day and residential care facilities. Our closure policy for mental-handicap institutions is the same as that for mental-illness institutions.

Residental or village communities may be part of the new range of facilities that will be built in the future. As long as those village or residential communities for mentally handicapped people are not isolated or inward looking, they will have an important role to play. Hon. Members have a duty to explain to our local communities the importance of caring for mentally handicapped people in the community. Too often, we learn of community groups' opposition and of planning permission for the purchase and construction of small homes in the community for mentally handicapped people being contested.

Mr. Worthington

The Minister said that 15,000 fewer people are being catered for in hospitals for the mentally handicapped. The way in which he gave the figure was unintentionally deceptive. Those figures have fallen because, first, local authorities have prevented people from entering hospital, despite their lack of resources, and, secondly, because people are dying in those hospitals. Only a minority are being discharged into the community.

Mr. Freeman

By and large, local authorities have done an extremely good job caring for mentally handicapped people in the community.

Mr. Tony Favell (Stockport)

My hon. Friend said that the community has a responsibility to look after people who are less fortunate, especially mentally handicapped people. My hon. Friend will be interested to learn that recently a survey was held in Stockport of patients who had been discharged from Offerton House hospital. Every one of them said that they would prefer to be in the community rather than to return from whence they came. The local authority and the local community take their responsibility seriously. I am president of Stockport Mencap, and I accept that it has a responsibility to people who are less fortunate.

Mr. Freeman

I pay tribute to Stockport, which is renowned for its care of mentally ill and mentally handicapped people.

Between 1980 and 1986, the Government spent about£11 million on 40 schemes to move 340 children out of long-stay institutional care into the community. That represents a cost of £30,000 per place. I do not begrudge —neither, I am sure, does the hon. Member for Livingston—a penny of that money. They are immensely expensive but immensely valuable schemes. The Government do not want any mentally handicapped children to be looked after in the larger, isolated long-stay institutions. The number of children currently in such institutions is less than 400 and we want that figure to be reduced to nil.

We are well aware of the demographic pressures and their effect on care of the elderly. The over-65 population has gone up by some 6.7 per cent. between 1980–87. The number of the very elderly will substantially increase. With regard to the National Health Service, it is important that we do not keep the elderly who are medically cured in hospital beds for longer than necessary. They consume a lot of medical and nursing care and, once medically cured, many of them prefer to be back in their homes or in the community under some form of rehabilitation care.

The elderly have benefited enormously from the NHS. Some 40,000 hip replacements are now performed each year compared with some 5,000 undertaken 20 years ago. Such operations bring great relief to a number of elderly people.

The hon. Member for Edinburgh, South asked me about assistance in the home. There has been a significant expansion in such assistance between 1980–87 and in real terms home help expenditure has gone up by 28 per cent., meals-on-wheels expenditure by—

Ms. Harman

What about resourcing?

Mr. Freeman

If the hon. Lady will permit, I will come to resourcing in a moment.

Expenditure on meals-on-wheels has gone up by 11 per cent., on nursing care by 14 per cent. and day centre expenditure is up by 16 per cent. In our review of Griffiths, we are tackling the issue of how to spend taxpayers' money wisely and efficiently. As I have already said, we spend £1 billion through income support on care for the elderly in residential and nursing homes. Clearly, it is right for the majority of those elderly people to be in such homes, but we are considering how care can also be given in the home to ensure that elderly people remain in their homes for as long as possible.

Mr. Ieuan Wyn Jones (Ynys Môn)

Perhaps I could tempt the Minister into giving us some idea of the Government's thinking on this issue. Is he suggesting that the Government have shifted the emphasis away from ploughing money into providing care in residential and nursing homes back towards care in the community? Will the Government's response to Griffiths be the provision of resources for people in their own homes—the Minister has already said that 25 per cent. of such cases could be cared for in their own homes if they were provided with resources. Is the Minister saying that the inevitable additional resources will be given to a public body, either the local authority or the district health authority, or will they be given to the local authorities to buy in care from private or voluntary concerns?

Mr. Freeman

The hon. Gentleman is trying to tempt me into foreshadowing our response to Griffiths. I have noted what he has said and, if he can be patient, I am sure that he will be able to contribute to the debate on Griffiths that will come in Government time.

It is important to consider the role of the family and the private and voluntary sectors in giving support to those living in the community. We have no philosophical objections, unlike, I suspect, the hon. Member for Livingston (Mr. Cook) to the private sector providing care for the mentally ill and the mentally handicapped. Over the past few years, some local authorities have pioneered the private sector care of such people under the quality control of the NHS and themselves. So long as there is a proper contract and proper quality control, we want to see such care expanded.

Care in residential and nursing homes is provided largely by the private sector, although local authorities and the NHS play an important role. Lady Wagner made some important recommendations about residential care in her report. We have started a three-year programme to improve quality. We are looking at projects that encourage better contacts with the local community, better information about what is offered, training for care staff and a complaints procedure. We are taking Lady Wagner's other recommendations as part and parcel of our overall review of care in the community. I shall make a statement about some of her other recommendations shortly.

In 1988, we increased the fees for registration and inspection to help local authorities to inspect. We have laid down a minimum inspection rate of two a year. As I have said, we need to consider the other matters that fall to central Government, although many of the recommendations in the Wagner report were for local authorities and there is no reason for them to delay in implementing the recommendations that were addressed to them.

This Government believe that the voluntary sector has a vital role to play. The Department of Health contributes£36 million a year to voluntary organisations, much of it to those involved in care. Districts and regions provide £25 million a year locally. I pay tribute to the work of the voluntary sector whch is so vital, especially for the carers. As the House will know, we launched the "Helping the Community to Care" initiative with about £10 million of funding and a separate initiative, "Care in the Community", which has evaluated about 28 pilot projects, including one in Bolton for the care of those coming out of institutions for the mentally handicapped, as my hon. Friend the Member for Bolton, North-East (Mr. Thurnham) will know. We have funded the voluntary sector, which has a vital role to play.

I want to deal with the role of family and friends. It is important that we do not seek, as Members of Parliament or members of society, to shuffle off wholly to the state responsibility for caring for those in the community. Families, siblings and friends have an important role to play. They must be involved and we all have a responsibility. It is true that we are a more fragmented society. Children live much further from their parents than they did 20, 30 or 40 years ago. It is most important that family and friends retain and build on their responsibility to care for relatives when they come out of institutions.

Mr. Dennis Turner (Wolverhampton, South-East)

The Minister talked about fragmentation. The Government have it in their hands to resolve that and that is the essence of this debate. The Minister talked about the voluntary sector and the service it provides. Yet there is a crisis of resources in the voluntary sector at present. The Government are not facing up to that. How can the Minister tell us that he is responding positively to the needs of the voluntary sector when the Government are reducing the amount of income for the voluntary sector to meet the needs of the mentally handicapped, the mentally ill, the homeless and those in despair? We know that the Government are not doing that and that is why we are having this debate today.

Mr. Freeman

The hon. Gentleman is misinformed about the voluntary sector. The total income of voluntary organisations has risen substantially and the level of support provided by this Government has also increased.

Care in the community is a vitally important subject. It touches the lives of most of us through our relatives and friends. It is the mark of a civilised society that we provide high quality care in community. The Government take that seriously and we shall bring proposals forward shortly. I commend the amendment to the motion.

4.42 pm

Mr. Andrew Smith (Oxford, East)

I welcome the opportunity to take part in this debate, which addresses the most important social challenge facing us for the next 50 years. I do not envy the task of the Under-Secretary of State who has been put up this afternoon to defend the indefensible. Although one can agree with what he said generally about the need for humane treatment for mentally ill people and for support for elderly people who want to remain in their homes, it was all rhetoric. His lofty sentiments were not backed up by one jot of a concrete proposal for action to address the needs of people who are suffering now and who have been suffering during the long period during which the Government have scandalously not responded to the Griffiths report.

I remind the House that the report is subtitled "Agenda for Action". For the Government, it has been nothing more than an agenda for prevarication. We are at last promised a statement and a debate on the matter before the recess. I ask the Minister whether that statement will set out in full and practical terms how care in the community is to be delivered in line with the Griffiths report, or whether it will be a holding statement which merely promises a White Paper later in the year after more months of delay and prevarication. I shall gladly give way to the Minister if he wants to answer the question. Shall we have a definitive statement before the recess, or will the White Paper come later? Evidently the Minister does not want to take this opportunity to answer that question. I strongly advise him to do so by the end of the debate, because millions of people cannot afford to wait any longer for the answer.

When the Government make their statement, I hope that they will take full account of the extensive consideration of the matter by voluntary associations, professional bodies, the trade unions, local authorities and the Select Committee on Social Services. Policy on this matter is far too important and too long-lasting in its implications and inevitably involves too many parties in delivery to be tackled successfully on a blinkered or partisan basis. The framework for community care must command sufficient general support to be administered and developed by Governments and local authorities of different political persuasions. The vulnerable people whose needs the policy must address deserve better than the political shuttlecock treatment. The overriding objective must be to place their needs and preferences at the centre of the system; to that end, the key problems that must be addressed are clear.

First, the range of community care options and services is such that there is an enormous premium on effective co-ordination, which does not exist at present and which can clearly be delivered only by local authorities working under a comprehensive and coherent policy, organised centrally through Government, with people of sufficient standing in the Cabinet sufficiently committed to making of a success of it for us to know that resources will be available to enable the local authorities and other carers to do the job.

Secondly, this is an area of policy where services must be demand led. We must not have a system in which people's needs are perpetually bashed against cash ceilings which bear no relation to the real level of need and the cost of delivering services. Thirdly, we are considering people who, inevitably, are dependent to some degree or other. It is all the more important that they have a degree of choice open to them and a meaningful voice in the way in which services are delivered. Fourthly, that applies very much to the carers in families, as it does to those for whom they care.

In the limited time available, I want to concentrate on the implications for local authorities and resourcing and the implications of that for choice. The present financing of community care is chaotic to the point of imminent breakdown. Oxfordshire illustrates that well. I was interested that the Under-Secretary of state should praise the Oxford region bridging scheme. If the situation in Oxfordshire is good, I dread to think what it is like in the rest of the country. If things are so marvellous in Oxfordshire and if there is bridging finance, why was Oxfordshire faced with the imminent closure of a hospital for the mentally handicapped, which had been known about for a year in advance?

Why was I in the district health authority manager's office, one week before the closure was due to take place, with tearful and angry parents, who still did not know where their mentally handicapped son was going to go? If it had not been for my intervention, what would have happened to that young man? That story of personal tragedy is repeated thousands of times throughout the country as a result of the inadequacy of the way in which the system works at present.

The position on costs and the finance available for meeting them is no better in relation to residential care. A survey undertaken by Oxfordshire Welfare Rights of local residential care homes and nursing homes showed, on a 69 per cent. response rate, that more than 200 elderly residents in Oxfordshire had to contend with a gap between the cost of home care charges and what they received in income support, with an average shortfall being made up either by the elderly person, who was often exhausting his or her savings, or by relatives. I am sure that I am not the only hon. Member to have received heart-breaking letters from people who can no longer meet the difference and make up the shortfall in the cost of their relatives' care. Some of those letters come from people who are themselves elderly and who are trying to find the money out of their pension or inadequate income.

In the other half of cases in the survey, people could not make up the shortfall at all, and were being subsidised either by the homes or by the other residents. How did homes respond to that state of affairs? The survey quoted the remarks of representatives of two private residential and nursing homes. One said: We are not now accepting any DHSS funded residents unless the top-up is made. Existing residents we are still caring for, but as you can see at great cost. The private sector cannot continue to sustain these losses. The second home said: Moved two back to hospital"— that is not to say that the residents needed on medical grounds to go back to hospital; they were merely moved back to hospital— rest are in the nursing home by our generosity but it is jeopardising the business. I am sure that hon. Members—especially those who represent southern constituencies—will be no strangers to this alarming state of affairs.

Ms. Armstrong

It is the same everywhere.

Mr. Smith

My hon. Friend tells me that the problem is equally bad in other parts of the country. We cannot allow it to continue.

The Minister rightly said that those who stay in their own homes need support if they are to remain as independent as possible. Clearly, they need a much better co-ordinated policy on domiciliary support services. At present, the rhetoric has it that independent elderly people are receiving support in their own homes, but in reality many of those people have been dumped and neglected. They are isolated and alone and do not receive the support they need. If they are to receive that support, and if local authorities are to be able to undertake the key co-ordinating role that Griffiths prescribed for them, we shall need nothing short of a revolution in the organisation of local authority finances.

In Oxfordshire, the cost of upgrading old people's homes to the standard that the authority requires the private sector to maintain and of providing effective community care services for elderly people alone would require an additional £7 million revenue over the next five years, while the capital costs would run up to £17 million gross. Those are not extravagant sums in relation to the needs to be met, but we have to remember that, in common with other authorities, Oxfordshire faces severe restrictions on its revenue budgets and the massacre of its capital programme as a result of reductions in capital receipts and the changes in the rules for capital financing under the Local Government Finance Act 1988.

While the Department of Health says that it is actively promoting care in the community and is attempting to push people out of long-stay institutions and hospitals—a fact to which the hon. Member for Macclesfield (Mr. Winterton) referred—we have an unco-ordinated, exploding but inadequate Department of Social Security budget and the cuts and restrictions imposed by the Department of the Environment make it quite impossible for local authorities to pick up the pieces.

That illustrates two great dangers of the Griffiths recommendations, especially in the hands of this Government. First, it would be disastrous if local authorities were given the prime responsibility for community care while at the same time being denied the powers or resources to meet those responsibilities. Secondly, if the Government specify that local authorities should not, in the main, be the deliverers of care but merely the planning and contracting agents for the voluntary and private sectors, those in need of care will be denied an important degree of choice, and those planning the provision will be denied the most direct means of ensuring that needs can be met at the quality standard that the community rightly expects. Everyone knows what a disaster the contracting out of hospital cleaning, for example, has been, and we do not want the same to happen to domiciliary services.

As many of us have said throughout, care in the community is not a cheap option. If it is to work at all satisfactorily, it requires a large injection of resources, as well as the very best and most efficient management of those resources. That cannot be achieved through any private insurance scheme proposed by the Adam Smith Institute, any more than such schemes can act as a substitute for the National Health Service.

We are talking about a common public obligation which must be met by all contributing to the cost in proportion to their means and receiving care in proportion to their needs. I believe that that is what the public wants.

As we bring such a system into operation, let us remember that we have a terrific commitment to caring for other people—in the local authorities, health authorities, social service departments, home help service, council housing departments, housing associations and voluntary associations and among private providers, as well as within families. People go into such jobs because they want to help other people and spread a bit of human happiness. Let us—and let the Government—harness that energy and commitment to caring so that people's eyes can be lifted from the demoralisation of knowing that they cannot give of their best because they do not have the wherewithal to do so. Let us set our sights on a civilised society in which carers have the resources and support necessary to do their job and in which all those in need of community care can help themselves to some of the dignity that should be everybody's right.

Planned provision, adequately funded and properly co-ordinated, with a variety of client choice in delivery, is the key to success in that endeavour. I hope that those aims will command the support of the whole House and that the Government will take notice. If they do not, millions in need of care will pay a terrible price in the years to come.

4.58 pm

Mr. Nicholas Winterton (Macclesfield)

I am pleased to be able to make a brief contribution to this very important debate. First, let me make it clear to my hon. Friend the Minister that I think that it is a great pity that the Government did not make a statement on the Griffiths report before they issued the White Paper "Working for Patients" because the two go so closely together. It is difficult to make a proper assessment and analysis of the many radical proposals in the White Paper without knowing precisely where the Government stand in relation to the Griffiths report.

We are dealing with three main categories of people —the mentally ill, the mentally handicapped and the elderly and infirm who require some form of special care or accommodation. I intend to direct my remarks mainly to the care of the mentally ill. I know that my hon. Friend the Minister is aware of my deep concern for and interest in that matter. It is appropriate to look after most of those who suffer from mental handicap through care in the community—that is desirable, humane and compassionate. There is one caveat, however, and it is that when people with mental handicap also suffer from mental illness, some of them should be looked after in long-stay hospitals because of the complexity of their condition.

In respect of the elderly, the infirm, and those requiring special accommodation or care in the community, and not in an institution or a hospital, it would be wrong to put all our eggs into the one basket of private provision. I served on a county council which had responsibility for social services and the provision of part III accommodation. Since I entered Parliament 18 years ago, I have taken a great interest in that subject and have regularly visited all the part III homes in my constituency and virtually all the private and independent homes—some of which I opened with great pleasure. It would be wrong and very damaging to put all our eggs into one basket and hand over the care of the elderly to the private sector. Indeed, from the representations from people operating wonderful caring homes in the independent sector, I do not think that even the private sector wants that.

My main concern is for the mentally ill. I generally support the policy of care in the community. However, unlike a number of people in my hon. Friend's Department, and unlike organisations such as MIND, my long interest and service in this area make me believe that there is a permanent need for long-stay hospital places for many mentally ill people, especially those suffering from schizophrenia. It is a tragedy that for purely commercial reasons some magnificent hospitals are being closed and their sites redeveloped. Part of the treatment of the mentally ill is the environment in which they live—the refuge and the asylum aspects of hospital care. Again, speaking from some knowledge, I know that although some of the hospitals for the mentally ill may be the Victorian institutions that some have described, built when buildings were intended to last virtually for ever, many can be altered, upgraded, rehabilitated and turned into the most attractive accommodation for the modern care of the mentally ill. Those hospitals are often sited in wonderful parkland, woodland and gardens.

I was a member of the Select Committee on Social Services which carried out an in-depth and very lengthy inquiry into care in the community for the mentally ill and mentally handicapped. Many of those who treat them believe that their environment—that refuge, asylum, quiet and tranquility—is part of the treatment and care that they require. I view with deep concern the rapid closure of those hospitals, with the patients being discharged into the community and often inadequately catered for in accommodation or in the number of skilled and qualified personnel available to look after them.

As the hon. Member for Livingston (Mr. Cook) said, it is tragic that hundreds of mentally ill people frequently end up in prisons. Some hon. Members may ask how I know that. It is because as a member of the Select Committee, having completed and reported on our inquiry into care in the community for the mentally ill and mentally handicapped, we carried out an inquiry into the prison medical service. We visited at least 20 prisons in Scotland, England and Northern Ireland, where we came across many dozens of prisoners who should never have been there; more appropriately, they should have been receiving treatment and care in a mental hospital. When discharged into the community they had committed minor offences, although some were, perhaps, a little more serious. They had not done so intentionally, but because of their mental condition. When they appeared before the courts either the hospitals were not prepared to take them back or there was no hospital place available, so they were put into prisons. That is a tragedy not only because they are not receiving the care and treatment that they need either to contain their condition or, as one would hope, to make them better, but because their condition is being exacerbated and they are receiving no meaningful treatment.

I am pleased that my hon. Friend the Minister said that his Department was carrying out some form of survey. He was kind enough to allow me to bring a delegation from the National Schizophrenia Fellowship to see him a few weeks ago. I wonder whether he has now had time to consider whether his Department can financially assist Professor Kathleen Jones of York university, who is an expert in that area and is embarking on an inquiry into the whereabouts of a specific number of people who have been discharged from mental illness hospitals.

One of the tragedies of what has happened since we put the policy of care in the community into practice is that those who have been discharged have not been followed up and monitored. I hate to quote yet again the hon. Member for Livingston, but I accept what he said about many of those sad people now sleeping in cardboard boxes, on streets not many yards from this Palace of Westminster or under the arches at Waterloo.

Mr. James Couchman (Gillingham)

My hon. Friend and I shared the Select Committee investigation into care in the community. Does he agree that although we saw some appalling examples of deinstitutionalisation from here to the west coast of America, we also saw some extremely good examples of people who had been discharged into the community being supported in very good circumstances?

I agree with my hon. Friend that there are a number of patients for whom the asylum offers by far the best remedy. Does he agree that we should be seeking a continuum of care from informal accommodation within the community right through to something similar to the existing mental hospitals?

Mr. Winterton

I am happy to agree strongly with my hon. Friend's remarks. When my hon. Friend the Minister responded to the hon. Member for Livingston, he said that he felt that at least two health authorities provided excellent facilities within the community and that those examples should be followed elsewhere. I agree with my hon. Friend the Member for Gillingham (Mr. Couchman) that in America we saw the extremes of absolutely superb facilities in some areas and absolutely grotesque, horrible facilities, of the sort we just would not want to think about, in other areas. We need to strike a balance and achieve a continuum of care.

I hope that my hon. Friend the Under-Secretary will confirm when he winds up that, in the immediate future, the Government will recommend to health authorities not to close or dispose of any additional psychiatric, mental illness hospitals. It is vital that we review the position to see exactly where we stand before we dispose of any more valuable sites.

I know that my hon. Friend would not expect me to sit down without mentioning Parkside hospital in my own constituency. Sad to say, some of the Mersey and Macclesfield regional and district health authorities' senior management appears more interested in realising capital assets than in caring and treating people with mental illness and mental handicap. Parkside hospital, Macclesfield which is renowned for its care of the mentally ill, is not isolated in the middle of some bleak moor. It is in the community, in the heart of Macclesfield and situated in magnificent parkland and gardens which, as I have said, constitute part of the therapy of caring and treating the mentally ill.

The Mersey regional health authority and the Macclesfield district health authority are seeking to dispose of more than 80 per cent. of the site for housing and other development. That would be a rich capital harvest for the health authority, but what of the environment for those still requiring treatment and care for their mental illness? Will any of the gardens, parkland, ayslum or refuge, which are such a valuable part of the treatment and care of the mentally ill, remain? No. All that will go under bricks, concrete, pipes and road. That should not happen.

On behalf of the community I am fighting what is almost a last ditch battle to try to persuade the health authority to rethink. As my hon. Friend the Under-Secretary knows, I invited him to visit Parkside hospital and the nearby young persons' unit and am pleased to say that, in principle, he has accepted. I urge him to come before too long if he does not want to see a hospital that has been closed and facilities that are no longer available.

It is vital that the Government realise what is being done in their name up and down the country. I know from the work which I do on the Select Committee on Social Services that Parkside hospital is not an isolated case, and the Under-Secretary should come to Macclesfield as soon as possible. The future welfare of those suffering from mental illness and mental handicap, as well as the elderly requiring specialist accommodation, is at stake and these groups should be able to look to a Government of any political view for the care, humanity and compassion which I believe all hon. Members would wish to give them.

As many of my hon. Friends are aware, I feel deeply about this matter. The lengthy inquiry that we had into care in the community just a few years ago opened my eyes. I went into it with an open mind and I came out realising that we have to do a lot for the elderly and particularly for the mentally ill and handicapped and that we would not serve their future welfare and well-being if, for the wrong reasons, we disposed of valuable hospital sites. Why not bring the community into those hospitals, where necessary? Why not build care and cluster group dwellings for the mentally ill on those sites?

One aspect which I am afraid my hon. Friend and, dare I say it, Sir Roy Griffiths do not fully appreciate is that the facilities that exist for the mentally ill and handicapped within their respective hospitals are such that it would be difficult to replicate them within the community. Such facilities include sheltered workshops, hydrotherapy pools and all the specialist facilities that are so important to the well-being and meaningful life of these people.

Is it not stupid and crazy that dozens of people from Parkside hospital in Macclesfield have been discharged into the community and are now being collected every day in buses and minivans to be brought back to the hospital? Facilities should have been built within the wonderful grounds and areas surrounding the hospital which are so treasured by the people of Macclesfield. The hospital is a valuable community facility which, by the way, in essence cost the Health Service next to nothing because it was vested in the Health Service when it was formed so superbly in 1948.

I believe that I heard my right hon. and learned Friend the Secretary of State for Health say in an earlier intervention that the Government's pronouncement on the Griffiths report would come within two weeks. Perhaps my hon. Friend the Under-Secretary will tell me whether I am right when he winds up the debate. The Government's statement on that report is urgently awaited and it is so important that the Government should get it right.

5.16 pm

Mr. Ronnie Fearn (Southport)

On numerous occasions in this House during the past two years I have experienced a phenomenon known as deja vu when we have debated serious issues, such as that we debate today. There may be many reasons for that. One is that the Government never listen to the pleas of the public or the Opposition, no matter how forceful their case may be.

When I first entered the House in May 1987, I did not expect to participate in so many debates on care, of which I believe this is the seventh. I am not sure whether the hon. Member for Livingston (Mr. Cook) feels the same, but the House has heard a great deal from him on the subject in recent months. I note that he did not speak in the care in the community debate which I introduced on 19 April and which covered many of the points raised so far today. That aside, I cannot deny that I welcome this opportunity to discuss the subject and to highlight the plight, suffering and degradation of many of our citizens.

When I opened the previous debate on this matter, I pointed out the critical position in which many thousands of mental health patients found themselves as a consequence of pressures on health authorities and hospitals. Those pressures resulted in many mental health facilities closing and patients being discharged from units without being found alternative arrangements and with no provision for their care being made in the community.

In that debate, I also highlighted the difficulties faced by numerous elderly people who were unable to care for themselves and were not receiving the services they needed because health authorities and social services departments did not have the resources—this was true of those in my own constituency. The authorities were not receiving the resources or the financial or manpower help to cope with their needs.

I also referred to the effect that demographic changes and the great increase in the number of elderly people would have on services in the future, and of the increasing number of elderly people who would be totally dependent and in need of 24-hour care. I also mentioned the direct and disturbing effect which the proposals in the National Health Service White Paper—I refrain from using its title because I believe that it works against patients, particularly those in need of chronic care, rather than for them—would have on community services.

I am sorry to say that everything I said then still applies today and, because of the nature of the subject, the numbers in need of care and support services will have multiplied, and the distress and anxiety felt by those individuals and their carers will already have taken its toll. It is an absolute disgrace that so many vulnerable people should be left without the support services that they so desperately need—some of them, such as the mental health patients who are discharged into the community, without even a roof over their heads.

Even worse, it is obvious that the Government are aware of the difficulties and the disorganisation which confront all who are involved. It is also obvious that the reason for the Government's lack of action is purely ideological. Words fail me when I contemplate the possibility that the major stumbling block is not Conservative ideology but the stubbornness and idiosyncrasy of one person—the Prime Minister.

I was pleased to hear the Leader of the House say last Thursday that he hoped that the Government would bring forward proposals about the Griffiths report before the summer recess. The Minister confirmed that today, although I did not hear the "two weeks" mentioned by the hon. Member for Macclesfield (Mr. Winterton). I was a little worried to hear him say, however, that the question whether to hold a further debate on the matter would best be considered then. I should have hoped that, once the Government had announced their proposals, we should have the opportunity to debate them in full.

We must ensure that all the consequences of the Government's proposals are clearly worked out and that no area of community need is ignored. Reports that the Cabinet Committee will now recommend that local authorities play the major role in managing community services are welcome up to a point. Not so welcome is the report that a hard-fought battle is being waged about the amount of control that the Government are to have, with the likely result that councils will be forced to contract out services to the private sector.

I would have some trouble accepting these proposals in their totality. The Social and Liberal Democrats' green paper, "Prescription for Health", states that we would implement the Griffiths proposal for making local authorities the lead agency for co-ordination of delivery and development of services, but with certain additional safeguards and modifications. Hon. Members will find our green paper comprehensive and interesting. Should they want to read it without purchasing a copy, I should certainly let them have one. I shall not quote it in full, but no doubt hon. Members will read its contents soon.

One of the safeguards that we want would be an increase in the statutory obligations of local authorities to ensure that certain client groups who are not covered by present legislation—the elderly, for instance—are not given lower priority. We should like the introduction of a general-management style organisation, with clear functional responsibility, delegated authority and budgets. Above all, we recognise the need to tackle present inadequacies of funding and to provide the additional resources that Griffiths implies. This is necessary if care in the community is to work well.

Although we see many of the attractions of a puralist approach to the provision of care, under which local authorities are the enablers, we would have difficulty supporting enforced contracting out. The local authority should decide that. If voluntary organisations were given security of funding they would make a valuable contribution to community care, and in some cases the private sector would have a part to play, too. I know the Minister mentioned £36 million being put into the voluntary sector, but to my knowledge no authority has the security of knowing that funding will be forthcoming year after year, or that it will increase.

It cannot be stressed too much that there will never be an adequate alternative to public provision in all types of services. Public provision must remain an option for the individual and must always be available as a last resort. Local authorities must be given the means and the power to provide systems of services based on individual clients and their carers' needs—ideally, systems selected by those in need of the services.

One of the most serious consequences of the Government's drive to reduce public spending regardless of the human cost is the appalling state in which social services departments find themselves. There are serious shortages of all groups of staff across the country, and alarming shortages in some areas. Needless to say, they tend to be in the most deprived areas and in places in which housing is virtually impossible to find or its cost is out of most people's reach. At a time when reported child abuse cases are at their highest ever level—as we heard in the Standing Committee considering the Children Bill—and when the number of mentally ill and elderly people in need of care is on the increase, it is imperative that social services departments be given the means to rectify the problem. Many of them are collapsing under the pressure, and it is now up to central Government to do something about that.

I hope that before any new enterprise resulting from the Griffiths recommendations is embarked upon, the problems being faced by social workers and other social services groups will be well and truly ironed out. Unless they are, the smooth implementation and success of any scheme is doubtful.

Many organisations involved in health and community care services are worried about the lack of reference in the recent proposals to the responsibility of health authorities in relation to community care services; perhaps general practice services should be included in this context. Doubtless the Minister will mention them. Some medical and health services are inextricably linked to community care services—for example, geriatric psychiatry, various out-patient services, discharge procedures and many community health services. I hope that the Government have something in mind which will ensure that the services required by community care clients are available and within easy reach.

I am convinced that the present proposals are nowhere near adequate to cover these needs. In the last debate on this topic, I pointed to the valuable service with which the millions of informal carers provided the country. At that time, I did not say that it is estimated that 100,000 children carry some of the burden of this care. Although it is right that young people should be taught responsibility and care for others, they should not bear the brunt of our failure to provide the resources that are necessary. Youngsters facing difficulties must not be overburdened and must be as free as possible to pursue a course that will lead to self-fulfilment and independence.

The current approach to informal carers in general is in danger of creating an ever increasing circle of dependency. It would be far more sensible and cost-effective in the long term to take more care of our carers by providing them with the financial and support services which they undoubtedly need and by ensuring that we do not hasten the day when the informal carers themselves become dependent on the care of others.

The long-term aim of any policy for care in the community should be to enable people to lead their lives as independently as possible and to ensure that the quality of their lives is as good as it can reasonably be expected to be. Community care and health care are not appropriate services to be subjected to market forces. Too many customers will be left defenceless. Two-tier systems will develop. A person in need of such care should not have to fight to receive it. For the common good, it is part of the Government's duty on behalf of us all, who may well need these services one day, to enable the individual to live life as fully and independently as possible by ensuring the provision of comprehensive and good quality care services for all.

5.29 pm

Mrs. Gillian Shephard (Norfolk, South-West)

The hon. Member for Southport (Mr. Fearn) has confessed to a feeling of deja vu in this debate. It is true that two points always emerge from debates on community care. First, the policy has been around for a long time. Indeed, it has been pursued by Governments of different hues for at least a quarter of a century. Secondly, although, and even to judge by this debate, it is clear that there is no absolute consensus on what is meant by successful community care, some useful principles over that period have—as is to be expected and hoped—emerged to govern what can and cannot work in care in the community.

A most useful contribution to the debate was the Audit Commission's report "Making a Reality of Community Care" which was published in 1986. That identified the following principles: strong and committed local champions of change; a focus on action, not bureaucratic machinery; locally integrated services cutting across agency boundaries; a focus on the local neighbourhood; a multidisciplinary team approach; and a partnership between statutory and voluntary organisations.

I would add another principle to those of the Audit Commission, which is that residential and institutional care should remain part of the spectrum of care in the community to cope with crises, and with respite care when it is needed. That is not just for the mentally ill, but for the elderly who can suffer crises of illness or of chronic difficulties and need to be admitted to hospital for a time but can then be returned safely to the community, and for people with a mental handicap who, from time to time, can cope well in the community but who, perhaps for a short period, need to be returned to institutional care—sometimes to help those who are caring for them. A wide range of principles are established on which community care can operate. I believe that there has been a recognition in the Department of Health, which has been underlined by my hon. Friend the Minister this afternoon, that there is a need to retain some inpatient care within the full range of community care.

While all those of us who are concerned with health and social service issues are eagerly awaiting the Government's response to the Griffiths report, those who know the practical difficulties involved in community care provision sincerely hope that the response, when it comes, will draw heavily on experience in the field. I hope, too—here I am not in agreement with the hon. Member for Oxford, East (Mr. Smith), who has left the Chamber—that ample time will be allowed for discussion and consultation, especially bearing in mind the criticisms that have come from a not dissimilar quarter about the so-called lack of time for discussion and consultation on the National Health Service White Paper. We need time to draw together experience from those working in the field. It is most important that consultation is taken seriously and built most thoroughly into the White Paper.

I make those points specifically because, if there is one comment to make about community care it could be that there is a multiplicity of ways of making it successful. Some of those ways have emerged from the Government's own pilot projects which were begun in 1984–85 and which were generously funded with a large sum of money from joint financing allocations. Twenty-eight projects were selected and every health region and every client group was represented. The university of Kent was commissioned to assess the projects, and I believe that a final report on its assessment is awaited. Perhaps my hon. Friend can refer to that in his final comments.

Other ways of providing community care will certainly emerge from the private sector and will be supported from this side of the House. Experiments with sheltered housing and care provided on a continuum in the private sector, not to mention some valuable work and experiments done by the Federation of Private Residential Home Owners, provide interesting examples of partnerships between the statutory and voluntary sectors, which should be developed and followed up.

In that connection, it is worth mentioning that for many people who will be in their 80s after the turn of the century money may not necessarily be the main problem. The main problem for those people, who may have access to the income from the disposal of their homes, will be personal security and the knowledge that they will be cared for to the end of their lives. Those will be the most important considerations in the minds of such people and the private sector should be, and I believe will be, ready to face that challenge. Indeed, it is the least that we can expect of it, given that £1 billion of taxpayers' money is currently going directly from social security funds to finance people in private residential homes. While the vast majority of those homes are well run, the response to Griffiths must suggest ways in which the use of that £1 billion is effectively monitored and targeted.

Although there is a clear need for a strong Government policy framework in community care, there is an equally strong case for that policy to be interpreted locally and in accordance with local needs. That was, indeed, the thrust of the recommendations emerging from the Audit Commission. That may seem an obvious point, but it needs making because on the ground there is a such a wide diversity of provision and problems across the country. For example, Surrey has the problem of a number of clusters of large psychiatric hospitals and hospitals for the mentally handicapped. The solutions for Surrey will not be the same as, for example, those for west Norfolk, where the health authority is in the fortunate position of building up from scratch the provision of community care for the mentally handicapped and the mentally ill. There are similar clusters of large hospitals and institutions in the north-west of England, which no doubt give particular point to the remarks of my hon. Friend the Member Macclesfield (Mr. Winterton).

Mrs. Ann Winterton (Congleton)

On the question of large community homes, is my hon. Friend aware that in the north-west of England in my constituency, there is one specific home called Cranage Hall hospital, which is an excellent example of what could happen? That hospital could turn into a village-type community, with a revolving door principle, so that people who are already in the community can go back into the hospital home for specific respite care and to use the facilities. It is set in beautiful grounds. It has not only been supported by the local community for some considerable time, but the community has contributed to many of its facilities. The Congleton Lions, for example, have recently contributed a rumpus room. Is my hon. Friend also aware that parents and relatives of mentally handicapped people in residential care are often concerned that homes may be closed and that their children may be moved elsewhere, rather like a pound of carrots, without being fully consulted?

Mrs. Shephard

I was not aware of the particular examples that my hon. Friend drew to the attention of the House, but, knowing her excellent record and her knowledge of her area, I am sure that the House will wish to give the fullest possible credence to her praise of the work of those particular institutions.

It is worth remembering, when one is talking about institutional care, that the people who are least enthusiastic about it, are those who are consigned to it. That must be borne in mind, too, when one is considering a balanced spectrum of care for the mentally ill and the mentally handicapped.

Other variations in what already exists on the gound can be centred on the number of private residential homes and the amount of private residential accommodation which is available, and that varies enormously across the country. In the south-coast resorts and in parts of Norfolk, there is an enormous concentration of such provision. In parts of northern England, Wales and Scotland, clients and patients do not have the same range of choice.

Sir Roy Griffiths's report laid emphasis on the important role of social services departments as providers, organisers and enablers for community care. He saw them as facilitators. However, that is not a very revolutionary concept, because in the best-run authorities that is a role that they already fulfil. They, together with health authorities, organise joint financing for community care, they grant aid to the voluntary sector, either directly or through joint finance, they co-operate with the private sector and, for example, in Norfolk they are actively involved in training provision with the private sector. They must inspect and monitor standards in the private sector.

I am assured that there is now no resistance to the concept of direct and specific funding to local authorities from central Government. I hope that, when the Government's response to the Griffiths report is announced, it will take account of the current role of social services departments and note that their attitudes and activities have changed greatly and become extremely realistic over the past five years.

I want to consider briefly community care for the mentally ill—a matter which I have raised several times in this House. As my hon. Friend the Minister said in an earlier debate: hospital closures should be occurring only as a consequence of the development of better alternative forms of provision. The closure of hospitals per se is in no sense a primary aim of Government policy."—[Official Report, 1 February 1989; Vol. 146, c. 406.] I know that my hon. Friend has been visiting as many health regions as possible to see what is happening at the grass roots. I am sure that as a result of that, he will sympathise with the frustration felt by many people working with the mentally ill that huge sums of money are currently locked up in keeping open large, old-fashioned hospitals when, if that money could only be released before the closures, it could be used to provide a range of suitable alternatives, including in-patient care, as part of the spectrum. My hon. Friend referred to that in his opening remarks. He referred to the East Anglian health region where bridging finance has been used to good account.

Despite that, a mechanical problem remains which concerns not principle or resources, but the budgeting procedures which make the co-ordination of the closure of large hospitals—which, in so many places, are totally unsuitable to the needs of the modern day patient—and their replacement almost impossible to achieve. I raised that matter with my hon. Friend in an earlier debate and he assured me that the Government would be exploring actively ways to work with the private sector to release capital as bridging finance from old, unsatisfactory, crumbling, uncomfortable psychiatric hospitals which were destined for closure. I hope that my hon. Friend will be able to say something in his reply about any progress which may have been made in that respect.

The sheer complexity of the joint financing mechanism is most off-putting and a sure way of discouraging health authorities, local government, voluntary organisations and the private sector from working together. Whatever else comes from the Government's response to the Griffiths report, I hope that there will be a radical simplification of the current mechanism of joint financing. That mechanism is the greatest possible disincentive to the kind of working together between the authorities concerned that we all want to see.

5.42 pm

Mr. David Hinchliffe (Wakefield)

If there is anyone left in this country who still does not understand the reasons for the opposition to the Government's proposals in their White Paper on the National Health Service to running the NHS on market principles, he need only consider the current state of free-market community care. That shows precisely what will happen if we allow our caring services to be run on the lines of market principles.

Today's debate is not simply about the Government's political indifference and incompetence: it is about the appalling human consequences of leaving the care of dependent and vulnerable people to the marketplace. It is about the human tragedy of a care policy which has led to insecurity and fear for thousands of elderly and handicapped people who are victims of a system that is geared nowadays primarily to business interests instead of to properly thought out social care.

The current shambles which is described as community care arises directly as a result of the Government allowing provision to be determined primarily by the free market. For the past 10 years or so, decisions on policy have been determined primarily by business motives and not by the needs of individuals. In effect, the Government have freed the market, but conveniently they have ignored the fact that many potential consumers of care have no real choice, in many instances have no purchasing power and often do not want or need the product of institutional care which is being forced on them.

In his opening remarks, the Minister referred to £1 billion being poured through income support into private residential care. I want to draw the Minister's attention to the report from the Public Accounts Committee, which stated that nearly a quarter of the individuals in private institutional care who receive income support could have remained independent in their own homes in the community had proper community support been available. We are talking about £250 million a year of income support which is used for people in private institutional care who do not want or need to be in institutional care. That is very worrying.

I have been interested in community care since I entered social work in the late 1960s. The Government's record on community care is one of turning the clock back generations, away from genuine community provision and back to institutional care as the main response to elderly and mentally handicapped people who are in need. I reject that policy, because it belongs to the dark ages. It has no place in the latter part of the 20th century.

The Minister talked about getting people out of isolated Victorian institutions. In many areas, the isolated Victorian institutions which have been used by the NHS over many generations, which I admit are totally unsuitable for care, are being closed. However, they are being re-opened privately to provide the same kind of care.

I hope that the Minister will visit my constituency soon and see Snapethorpe hospital for which closure has been proposed. That is the most modern hospital in my constituency. I will show the Minister Sandal Grange, an isolated Victorian institution which was closed 10 years ago because it was deemed unsuitable for the care of elderly people. The people were moved to Snapethorpe hospital. Sandal Grange was sold off and re-opened for precisely the same function in the private sector. Vast numbers of mentally handicapped people are being moved from outdated Victorian public institutions into outdated private institutions. That policy is a non-starter.

The Government have not only concentrated resourcing on the creation of institutional care; they have cut resources to fund preventive networks and support services. I challenge the Minister to tell us in his reply how he has increased the resources. We all know that there has been a huge growth in need in terms of the number of elderly people who are dependent on support, while the funding for that support has not been increased relative to the growth in need. The Government have created an incentive to enter institutional care by attacking local authorities' abilities to provide real community provision.

I noticed a letter in the British Medical Journal on 9 January last year from Dr. Bennett, a geriatrician at the London hospital. He referred to problems he has encountered when families refuse to take back an elderly relative from hospital care because they cannot cope with caring for the elderly relative in the community. Dr. Bennett stated: The patients are alone and frail, and they and their carers are desperate. All have experienced failings in the health and social services—a home help sick and no replacement available, day centre waiting lists of many months, faster and faster discharges from hospitals into community 'support' despite mental and physical frailty … Places in old people's homes are diminishing rapidly and waiting lists grow. Increasing pressure is put on all concerned to consider private care. For my patients this means leaving a community they have known for 80 or more years and moving 80 kilometres away for an affordable place, beyond reasonable visiting reach for most relatives. That is what is happening in hospitals. That problem probably confronts geriatricians throughout the country, with families saying, "We cannot go on caring for our elderly dependant because there is no support."

There is a desperately urgent need to examine also the ease with which the present system allows the individual's independence to be removed. Under Government policy, families who have been struggling to care for their elderly, physically or mentally handicapped relatives are told, "Sorry, their condition is not bad enough to merit the provision of a telephone. Sorry, we can provide a home help only two hours a week. Sorry, we can provide meals on wheels only twice a week. Sorry, we can provide respite care, so that you can have a break, only one week of the year. Sorry, we have no day care facilities but we will put you on the waiting list for day care once a week."

When relatives finally give up the ghost and say, "We have had enough," what is on offer? There is a no-questions-asked offer of £140 a week if the relative concerned is packed off to private institutional care. That is not on. A similar level of financial support should be available to relatives who are struggling to care for their dependants in the community. There should be no incentive for them to wash their hands and say, "Let us put them into an institution, wash our hands of them, and make our lives much easier and happier."

My experience is that Government policy makes it as difficult as possible for the elderly to remain independent in their communities, and as easy as possible to slip them away into private institutional care, which is in no way humane. There are people in institutional care who do not want or need it, and who would be happier receiving support in the community. It is an indictment of Government policy—this has been admitted by hon. Members in all parts of the House—that people are placed in private institutions because of a lack of appropriate Health Service or local authority provision.

For many elderly people, entering private care may be just the start of their problems. Apart from losing their independence and having to move from the place where they have lived all their lives, there are the financial consequences, to which my hon. Friend the Member for Oxford, East (Mr. Smith) referred. In many cases their capital dries up and their home has to be sold. There is evidence from Age Concern, which I know has written to the Minister for Social Security, that homes have been sold when the carer is still living there, so that the person who gave so much care over the years suddenly finds himself homeless. That is a consequence of the person entering private care requiring the capital from the sale of their property to pay for their fees. Subsequently, the resident may have to move to a cheaper home, and could ultimately end up in a local authority part III accommodation.

A number of people who have lived in my constituency all their lives, and who were compelled to enter private care because Health Service provision dried up, were moved 20 or 30 miles away. Six weeks later, under the provisions of current legislation, they were deemed residents of that new area, and were unable to secure local authority funding to return to part III accommodation in the locality in which they lived all their lives. It is scandalous to shunt people miles away from their natural homes when they are at their most vulnerable and need help and support of the kind that should be available in the final years of their lives.

I am sure that my hon. Friend the Member for Oxford, East is familiar with the recent work of the Oxford welfare rights group on income support as it relates to private residential care in Oxford. It found recently that 69 per cent. of those living in private homes cannot meet their fees but depend on top-ups from relatives or outside agencies to meet them. In Oxford, there is an average shortfall of £37 per resident per week. I have no reason to believe that that situation is not to be found elsewhere.

Evidence from registered homes tribunals reveals the way in which many elderly or handicapped people become pawns in the operation of free market care. There is proof —some of it published by my hon. Friend the Member for Peckham (Ms. Harman)—that private homes, many of which operate on a very tight profit margin, cut standards to keep down their costs. Research by the north London polytechnic published in 1985 also revealed that private residential homes cut staffing levels to save money, to the detriment of their residents.

I could speak at length about the problems of provision for the elderly, particularly in the private sector. However, I am not anti-private sector. Rather, I am concerned that the Government allow the fate of vulnerable people to be placed in the hands of individuals who are preoccupied only with profits, and when the elderly or handicapped person's income dries up, they are sent down the road. That is the point at which private care finishes, and that is my grievance against the profit-based system, which is an unsuitable basis for health and social care.

The present system cries out for urgent changes, far beyond those that Griffiths has on offer. The Griffiths report makes a very conservative response when radical changes in community care are needed. We must address all needs, and public investment must be concentrated on preventing, not creating, the institutional dependence that the existing system so often creates. The Government's free market experiment in community care is an abysmal failure, at the cost of billions and billions of pounds. More importantly, it has failed at great personal cost to many elderly and handicapped people, who have endured great misery as a result of the Government's policies.

5.56 pm

Mr. Peter Thurnham (Bolton, North-East)

The hon. Member for Wakefield (Mr. Hinchliffe) claims that he is not anti-private sector, but most of his speech comprised a long diatribe against it. My experience is that it performs in a much better way than the public sector.

I support Griffiths's recommendations, and particularly paragraphs 1.3.3 and 1.3.4, which go to the heart of the debate. They refer to building first on the available contribution of informal carers and neighbourhood support. They add that local authorities should act as the designers, organisers and purchasers of non-health care services, and not primarily as direct providers, making the maximum possible use of voluntary and private sector bodies to widen consumer choice, stimulate innovation and encourage efficiency. The hon. Member for Wakefield cast doubt on the role of the private sector, claiming that only the public sector can meet the needs of the community, whereas I believe that the whole essence of care in the community is building on and reinforcing private and voluntary efforts. Our response to the Griffiths report should reinforce and enhance private and voluntary work. Although, obviously, no payment is made for voluntary work, a recent report valued its contribution at £11 billion by comparison with the £6 billion at which the Audit Commission valued public sector provision. Therefore, two thirds of the effort is currently made by voluntary workers, and that sector should be reinforced.

The Government are right to deliberate carefully over the Griffiths report. Obviously the National Health Service White Paper had to be published first because provision there is of a different order, amounting to a cost of about £24 billion. It was only right and proper that the NHS review should be conducted first, before the Government turned their attention to community care. We all look forward to the Government's response, which I know will pay full care and attention to the way in which informal carers can work with voluntary bodies such as Crossroads, which perform a very effective role and provide greater value for money in the provision of care and services to people needing help at home than the public sector can now, or could ever do in the future.

I was disappointed by the speech of the hon. Member for Livingston (Mr. Cook). The Opposition are engaged in a flirtation with popularity in the opinion polls at present, and I imagined that that might lead to some new thinking and, perhaps, a more statesmanlike approach in today's Opposition debate. I heard no new thinking, however; the Opposition's only solution appears to be more expenditure, although the present Government have provided more money than Labour.

Mr. Favell

Given the number of mentally ill, mentally and physically handicapped and elderly people who we all hope will live in the community, it is surely stupid to expect local authorities to provide everything. To denigrate the efforts of the voluntary bodies is sheer stupidity.

Mr. Thurnham

It is significant that the Labour party's review disagreed with Griffiths on that very point, suggesting that local authorities should be the providers. That is the heart of the difference between us.

The recipients of services—the patients and the carers —want a greater say. I thought that I was beginning to agree with the hon. Member for Livingston when he said that he wanted a policy that would enable users to play their part, but he did not go on to explain how he thought that that could be achieved. My hon. Friend the Member for Norfolk, South-West (Mrs. Shephard) said that the answer lay in a multiplicity of services, but the Opposition seem to think that there is a simple bureaucratic answer to the problem of providing such massive amounts of care for such vast numbers of people, most of whom want to be cared for at home rather than in institutions.

I can speak from personal experience, having fostered and then adopted a handicapped child who had been in care for six years. That is an example of how the best care is—and, I believe, should be—provided in the family home. Every child should have the love of a family. One of the most surprising statistics that I have seen recently appears in the survey by the Office of Population Censuses and Surveys on the prevalence of disability in children, which states that 5,500 children in England, Wales and Scotland are in institutional care. My inquiries had suggested that there might be as many as 3,000, including those in Northern Ireland; the OPCS figure is nearly twice that, and shows how much more should be done to help families to continue to care for their own children and to foster and adopt children.

An OPCS survey on disability in adults states that about 50 per cent. of the 210,000 people in category 10 —the most severely handicapped—are being cared for in private households. If the most disabled people can be cared for at home that is where our efforts should be directed, and I support the calls for more respite care and home helps.

Mr. Andrew Rowe (Mid Kent)

Does my hon. Friend agree that one of the most striking features of community care is the smallness of the amount required by the many people who want to continue to care? The reason why we are all so anxious to hear the Government's response to Griffiths is that Griffiths has made a real attempt to find a way of co-ordinating the finance available so that it is possible for consumers to demand the small amounts that they want, rather than waiting for ages to receive the large amount imposed on them.

Mr. Thurnham

I agree. It is not just a question of the smallness of the amount, however; it is also a question of the type of help required. One of the current difficulties with local authority provision is that people must take what is on offer, and if what they want and need does not coincide with that it is too bad. They may be told that their child is too handicapped for anyone to be able to help.

Bolton council, which I believe has done more than most councils in this respect, has just produced a report called "Goal 2000". One of its conclusions is that there is virtually no service provision specific to the needs of people with challenging behaviour. That shows how far local authorities' current provision falls short of what is needed. I want carers and committed individuals to play a part in the direction of public funds, so that those funds reinforce the massive contribution made by informal carers and voluntary groups. I shall be interested to learn what mechanisms the Government can devise to achieve that. The Department of Employment has set up new training and enterprise councils to take charge of a £3,000 million training budget. The private sector will have two thirds of those councils, and will play a leading role in the direction of public spending. I hope that we can look to such models in this context.

I was amazed at the number of people who came up to me in Bolton during the general election and said that they could not cope any longer with their children—who, in some instances, were well into their twenties—and wanted help. After the election I called a meeting of those people, who then formed a handicap action group. I was astonished at their commitment. A report was produced stating their needs and explaining how far local authority provision fell short of what was required. Under the excellent chairmanship of Mr. John Seddon, they put forward proposals which have been largely accepted by the local authority and the health authority.

Bolton has been the subject of a number or reports; it has been at the forefront of most of the thinking on care in the community. A report by the local district audit committee called for more co-operation between the local authority and the health authority, and we shall look closely at the Government's proposals in that regard.

I agree with the Opposition calls for more expenditure. We do need more money, but it must be spent much more in accordance with the wishes of patients and carers, and it must reinforce the £11 billion of voluntary care that is currently being provided, without being seen as a substitute for private care. Private and voluntary care is an excellent medium, and it should be helped and enhanced in every possible way by Government policy.

6.8 pm

Mrs. Alice Mahon (Halifax)

I intend to concentrate on the care of the elderly. Over the past 10 years we have witnessed the wholesale privatisation of care, at great and unnecessary cost to the taxpayer and with tragic results for many elderly people. My hon. Friend the Member for Wakefield (Mr. Hinchliffe) was right to draw attention to that.

It is no good the Minister or anyone else hiding behind clinical decisions. As hospitals have emptied beds 'or the elderly and mentally ill, consultants have had no choice but to go around the wards with lists of private accommodation. At the same time cuts have been made in social service budgets, and local authorities have not been able to make up the shortfall. Approximately £10 million was provided in 1980 for the care of the elderly in the private sector. It is now well over £10 million each year. It is no use the Government trying to justify their decision by using value for money arguments, because that is a massive waste of resources.

I criticise the private sector, and I admit to having a vested interest in the matter. As a Member of Parliament, as a councillor for five years before that and as a spokeswoman for social services I came into close contact with the elderly in many private homes. Many of those homes are very pretty, with chintzy furnishings and Laura Ashley decor, but that is only to attract people to them. The fact is that they offer little dignified care to the elderly. Most elderly people have no contract with the home, so their position is very insecure. I heard recently of an elderly person in my constituency having to be moved out of a private home, purely for cash reasons. There is no complaints procedure. There is no one to put forward their case if elderly people feel that they are being treated unfairly.

My other major complaint about private homes is that when old people apply for admission there is only a perfunctory evaluation of their financial assets. It has led to wholesale institutionalisation. The Public Accounts Committee reported that a quarter of those in care need not be in care. That is right. The Government were warned about that in the early 1980s when they deliberately moved towards the privatisation of care for the elderly.

I had to smile during the Euro-elections. I canvassed in an area where the number of private homes has gone up significantly. It is a Conservative ward. Nearly all those private homes were exhibiting Tory party stickers. I think that they were saying "Thank you" to the Conservative party for the lucrative cash handouts that they had received for caring for the elderly. However, some do not care properly for the elderly. Many of them employ low-paid, untrained staff, many of whom were YTS trainees. No occupational therapy is provided in most of the homes. Even in homes where occupational therapy is provided, the amount is small. Some homes do not provide a planned programme of orientation, but it is provided in local authority homes where the staff are trained to ensure that elderly people remain very much in touch with what is going on. The staff in local authority homes take training courses. I have yet to come across a private home that sends its staff on training courses.

Mr. Couchman

Is the hon. Lady saying that all is well with local authority old people's homes? As a councillor, I chaired the social services committee for five years and my experience was that local authority homes are among some of the most institutionalised establishments that can be found. They institutionalise old people in the same way as the large, long-stay hospitals institutionalise the mentally ill and the mentally handicapped. Does the hon. Lady not agree?

Mrs. Mahon

No, I do not. That has not been my experience. We have moved away from rigid, institutionalised care in large hospitals. My experience is that local authority homes can be monitored and that, if necessary, the management can be changed. That cannot be done in private homes. There is very little monitoring. Only two officers in my local authority are trying to monitor hundreds of places. That cannot be done properly.

Mr. Favell

Will the hon. Lady give way?

Mrs. Mahon

No. I should like to finish this point.

I have been told recently about a private home in my constituency where residents are put to bed at 6 o'clock. Some of them are drugged. It is a case of out of sight, out of mind. When I went to that home they told me that they dared not complain. There is a lack of control and accountability of private homes and it is impossible to monitor them.

Mr. Favell

I agree with the hon. Lady that the worst thing to do with the elderly or the mentally handicapped or mentally ill is to institutionalise them, but is it not true that we are learning all the time? Local authorities are learning and the private sector is learning. It is important to give the elderly plenty to do. Does she agree that sheltered accommodation should be provided for as long as possible? People are then able to cook for themselves, make their own beds and look after themselves generally. That is very much better for the elderly than providing them with a bedroom and then sticking them in an awful rectangular room where they all gaze into the middle of the room. There is no more certain recipe for misery. Whether it is local authority or private sector care, we must ensure that we provide sheltered accommodation for the elderly.

Mrs. Mahon

I wish that the hon. Gentleman had put that point to his Government about 10 years ago. Then the £10 billion which I believe has been wasted on the private sector could have been used to provide an intensive care package for the elderly, which would have meant that they did not have to go into care.

Institutionalised care destroys independence and murders the mind. Care in the private sector is often provided only for the money that it brings in. There is a great need for much more humane care of the elderly.

When the Minister referred to carers, families and friends playing a major role in the care of the elderly I thought that he had no idea of the size and seriousness of the problem. The Equal Opportunities Commission estimates that there are 1.25 million carers, most of them women, looking after the elderly and the disabled in the community, but the Carers Association believes that there are many more. There has been a huge growth in the number of elderly people. I have a vested interest, because my constituency contains a large number of elderly people and ranks third in the country. Therefore I have a great deal of experience of talking to carers.

There are now more women caring for elderly dependants than there are women caring for children. It is estimated that between the ages of 35 and 65, over 50 per cent. of all women can expect at some time to provide care for the elderly or the infirm. It is often provided at great cost to themselves. People who give up work to care for the elderly are immediately put at a financial disadvantage. They receive a pittance in benefits. Their benefits have been cut during the last few years, particularly last year. Many of the carers are elderly, too. An elderly couple in my constituency is trying to look after a violent, mentally ill son. He is twice as big as they are and he weighs more than they do. They find it very difficult to care for him. A growing problem is mental stress and granny bashing. We have not paid enough attention to that problem but it causes heartbreak on all sides.

Recently I visited a constituent who told me that she never goes out, because no one will sit with an incontinent granny, and that she spends her life washing and cleaning. She went on to say, "I love my mother dearly, but I am waiting for her to die." She was at the end of her tether. Then she said, "I haven't had a holiday for five years." She told me that she had given up a very good job and that she had not had a full night's sleep for a very long time. Finally she told me, "I don't like asking people to the house because it smells like a toilet." That woman had received very little help from the local authority or anyone else. The £10 billion that has been provided for the private sector could have given her a great deal of respite. Good hospitals and other kinds of good care have been closed down, purely on economic grounds, during the last 10 years.

The Government say that they want to provide choice, but that woman has not been given any choice. She has had to sacrifice her own life to look after her elderly mother. The majority of the 1.25 million carers have not been given any choice, either. It is hell on earth for some of the carers who are trying to cope.

The Minister replied to my intervention about mentally ill people in prison by saying that the Home Office was carrying out a survey. That is too little and too late. Warnings have been flooding in to the Government about what is happening in the prison service and about what is happening to people sleeping under bridges and in cardboard boxes. The Government have been responsible for closing hospitals prematurely throughout the country without making sure that there is somewhere where those vulnerable people can go. The Government have taken 10 years to initiate a Home Office inquiry and they should be ashamed of themselves.

I very much welcome the debate, but I shall welcome even more a debate in Government time. I hope that they will come to the House with some humane and decent proposals for caring for the elderly, the mentally ill and the mentally handicapped.

6.20 pm

Mr. Tony Favell (Stockport)

I am an enthusiastic supporter of the mentally disabled, the mentally ill, the physically disabled and the elderly leading as full a life as possible in the community. I am very glad that, throughout the debate, hon. Members on both sides of the House have supported that view. That is what the disabled want. They do not want to be institutionalised; they want to lead as full a life as possible in the community. From time to time that can be a disadvantage to them and possibly embarrassing to those of us who are not disadvantaged.

Dorothy Birch, a lady in my constituency who is disabled and who does an enormous amount for disabled people in Stockport, visited West Germany recently. When she came back she said, "You do not see any disabled people in West Germany." I said, "Is that a good thing or a bad thing?", and she replied, "It is a bad thing. If no disabled people are seen, that means they are kept out of sight and out of mind." It is to the credit of our community that disabled people are not kept out of sight and out of mind.

However, from time to time we have to provide respite care for disabled people who require help. I strongly urge my hon. Friend to look very carefuly into the funding of sheltered accommodation instead of the more traditional caring accommodation. According to housing associations such as the Anchor housing association and the Collingwood housing association, it need be no more expensive to provide sheltered accommodation for elderly and handicapped people than to provide 24-hour care.

It is so much better for disabled people to have a little privacy—perhaps their own bedsit where they can invite friends—to be able to cook their breakfast and make their own bed, although it may take a long time, than to be got up, have their beds made for them and their breakfast provided and then to sit in a rectangle gazing at each other for the rest of the day. Many hon. Members will have had the awful experience of visiting such places and seeing people who in many cases have absolutely nothing to look forward to but death. That is disgraceful. It should be investigated, and the sooner something is done the better.

Many hon. Members have commented on the Griffiths report. I agree with paragraph 1.3.1 which states that local authorities should assess the community care needs of their locality, set local priorities and service objectives, and develop local plans in consultation with health authorities… Ultimately, the local authority will have to ensure that there is provision for disabled people within its boundaries. However, I disagree with paragraph 1.3.2 which states that local authorities should identify and assess individuals' needs, taking full account of personal preferences (and those of informal carers), and design packages of care best suited to enabling the consumer. It is far better to divide the roles. It is fair enough that a local authority should ensure that there is overall provision for disabled people within their town, city or locality, but it is better for someone else to identify individual needs. I suggest that the best person to do that is the general practitioner, who has a full list of all his patients. The new contract, which contains many good things, as Conservative Members recognise, insists that every general practitioner sees each elderly person on his list at least once a year. General practitioners in my constituency do that more often. Many insist upon seeing elderly people at least once every six months. General practitioners are in touch with families and understand their needs over many years. They know whether a disability is transitory or permanent and they are the best people to assess what should be done, and of course the facilities exist already.

Mr. John Marshall (Hendon, South)

Does my hon. Friend accept that schizophrenics are mentally ill people who have not been helped by community care? They are frequently so aggressive that they lose their doctors and they often do not agree to carry out the treatment that has been prescribed for them. Does he agree that, if they are to be cared for within the community, they need far greater supervision than they have had until now?

Mr. Favell

I understand my hon. Friend's point, but most mental illness does arise from schizophrenia. As he will know, one in 10 people require some kind of mental treatment at some time in their lives. It has to be the general practitioner's responsibility as it would be impossible for the local authority to supervise one in 10 people living within its boundaries.

I suggest that my hon. Friend the Minister looks very carefully into the possibility of general practitioners assessing individual needs while the town hall is responsible for ensuring that there is provision for people who require the help that general practitioners consider their patients need.

6.27 pm

Mr. John Marshall (Hendon, South)

I believe that one aspect of mental health policy has been a gigantic failure —the treatment of schizophrenics. I went to a meeting of my National Schizophrenia Fellowship branch, where one lady told me that her daughter had been released into the community. What did release into the community mean? It meant that that night, she was sleeping somewhere in one of the parks in London. Her mother did not know which park it was, only that she was sleeping rough and that she was not using the treatment that had been prescribed for her.

This morning I received a letter about a particular patient: He returned to his flat … on 5 June and since then he has been arrested by the local police a few times, they have called the crisis team who do nothing and next morning Hendon Magistrates court discharge him. The residents … live in fear of his verbal abuse, loud music played day and night through his open windows and at times violent behaviour—then the police are called and arrest him and so the pattern repeats itself—I could write for hours. He has no doctor in Barnet … Doctor … struck him off for bad behaviour and no one else will accept him. What can you do to help us? Such individuals are not calling for care within the community. I suspect that we have to accept that, if certain schizophrenics are cared for within the community, they will refuse to accept the treatment prescribed for them. There is quite inadequate supervision of their lifestyles, and as a result they, their parents and the community suffer. I believe that we should do much more for them. Sometimes, the mentally ill are treated as the Cinderellas of the social services.

Mr. Rowe

My hon. Friend is making a very powerful point. Does he agree that it is part of a larger, extremely difficult problem—that of how far we should allow self-determination to people whom we are trying to treat in a much more mature and adult way? My hon. Friend is talking about one extreme, but the problem runs right through community care.

Mr. Marshall

I accept that the problem of self-determination has existed for a long time. I suspect that we may have moved from one extreme to the other.

I shall quote two examples of people who have come to my surgery for advice. One man came to me without an appointment saying that he had a terrible problem. He had received a telephone call from Marseilles. His son had walked out of the local mental hospital, emptied his account at the local building society and gone to Marseilles. The phone call was asking for money to enable him to come back home. That is an example of self-determination, someone walking out of treatment that he should have.

It is all very well talking about the philosophical advantages of self-determination, but I am talking about the practical disadvantages to the patient, the community and parents. I shall always remember a group of people who came to me in my constituency and said, "You must help us. Mr. X has been given a flat in our block and he plays music 16 hours a day. He starts at 8 pm and carries on through the night." That course of action is not benefiting him, his family or the community. I hope that the Government will do something about it.

6.30 pm

Mr. Tom Clarke (Monklands, West)

My hon. Friend the Member for Livingston (Mr. Cook) introduced this excellent debate, which reflects the importance of this crucial subject at a time when so many expect so much from the Government. Alas, they must have been disappointed by events this afternoon. In many ways, this has been a remarkable debate. The Secretary of State for Health appeared, albeit briefly, and made one short intervention. He accused my hon. Friend of being greedy in a team sense. When the right hon. and learned Gentleman occasionally looks at an egg and reflects on his hon. Friend the Member for Derbyshire, South (Mrs. Currie), he might regret not employing the tactics that he wrongly attributed to my hon. Friend.

If ever there were a debate involving Hamlet without the grave digger, this is it. There is no doubt that the Secretary of State should have been present throughout and should have told us the Government's thinking on these crucial matters. It is true that we have had three debates on community care recently—one was introduced by my hon. Friend the Member for Bristol, South (Ms. Primarolo) in a Consolidated Fund Bill debate; one was introduced by the Social and Liberal Democrats through the hon. Member for Southport (Mr. Fearn), who spoke earlier; and today we have this debate introduced by the Labour party in Opposition time. It is not enough, fifteen months after the report by Sir Roy Griffiths, for the Government to say again that they will make a statement, giving every sign that it will be a holding statement. If this trailer means that, after a long delay, a White Paper will be published during the recess and there will be inadequate debate before the Government rush through legislation, the Government can expect the utmost vigilance from the Opposition.

Now that the Minister has had time to consult the Secretary of State, I shall press him on one matter. In this crucial matter, the House has to depend for its information almost exclusively on rumour. What is happening with the famous E committee? Is a Cabinet committee considering the Griffiths report? If so, what have been the influences during its deliberations? We are told that the committee has been largely influenced by the Right-wing think tank, the Adam Smith Institute. We are told that the Secretary of State has been handbagged by the Prime Minister who, once again, finds herself at odds with one of her senior Ministers. If, as the Minister said in reply to me, these are mere rumours, why does he not take the opportunity to tell us the precise facts? This is a mature Chamber. There are many hon. Members on both sides whose input to our debate has been particularly helpful, who are well informed, who have tried to encourage mature input into the debate and who expect better than we have had from the Government so far.

We expect better because we were told that we should wait for the Government's White Paper on health, "Working for Patients". There was little in it about community care and what there was, as we have heard from virtually every general practitioner in our constituencies, was extremely unhelpful. As my hon. Friend the Member for Wakefield (Mr. Hinchliffe) rightly said, the problem remains. As hon. Members have insisted, within a few minutes' walk of the House of Commons there are people living in cardboard boxes. As the hon. Member for Macclesfield (Mr. Winterton) said in a thoughtful speech and as my hon. Friend the Member for Halifax (Mrs. Mahon) said in a telling speech, far too many people who are mentally ill or mentally handicapped are being sent to prison because the courts do not know where to put them.

This morning in The Times, in an article dealing with the problems of prisons, we read almost as an afterthought the comment: The board of Canterbury Prison, Kent, says: 'The problem will become worse as mental hospitals devolve their inmates into the community without adequate support services and because changes in the rules governing housing benefit seem likely to lead to a reduction in hostel places'.". All that is happening when, as my hon. Friends have said, public money is being spent, but as a contribution to the unplanned explosion of private residential homes. Sir Roy Griffiths has asked why that is happening, and we are entitled to know the Government's thinking. The Public Accounts Committee has said that the sum involved is about £250 million. With that money, we could do much in a planned way for the aspirations of community care that have been expressed in the debate.

The Government still offer no strategy for community care—worse, while we have been waiting all this time for a response to the Griffiths report, we have seen fragmentation in various Departments, including the Department of Health. We have seen Departments acting independently and Departments imposing policies that appear to be in conflict with the strategies in which, we are told, the Government believe, including the poll tax. If ever there was a perverse incentive for community care, that is it.

The Department of Health and Social Security has been split into two Departments, without an explanation of how that may influence our attitudes to community care. We have seen the impact of social security cuts. The hon. Member for Bolton, North-East (Mr. Thurnham) referred to Crossroads. The Labour party accepts that there is a role for voluntary organisations and that the private sector often fulfils a useful function. Why should a Government and their supporters who are so committed to voluntarism appear to ignore the views of the voluntary organisations? If ever there was a crisis, it was on the funding of Crossroads, as we know from our constituency correspondence. Again, as part of fragmentation, Lord Young interfered in these matters. We know that employment training schemes have an impact on what is happening in the community.

As for my constituency, I shall merely tell the story of a man who was involved with Crossroads. His wife suffers from Alzheimer's disease. He was given some help, which he very much appreciated, in visits two or three days a week which were ordered by Crossroads. Because of the argument about funding, which has not been wholly resolved, he was told that that help would be taken away. He came in tears to see me. We should remember that his wife will not be exempt from the poll tax. If people are contributing to local authority services, it ill behoves those who impose their ideology to argue, as many do, that the role of local authorities should be reduced.

There are strong suspicions that, as the Government think these matters out, there are influences on their thinking that are not necessarily helpful and are almost wholly based on ideology. I note that the Secretary of State for Social Security is sitting on the Front Bench. His presence late in the debate confirms my point.

We are told that the Under-Secretary of State for Scotland, the hon. Member for Stirling (Mr. Forsyth), had considerable influence on Government thinking, about which we shall hear when they have concluded their long deliberations.

Mr. Dick Douglas (Dunfermline, West)

Lord help us.

Mr. Clarke

My hon. Friend the Member for Dunfermline, West (Mr. Douglas) says, "Lord help us". The influence of the hon. Member for Stirling has caused many problems in Scotland. If he has as much influence on the United Kingdom, we are in trouble.

I mentioned the fragmentation of and contradictions in Government policy. I remind the House of what occurred with Lennox Castle hospital. I am sorry that a Minister from the Scottish Office is not present; perhaps they have more important matters to deal with. The hon. Member for Stirling was aware of the many valid criticisms of conditions at Lennox Castle hospital. He was further aware of the television programme that told the world of some of the outrageous conditions there. What did he do? Did he involve himself in consultation? Did he say, "Yes, we are committed to community care, so let us consult"? Did he consult the Confederation of Health Service Employees or the consumers about whom we have heard so much? Did he consult those involved in joint planning, however inadequate it is in Scotland? No, he did not.

The hon. Member for Stirling, who is the most monetarist of monetarists, threw money at the problem by announcing £9 million of expenditure over the next two years without saying whether it was part of a strategy for community care—a policy which would be welcomed by the people of Scotland and, given the main stream of the debate, elsewhere. That proves that, if there is the will, the Government can find the necessary resources, which is why my hon. Friends were right to emphasise the importance of resources.

The Disabled Persons (Services, Consultation and Representation) Act 1986—I make no apology for returning to it—offers the Government an opportunity, if only they would grab it, of a framework for community care. It deals with citizens who have special needs and their right of access to information and it makes agencies, social services, housing and health departments accessible. We shall never solve the problem of people being discharged from hospitals, about which we have heard much today, including from my hon. Friend the Member for Oxford, East (Mr. Smith), until we realise that there is a role for bridging, preparation and assessment. It is scandalous that many people are leaving the community to go into community care that does not exist.

Many hon. Members, including my hon. Friend the Member for Livingston, referred to carers. We owe much to carers, who do so much work 24 hours a day. That commitment should not be exploited. The social security changes, which have worked to the considerable disadvantage of carers of disabled people, should not be allowed to continue without review. The changes are false economy, because no one is helped, least of all the Treasury, if the relationship between the carer and the person they are caring for breaks down and both become institutionalised.

The Audit Commission has said that it is gravely worried about the way in which the Government have organised the changes. It mentioned a lack of planning, strategy and auditing of expenditure of public money, with drastic consequences for the people involved. The Salvation Army estimates that up to three quarters of its hostels' inmates may be suffering from mental illness. Such problems must be taken on board by the Government. They cannot ignore the appalling problem, which was brought to the notice of the Standing Committee considering the Children Bill, of older children, who have no parents or other family, leaving care and facing the difficulties of community life. In many cases, they are being trapped into crime, drugs and prostitution because the Government are not prepared to accept the responsibility that parents would accept for their children. That is the responsibility of a caring Government.

The Government's delays and lack of commitment owe more to ideology than an appraisal of the problems. They are influenced by people who believe that we should consider only consumers, as explained by Mr. Norman Flynn, who in an article entitled "The 'New Right' and Social Policy" said: If possible, individuals should manage without help from institutions of any sort, except their own families. The Minister made that point, as though, collectively, the state had no responsibility. What does that attitude mean in reality? What did the National Council for Voluntary Organisations—volunteers expressing their views and pleading to the Government—say about the family and its input? It said: One woman, aged 73, who suffered from a stroke in 1986, is currently in hospital following a further stroke. The sheltered housing scheme where she now lives have said that her care needs are now too great for her to remain a resident there. Nursing home fees in the area—Berkshire—are around £300 per week and the woman concerned would be reliant on income support of £185. As the widow of a milk roundsman who died in 1959 this woman has only a small amount of capital which would soon be eroded by the need to 'top up' her own fees; her children both have financial family commitments of their own and would not be able to assist. I fear that that problem is reflected throughout many parts of the country.

We cannot dismiss such problems by saying that they must be dealt with by distant families or friends and that the Government have no responsibility. However, that would be the view of the Adam Smith Institute. I have had the benefit of reading the paper that we understand has been before Cabinet committee E. It shows the conflict in philosophy between the Government and the Opposition. The paper says: Government can, by providing very modest encouragement to the private sector, help it to grow with that rising demand. It can, by means of incentives to personal saving and personal provision, make it easier for most people to provide for their own care needs in retirement. In other words, the choice is artificial, because without good planning and services there is no option.

If local authorities are to be underfunded and denied essential resources, where is the choice? According to the mentality displayed in the paper of the Adam Smith institute, we shall have to rely on people who can afford to pay for services. What will happen to the rest? Are they not entitled to advocacy and consultation on what happens to services? Of course they are, but the overwhelming evidence before the House confirms the view of the Audit Commission that community care is in disarray and Sir Roy Griffiths's view that it remains in chaos.

For that reason, Opposition Members have a responsibility to promote the needs, demands and requirements for services of millions of elderly, vulnerable and disabled people and their carers. We do not believe that the Government have placed on such matters the priority which the British people would rightly demand. That is why the Government offer a proper suspicion of any scrutiny from Europe. They know that, if Europe is looking for best practice from central Government, it will not find it in Great Britain. For that reason we believe that the Government have failed the nation. We shall reflect our repugnance and our despair at their policies by voting in the Lobby tonight.

6.50 pm

Mr. Freeman

The hon. Members for Monklands, West (Mr. Clarke) and for Oxford, East (Mr. Smith) asked again about our response to Griffiths. As I made plain at the outset of the debate, we shall make a statement before the summer recess on our response to it, and there will be a debate in Government time at the appropriate time thereafter.

The hon. Member for Monklands, West is tilting at windmills that he has created in his own mind when he refers to the Adam Smith Institute.

Mr. George Foulkes (Carrick, Cumnock and Doon Valley)

Let us hear from the Secretary of State.

Madam Deputy Speaker (Miss Betty Boothroyd)

Order. The Minister is at the Dispatch Box, and he must be heard.

Mr. Freeman

We are carefully considering all the evidence and the results of our review of Griffiths. We shall make our announcement before the summer recess.

Mr. Andrew Smith

rose—

Mr. Freeman

I am about to answer the hon. Gentleman's point, if he will listen to me.

The hon. Member of Oxford, East asked me about the cost of upgrading local authority residential care homes to home life standard. Since 1978 local authority personal social services capital outturn expenditure has gone up by 22 per cent. in real terms under this Government. It was cut by two thirds by the previous Labour Administration.

My hon. Friend the Member for Macclesfield (Mr. Winterton) made a thoughtful, wide-ranging speech in which he raised a number of points about mental illness with which I shall try to deal. There is no moratorium on the closure of hospitals for those suffering from mental illness or a mental handicap, but no hospital will close until or unless there are adequate facilities in the community. I hope that I made that clear earlier.

My hon. Friend talked about the need for long-stay care and asylum care. My hon. Friend is right that there is a need for long-term facilities for those suffering from mental illness or a mental handicap. Certainly existing buildings can and should be re-used. At the beginning of this debate, I said that we were well aware that such institutions should not be isolated or too large, but should be part of the community. I accept that some of the institutions that are being run down currently are physically in the community and I am sure that some of those facilities can be re-used.

My hon. Friend also asked about discharged patients in prisons. Part of the problem is that the courts do not in all cases use their present powers to send potential prisoners to hospital for mental illness care. We would encourage the courts so to do. It is also important that consultants should visit prisoners and especially those on remand awaiting trial as promptly as possible. We are in close liaison with the Home Office to ensure that that happens. My hon. Friend also asked about the inquiry undertaken by Professor Kathleen Jones and I shall respond to that shortly.

My hon. Friend, in common with several other hon. Members, also spoke about those living under the arches at Waterloo. I have also visited those who are living in cardboard homes, not only under the arches of Waterloo but elsewhere. Those poor unfortunate people and their existence are a blot on society, but I must tell the House that those people have access to medical care; general practitioners visit those people. One cannot simply shovel all those who are living rough into institutions against their will.

Mr. Battle

rose—

Mr. Freeman

No, I shall not give way.

My hon. Friend the Member for Macclesfield also asked me about visiting Parkside hospital. I assure my hon. Friend that I shall visit that hospital with him and I plan to do so as quickly as possible in September, I hope.

The hon. Member for Southport (Mr. Fearn) properly reminded us about the importance of the voluntary sector. He was also right to emphasise the importance of long-term funding for voluntary organisations. It can be counter-productive for those organising voluntary societies to spend too much of their time chasing for money, whether it comes from the public purse or from other sources. It is important that those societies should be given some form of funding security, perhaps over three to five years. The Department of Health is carefully reviewing how it provides assistance through statutory means—we provide about £15 million a year. I am sympathetic to the hon. Gentleman's suggestion of extending the guarantee of funding, so long as that does not hamper our ability to provide new finance to new organisations when submissions are made.

My hon. Friend the Member for Norfolk, South-West (Mrs. Shephard), with all her experience in such matters, made a number of relevant points. She was right to talk about the multiplicity of ways in which to make community care work. There are a multiplicity of facilities, professions and authorities that provide such care, which represents a partnership between the NHS, the local authorities, the private sector and voluntary organisations. My hon. Friend asked about the evaluation of the pilot projects on care in the community. The university of Kent is evaluating the 28 pilot projects and the results should be available at the end of the year. The interim results suggest that the initiative has been successful. I will write to my hon. Friend—if I forget, I am sure that I shall be prodded —at the end of the year, and I shall send her a copy of the final report.

My hon. Friend also spoke about money being locked up in mental illness and mental handicap hospital sites. My hon. Friend is absolutely right that we need the necessary facilities now, in advance of those hospitals' closure. I repeat that they shall be closed only when there are adequate facilities in the community. We are looking at a number of imaginative ways in which existing capital and revenue can be released. When we respond to Griffiths shortly, I hope that my hon. Friend will be satisfied that we are pursuing a number of initiatives in that connection.

The hon. Member for Wakefield (Mr. Hinchhffe), in common with me, drew attention to the Public Accounts Committee report. He rightly reminded us that some 23 per cent. of those in residential care wanted to be al home. I believe that that is relevant; I would not necessarily agree with the percentage quoted by the hon. Gentleman, but the thrust of his remarks was correct. Our review of the Griffiths report has meant that we have carefully considered how resources should be devoted to help the elderly frail stay in their own homes.

My hon. Friend the Member for Bolton, North-East (Mr. Thurnham) again stressed the crucial role of the voluntary sector. Since 1978, we have increased funding to the voluntary sector by 130 per cent. in real terms. I share my hon. Friend's views about the importance of that sector. My hon. Friend also spoke about adoption, and I draw his attention and that of the House to the family placement scheme for the mentally ill. Under that scheme, mentally ill people are placed with families, outside institutions, and adequate financial resources are made available either from the social services as appropriate or from the Health Service. That scheme is in its infancy, but it is working well and I commend it to the House.

My hon. Friend also spoke about the services provided for those who are mentally handicapped or who display challenging behaviour. My hon. Friend may not know that, this week, we published a new report, the short title of which is "Needs and Responses". I hope that he will find it helpful. I also hope that local authorities and NHS district authorities will find it helpful in outlining the best practice to deal with those with challenging behaviour.

The hon. Member for Halifax (Mrs. Mahon) spoke of the resources available for local authorities and local authority homes. I must correct a statement that I made earlier about the increase in the resources available to the personal social services sector. I understated that expenditure increase, which represents 25 per cent. in real terms between 1980–88. The numbers of those who have been helped by nursing care during that time is up by 14 per cent. The number of day centres has increased by 16 per cent., the number of home helps by 28 per cent. and the number of meals on wheels by 11 per cent. The hon. Lady also asked me about consultants going round wards with lists of private accommodation. We have made it clear several times that elderly people should not be moved to private homes against their will if it means that they have to take responsibility for the fees.

My hon. Friend the Member for Stockport (Mr. Favell) talked about sheltered accommodation, which is extremely important, and I commend local authorities that have concentrated on the provision of sheltered accommodation for elderly people. It provides dignity and security in old age. He also suggested that the general practitioner should have a greater role in assessing care for the elderly. I am glad that he supports the new contracts that my right hon. and learned Friend the Secretary of State negotiated with the General Medical Services Committee. Under the new contract, every doctor is encouraged—indeed urged —to visit every elderly person in the practice each year, and higher capitation fees are paid for those over 75. We are ensuring that general practitioners care especially for the very elderly.

My hon. Friend the Member for Hendon, South (Mr. Marshall) talked about schizophrenics in the community. It is important to keep track of those discharged from hospital, or those who never reached hospital in the first place, who are suffering from schizophrenia. The Royal College of Psychiatrists is introducing an initiative on that, which I mentioned at the beginning of the debate. I hope that we shall make a further statement on that in due course.

The Labour party has talked tonight about the need for extra resources for care in the community, yet if one studies its proposals for the reform of the NHS and for care in the community, one sees at least three that are counter-productive for resources. The Labour party has said that it is utterly opposed to private practice in the Health Service. That will mean £60 million less, because of the loss of private beds. The Labour party has said that it will end compulsory tendering, which will mean the loss of £100 million a year. It has said that it will put local councillors and union representatives on health authorities. Nothing could be more calculated to make the management of resources in the Health Service more inefficient.

This has been a constructive debate on a vital matter. As Conservatives, we care deeply about care in the community for the mentally ill, the mentally handicapped and the elderly. The Government have increased resources over the past 10 years. We are in partnership with local government, the private sector and the voluntary sector. We will bring forward our proposals shortly. I invite the House to support the amendment in the name of my right hon. Friend the Prime Minister.

Question put, That the original words stand part of the Question:—

The House divided: Ayes 197, Noes 281.

Division No. 260]	[7.02 pm
AYES
Abbott, Ms Diane	Bradley, Keith
Adams, Allen (Paisley N)	Brown, Gordon (D'mline E)
Allen, Graham	Brown, Nicholas (Newcastle E)
Alton, David	Brown, Ron (Edinburgh Leith)
Anderson, Donald	Buckley, George J.
Archer, Rt Hon Peter	Caborn, Richard
Armstrong, Hilary	Callaghan, Jim
Ashdown, Rt Hon Paddy	Campbell, Menzies (Fife NE)
Banks, Tony (Newham NW)	Campbell-Savours, D. N.
Barnes, Harry (Derbyshire NE)	Canavan, Dennis
Barnes, Mrs Rosie (Greenwich)	Carlile, Alex (Mont'g)
Barron, Kevin	Cartwright, John
Battle, John	Clarke, Tom (Monklands W)
Beckett, Margaret	Clay, Bob
Bennett, A. F. (D'nt'n & R'dish)	Clwyd, Mrs Ann
Bermingham, Gerald	Cohen, Harry
Bidwell, Sydney	Coleman, Donald
Blair, Tony	Cook, Robin (Livingston)
Blunkett, David	Corbett, Robin
Boateng, Paul	Corbyn, Jeremy

Cousins, Jim	Loyden, Eddie
Cox, Tom	McAvoy, Thomas
Crowther, Stan	Macdonald, Calum A.
Cryer, Bob	McFall, John
Cummings, John	McKay, Allen (Barnsley West)
Cunliffe, Lawrence	McKelvey, William
Cunningham, Dr John	McLeish, Henry
Darling, Alistair	Maclennan, Robert
Davies, Rt Hon Denzil (Llanelli)	McWilliam, John
Davies, Ron (Caerphilly)	Madden, Max
Dixon, Don	Mahon, Mrs Alice
Dobson, Frank	Marshall, David (Shettleston)
Doran, Frank	Marshall, Jim (Leicester S)
Douglas, Dick	Martin, Michael J. (Springburn)
Duffy, A. E. P.	Martlew, Eric
Dunnachie, Jimmy	Meacher, Michael
Dunwoody, Hon Mrs Gwyneth	Meale, Alan
Eadie, Alexander	Michael, Alun
Eastham, Ken	Michie, Bill (Sheffield Heeley)
Evans, John (St Helens N)	Mitchell, Austin (G't Grimsby)
Ewing, Harry (Falkirk E)	Moonie, Dr Lewis
Fatchett, Derek	Morgan, Rhodri
Fearn, Ronald	Morley, Elliott
Field, Frank (Birkenhead)	Morris, Rt Hon A. (W'shawe)
Fisher, Mark	Morris, Rt Hon J. (Aberavon)
Flynn, Paul	Mowlam, Marjorie
Foot, Rt Hon Michael	Mullin, Chris
Foster, Derek	Murphy, Paul
Foulkes, George	Oakes, Rt Hon Gordon
Fraser, John	O'Brien, William
Fyfe, Maria	O'Neill, Martin
Garrett, John (Norwich South)	Orme, Rt Hon Stanley
Garrett, Ted (Wallsend)	Patchett, Terry
George, Bruce	Pendry, Tom
Gilbert, Rt Hon Dr John	Pike, Peter L.
Gordon, Mildred	Powell, Ray (Ogmore)
Gould, Bryan	Prescott, John
Graham, Thomas	Primarolo, Dawn
Grant, Bernie (Tottenham)	Quin, Ms Joyce
Griffiths, Win (Bridgend)	Randall, Stuart
Grocott, Bruce	Redmond, Martin
Hardy, Peter	Rees, Rt Hon Merlyn
Harman, Ms Harriet	Reid, Dr John
Hattersley, Rt Hon Roy	Richardson, Jo
Haynes, Frank	Robertson, George
Healey, Rt Hon Denis	Robinson, Geoffrey
Heffer, Eric S.	Rogers, Allan
Henderson, Doug	Ross, Ernie (Dundee W)
Hinchliffe, David	Rowlands, Ted
Hoey, Ms Kate (Vauxhall)	Ruddock, Joan
Hogg, N. (C'nauld & Kilsyth)	Sedgemore, Brian
Home Robertson, John	Sheerman, Barry
Hood, Jimmy	Sheldon, Rt Hon Robert
Howarth, George (Knowsley N)	Shore, Rt Hon Peter
Howell, Rt Hon D. (S'heath)	Skinner, Dennis
Howells, Dr. Kim (Pontypridd)	Smith, Andrew (Oxford E)
Hughes, John (Coventry NE)	Smith, C. (Isl'ton & F'bury)
Hughes, Robert (Aberdeen N)	Smith, Rt Hon J. (Monk'ds E)
Hughes, Roy (Newport E)	Smith, J. P. (Vale of Glam)
Hughes, Simon (Southwark)	Spearing, Nigel
Illsley, Eric	Steel, Rt Hon David
Ingram, Adam	Steinberg, Gerry
Janner, Greville	Stott, Roger
Jones, Barry (Alyn & Deeside)	Strang, Gavin
Jones, leuan (Ynys Môn)	Straw, Jack
Jones, Martyn (Clwyd S W)	Taylor, Matthew (Truro)
Kaufman, Rt Hon Gerald	Thompson, Jack (Wansbeck)
Kinnock, Rt Hon Neil	Turner, Dennis
Kirkwood, Archy	Vaz, Keith
Lambie, David	Wall, Pat
Lamond, James	Wareing, Robert N.
Leadbitter, Ted	Watson, Mike (Glasgow, C)
Leighton, Ron	Welsh, Michael (Doncaster N)
Lestor, Joan (Eccles)	Williams, Rt Hon Alan
Litherland, Robert	Williams, Alan W. (Carm'then)
Lloyd, Tony (Stretlord)	Wilson, Brian
Lofthouse, Geoffrey	Winnick, David

Wise, Mrs Audrey	Tellers for the Ayes:
Worthington, Tony	Mr. Nigel Griffiths and
Young, David (Bolton SE)	Mr. Frank Cook.
NOES
Adley, Robert	Dover, Den
Aitken, Jonathan	Dunn, Bob
Alison, Rt Hon Michael	Durant, Tony
Allason, Rupert	Dykes, Hugh
Amess, David	Eggar, Tim
Amos, Alan	Emery, Sir Peter
Arbuthnot, James	Evennett, David
Arnold, Jacques (Gravesham)	Fallon, Michael
Arnold, Tom (Hazel Grove)	Favell, Tony
Ashby, David	Fenner, Dame Peggy
Aspinwall, Jack	Field, Barry (Isle of Wight)
Atkins, Robert	Finsberg, Sir Geoffrey
Baker, Rt Hon K. (Mole Valley)	Fishburn, John Dudley
Baker, Nicholas (Dorset N)	Fookes, Dame Janet
Baldry, Tony	Forman, Nigel
Banks, Robert (Harrogate)	Forth, Eric
Batiste, Spencer	Fowler, Rt Hon Norman
Beaumont-Dark, Anthony	Fox, Sir Marcus
Bendall, Vivian	Franks, Cecil
Bennett, Nicholas (Pembroke)	Freeman, Roger
Benyon, W.	French, Douglas
Biffen, Rt Hon John	Fry, Peter
Blackburn, Dr John G.	Gale, Roger
Bonsor, Sir Nicholas	Gardiner, George
Boscawen, Hon Robert	Garel-Jones, Tristan
Boswell, Tim	Gill, Christopher
Bottomley, Peter	Gilmour, Rt Hon Sir Ian
Bottomley, Mrs Virginia	Glyn, Dr Alan
Bowden, A (Brighton K'pto'n)	Goodhart, Sir Philip
Bowden, Gerald (Dulwich)	Goodlad, Alastair
Bowis, John	Goodson-Wickes, Dr Charles
Boyson, Rt Hon Dr Sir Rhodes	Gorman, Mrs Teresa
Braine, Rt Hon Sir Bernard	Gow, Ian
Brandon-Bravo, Martin	Grant, Sir Anthony (CambsSW)
Brazier, Julian	Greenway, Harry (Ealing N)
Brooke, Rt Hon Peter	Greenway, John (Ryedale)
Brown, Michael (Brigg & Cl't's)	Gregory, Conal
Browne, John (Winchester)	Griffiths, Peter (Portsmouth N)
Bruce, Ian (Dorset South)	Ground, Patrick
Buchanan-Smith, Rt Hon Alick	Grylls, Michael
Budgen, Nicholas	Gummer, Rt Hon John Selwyn
Burns, Simon	Hague, William
Butcher, John	Hamilton, Hon Archie (Epsom)
Butler, Chris	Hamilton, Neil (Tatton)
Butterfill, John	Hanley, Jeremy
Carlisle, John, (Luton N)	Hannam, John
Carlisle, Kenneth (Lincoln)	Hargreaves, A. (B'ham H'll Gr')
Carrington, Matthew	Hargreaves, Ken (Hyndburn)
Cash, William	Harris, David
Channon, Rt Hon Paul	Hayes, Jerry
Chapman, Sydney	Hayhoe, Rt Hon Sir Barney
Chope, Christopher	Hayward, Robert
Churchill, Mr	Heathcoat-Amory, David
Clark, Hon Alan (Plym'th S'n)	Hicks, Mrs Maureen (Wolv' NE)
Clark, Dr Michael (Rochford)	Hicks, Robert (Cornwall SE)
Clark, Sir W. (Croydon S)	Hind, Kenneth
Clarke, Rt Hon K. (Rushcliffe)	Hogg, Hon Douglas (Gr'th'm)
Colvin, Michael	Holt, Richard
Conway, Derek	Hordern, Sir Peter
Coombs, Anthony (Wyre F'rest)	Howarth, Alan (Strat'd-on-A)
Coombs, Simon (Swindon)	Howarth, G. (Cannock & B'wd)
Cope, Rt Hon John	Howell, Rt Hon David (G'dford)
Couchman, James	Howell, Ralph (North Norfolk)
Cran, James	Hughes, Robert G. (Harrow W)
Critchley, Julian	Hunt, Sir John (Ravensbourne)
Currie, Mrs Edwina	Hurd, Rt Hon Douglas
Curry, David	Irvine, Michael
Davies, Q. (Stamf'd & Spald'g)	Irving, Charles
Davis, David (Boothferry)	Jack, Michael
Day, Stephen	Jackson, Robert
Devlin, Tim	Janman, Tim
Dicks, Terry	Jessel, Toby
Dorrell, Stephen	Johnson Smith, Sir Geoffrey
Douglas-Hamilton, Lord James	Jones, Gwilym (Cardiff N)

Jones, Robert B (Herts W)	Shaw, David (Dover)
Jopling, Rt Hon Michael	Shaw, Sir Giles (Pudsey)
Kellett-Bowman, Dame Elaine	Shaw, Sir Michael (Scarb')
Key, Robert	Shelton, Sir William
King, Roger (B'ham N'thfield)	Shephard, Mrs G. (Norfolk SW)
Knight, Greg (Derby North)	Shepherd, Colin (Hereford)
Knight, Dame Jill (Edgbaston)	Shepherd, Richard (Aldridge)
Lawson, Rt Hon Nigel	Sims, Roger
Lennox-Boyd, Hon Mark	Skeet, Sir Trevor
Lightbown, David	Smith, Sir Dudley (Warwick)
Lloyd, Sir Ian (Havant)	Soames, Hon Nicholas
Lloyd, Peter (Fareham)	Speed, Keith
Lord, Michael	Spicer, Sir Jim (Dorset W)
McCrindle, Robert	Spicer, Michael (S Worcs)
McNair-Wilson, Sir Michael	Squire, Robin
Marshall, John (Hendon S)	Stanbrook, Ivor
Marshall, Michael (Arundel)	Steen, Anthony
Martin, David (Portsmouth S)	Stevens, Lewis
Maude, Hon Francis	Stewart, Allan (Eastwood)
Maxwell-Hyslop, Robin	Stewart, Andy (Sherwood)
Miller, Sir Hal	Stokes, Sir John
Miscampbell, Norman	Stradling Thomas, Sir John
Mitchell, Andrew (Gedling)	Sumberg, David
Mitchell, Sir David	Summerson, Hugo
Moate, Roger	Tapsell, Sir Peter
Monro, Sir Hector	Taylor, Ian (Esher)
Montgomery, Sir Fergus	Taylor, Teddy (S'end E)
Moore, Rt Hon John	Temple-Morris, Peter
Morrison, Sir Charles	Thompson, D. (Calder Valley)
Moss, Malcolm	Thompson, Patrick (Norwich N)
Moynihan, Hon Colin	Thornton, Malcolm
Mudd, David	Thurnham, Peter
Neale, Gerrard	Townend, John (Bridlington)
Nelson, Anthony	Townsend, Cyril D. (B'heath)
Neubert, Michael	Tracey, Richard
Newton, Rt Hon Tony	Tredinnick, David
Nicholls, Patrick	Trippier, David
Nicholson, David (Taunton)	Twinn, Dr Ian
Norris, Steve	Vaughan, Sir Gerard
Onslow, Rt Hon Cranley	Waddington, Rt Hon David
Oppenheim, Phillip	Wakeham, Rt Hon John
Page, Richard	Waldegrave, Hon William
Paice, James	Walden, George
Parkinson, Rt Hon Cecil	Walker, Bill (T'side North)
Patnick, Irvine	Waller, Gary
Patten, John (Oxford W)	Walters, Sir Dennis
Pattie, Rt Hon Sir Geoffrey	Ward, John
Pawsey, James	Wardle, Charles (Bexhill)
Peacock, Mrs Elizabeth	Warren, Kenneth
Porter, Barry (Wirral S)	Watts, John
Porter, David (Waveney)	Wells, Bowen
Portillo, Michael	Wheeler, John
Powell, William (Corby)	Whitney, Ray
Price, Sir David	Widdecombe, Ann
Raison, Rt Hon Timothy	Wiggin, Jerry
Redwood, John	Wilkinson, John
Renton, Tim	Wilshire, David
Rhodes James, Robert	Winterton, Mrs Ann
Ridley, Rt Hon Nicholas	Winterton, Nicholas
Ridsdale, Sir Julian	Wolfson, Mark
Roberts, Wyn (Conwy)	Wood, Timothy
Roe, Mrs Marion	Yeo, Tim
Rossi, Sir Hugh	Young, Sir George (Acton)
Rost, Peter	Younger, Rt Hon George
Rowe, Andrew
Sackville, Hon Tom	Tellers for the Noes:
Sainsbury, Hon Tim	Mr. John M. Taylor and
Sayeed, Jonathan	Mr. David Maclean.
Scott, Rt Hon Nicholas

Question accordingly negatived.

Question, That the proposed words be there added, put forthwith pursuant to Standing Order No. 30 (Questions on amendments), and agreed to.

MADAM DEPUTY SPEAKER forthwith declared the Main Question, as amended, to be agreed to.

Resolved, That this House commends the Government's record on the development and funding of community services for all people in need of care; reaffirms its support for the policy of community care; believes that it will be complemented and strengthened by the proposals contained in the Government's White Paper, Working for Patients; and looks forward to an announcement of the Government's conclusions on Sir Roy Griffiths' report, Community Care: Agenda for Action, in the near future.'