HC Deb 01 July 1992 vol 210 cc936-44

Motion made, and Question proposed, That this House do now adjourn.—[Mr. Wood.]

10.3 pm

Mr. David Atkinson (Bournemouth, East)

As we have been reminded by the business that has just been transacted, the Government's long-awaited plans for community care based on the Griffiths recommendations are to be implemented on 1 April 1993. Henceforth, social services authorities will assume full responsibility for community care of the frail, the elderly, the disabled and other vulnerable groups to enable them to live as independently as possible. [Interruption.]

Madam Deputy Speaker (Dame Janet Fookes)

Order. Hon. Members who are leaving the Chamber should do so quickly, and not stand in the aisles.

Mr. Atkinson

The three years between the legislation being enacted and its implementation have raised the expectations of professionals, carers and patients. They have also enabled a better appreciation of the costs involved to ensure that implementation will ultimately be successful.

My right hon. Friend the Secretary of State has repeatedly confirmed that resources will be adequate, so I look forward to learning tonight from the Under-Secretary of State, my hon. Friend the Member for Suffolk, South (Mr. Yeo), when local authorities can expect to learn precisely how much they are to receive next year to enable them to complete their community care budgets.

One of the principal areas of care for which expectations for a better quality of life in the community are high is provision for the mentally ill. I have taken a personal interest in that subject as honorary parliamentary adviser to the National Schizophrenia Fellowship. My interest is firmly shared by my hon. Friend the Member for Norwich, North (Mr. Thompson), whom I am glad to see in his place tonight.

Your records, Madam Deputy Speaker, will show that I do not make long speeches in this House. However, I made a far longer speech than I intended on Second Reading of the Mental Health Act 1983, only because, regrettably, too few hon. Members were waiting to follow me in the debate. That speech enabled me to describe in detail the nature and problems of schizophrenia, of which I had not been aware until a friend, who I did not know was a sufferer, committed suicide because he could not face another day.

Fortunately, there has been a growing public awareness of schizophrenia in recent years, as well as awareness of how widespread its incidence is. It is estimated that 1 per cent. of the population—some 600,000 people—can expect to suffer at some stage during their lifetime. That growing public appreciation is due in large measure to the excellent work of the NSF, MIND and, more recently, SANES— Schizophrenia—A National Emergency—which is currently raising £3.5 million for research into schizophrenia and has introduced a helpline for sufferers to telephone when they are desperate. Those organisations welcome, as I do, the introduction of the specific grant last year to social service authorities, which was ring-fenced for the mentally ill and increased by 50 per cent. this year. They also welcome the doubling of the size of the homeless mentally ill programme in London.

In turn, Parliament should recognise the major contribution that the voluntary sector makes to services for the mentally ill and their carers and relatives, as we do through the Health Departments' funding. I look forward to learning from my hon. Friend the Under-Secretary how much extra support those voluntary organisations can expect from April next year, including the resources for organisations providing shelter for the mentally ill outside London in areas like Bournemouth, which do not benefit from much of the new money being made available to the south-east.

One of the greatest challenges that faces our so-called civilised society today is to reverse the cycle of deprivation and despair that afflicts the homeless mentally ill, a problem to which far too many people continue to turn a blind eye. That is why I welcome my hon. Friend the Under-Secretary to his new post, to which he brings his previous experience as Minister responsible for housing and his wide experience in dealing with the handicapped before he came to the House.

Regrettably, whatever provision is made in the community, there will always be a minority among the mentally ill who pose such a threat to themselves or others that they need to be admitted to hospital compulsorily under the Mental Health Act 1983. Although there appears to be widespread agreement that the provisions of the Act are satisfactory, concerns continue to be expressed, not least by the NSF, regarding the interpretation of the Act as described within its code of practice. The code of practice is the prime focus of this debate. Unfortunately, I must refer to a tragedy in my constituency to illustrate the deficiencies in the code.

In January 1990, I prayed that the code of practice issued by my hon. Friend's Department in December 1989 be withdrawn. My prayer received support from both sides of the House, and Lord Mottistone tabled a similar prayer in the other place. I take this opportunity to pay tribute to his continuing and personal commitment to sufferers of schizophrenia.

Our opposition to the 1989 code was based on its failure to qualify adequately the powers created by the very Act under which it was issued. I believe that the 1989 code had three major deficiencies. First, section 2(2)(b) of the Act clearly states that compulsory admission of an individual to hospital for treatment can be made in the interests of his own health or safety or with a view to the protection of other persons. By the use of the word "or" the Act stresses that any one of those three criteria is a sufficient condition for compulsory admission. But as the code lacks that stress, it is possible to form the impression that all three criteria must simultaneously be present before the sufficient condition for compulsory admission has been met.

The second deficiency is the 1989 code's emphasis, found in paragraphs 18.23 to 18.28, on the patient's freedom to dismiss himself from treatment even under compulsory admission. That emphasis does not exist in the Act. A code of practice cannot create rights or bestow freedoms that do not exist in the Act that necessitates the code's creation.

The third deficiency is that the 1983 Act provides for admission in cases of emergency under which a person can be detained for 72 hours for the purpose of mental assessment. Section 4(2) of the Act states: An emergency application may be made either by an approved social worker or by the nearest relative of the patient". However, the 1989 code greatly weakens the right of the nearest relative to apply for emergency admission by stating, in paragraphs 2.27 and 2.30, that a relative should be informed of his right only "where necessary" or if necessary".

Sadly, the 1989 code of practice was not withdrawn. Obviously, it was believed at the time that a badly drafted code was better than no code, as it has been six years since Parliament passed the legislation. That was not the first code of practice; years earlier, the Mental Health Act Commission drew up a code that was never officially published because it was completely unacceptable to the mental health professions, principally the Royal College of Psychiatrists.

As an acknowledgment of the 1989 code's deficiencies, the Government agreed that the code's text on the rights of the nearest relative was "very definitely ambiguous" and undertook to make the "proper meaning clear" in an introductory letter to the code. In addition, the Government referred the other two deficiencies to the Mental Health Act Commission. In March 1991, the commission recommended to my hon. Friend's Department that the wording on admission criteria needed amendment, but that the criticism of the wording on patient security was invalid.

My hon. Friend's predecessor, my hon. Friend the Member for Loughborough (Mr. Dorrell) accepted the commission's recommendations for an amendment to the code, which was laid before the House on 28 November last year. Why did not the Department of Health consider the security of a detained patient of paramount importance, both for the patient's own safety and for the safety of others?

Due to the fact that it was an inferior amendment and did not clarify the admission criteria, I prayed in December 1991 that it be withdrawn. Although I withdrew my latter prayer—I assume, and perhaps my hon. friend the Minister will give me confirmation, that the amendment came into force on 13 January this year—I believe to this day that the code of practice inadequately clarifies the powers created by the Act.

Sad to say, my belief in the code's inadequacy has been borne out by the death of my constituent, Miss Helena Thompson. Miss Thompson, who was living with her mother at Darracott road, Boscombe, died of malnutrition in Poole general hospital on the evening of 17 February last year. Before her death, Dorset social services had been aware that her mother, Mrs. Nellie Thompson, suffered from schizophrenia but felt unable to act, as she refused all help.

Over the years the Thompson house fell into a state of disrepair and after Miss Thompson's death it had to be demolished because it was uninhabitable. The chronology of events that led to her death clearly showed the inadequacy of the code of practice. On 16 February last year, having received telephone calls from neighbours who claimed to hear screaming coming from the Thompson house, Dorset police made a forced entry under the Police and Criminal Evidence Act 1984, which permits such action when life is believed to be in peril. The police found Miss Thompson bedridden and near death.

The following day Miss Thompson was removed from her home in Darracott road, under the National Assistance Act 1948, by Dorset social services and she died in hospital a few hours later. Under section 135 of the Mental Health Act, Mrs. Thompson, now clinically diagnosed schizophrenic, was compulsorily admitted to hospital for treatment.

I do not seek to place the blame either on Dorset social services or on Dorset police, who I believe acted properly in this tragedy. Indeed, they acted to the best of their ability. Nevertheless, they were acting under their interpretation of the 1983 Act—an interpretation reinforced by the incorrect and ambiguous wording of the code of practice.

I place the blame for my constituent's death squarely on the code of practice, which inadequately clarifies the powers created by the Act and thus misinforms local authorities, which are largely responsible for enforcement of the Act.

The Act permits social services officers to seek compulsory admission based on the three admission criteria, but because the code implies that the three criteria must simultaneously be present, Dorset social services felt that they could not act. The code of practice does not adequately clarify the criteria for compulsory admission, thereby preventing Dorset social services from acting sooner.

Would it not be better for the code to quote the Act's criteria for compulsory admission directly and to state explicity that any one of the three criteria is a sufficient condition for such admission? Furthermore, despite the frail condition of Miss Thompson and the known mental state of her mother, more than 24 hours were required to issue a warrant for the compulsory admission of Mrs. Thompson under section 135.

Finally, the Mental Health Act rightly permits relatives to seek emergency application for compulsory admission. Regrettably, because the code wrongly qualifies that right, Miss Thompson's sister—she is not my constituent—has told me that she was not specifically informed by Dorset social services of her powers to seek an emergency admission for the purpose of assessment because the code does not explicitly state that that power exists under the law. Rather, it relies for clarification on a circular issued by the Department of Health.

Given that a circular does not carry the same weight or importance as the Act's text, would it not be better to amend the code itself?

The untimely and unnecessary death of my constituent, Miss Helena Thompson, has shocked my constituents, who rightly ask why, in this so-called civilised age of the welfare state, the tragedy and the circumstances and events leading up to it could not have been avoided. Had the code of practice issued under the Act properly clarified the rights created in the Act Miss Thompson's death could have been avoided. If the code were properly amended in the way that I have outlined, such tragedies could be prevented in future. I understand that the code is currently the subject of a further review, and I hope that what I have told the House will result in such an amendment.

10.19 pm
The Parliamentary Under-Secretary of State for Health (Mr. Tim Yeo)

I congratulate my hon. Friend the Member for Bournemouth, East (Mr. Atkinson) on raising this extremely important subject, and I pay tribute to his interest over the years in the whole issue of schizophrenia. I am grateful for the interest shown by other hon. Members. The attendance for this Adjournment debate seems to be higher than it usually is when I finish the day's proceedings.

Before responding to the particular points that my hon. Friend has raised, I should like to put them in the general context of our approach to the care of mentally ill people in the community. Our policy is that people with a mental illness should have access to all the services that they need, as locally as possible, from long-term in-patient care to domiciliary support for those who can live nearly normal lives outside hospital.

From 1 April last year, all district health authorities were required to initiate, in collaboration with social services departments, explicit individually tailored care programmes for all in-patients about to be discharged from hospitals and for all new patients accepted by the psychiatric services. At the same time, we introduced a new revenue grant to local authorities to encourage them to improve social care and support provision for mentally ill people. This year, the grant has been increased by nearly 50 per cent. to over £31 million, which supports expenditure of over £43 million. To complement this, we authorised additional capital spending of £10 million last year and £10.5 million this year.

The care programme approach and the mental illness specific grant are designed to secure improvements in community services and to ensure that mentally ill people are cared for in the community only if there are adequate health and social services to meet their needs.

My hon. Friend asked about the resources for community care. Standard spending for personal social services this year has been set at £4.85 billion—an increase of 7.7 per cent. in cash terms or 3.1 per cent. in real terms over the previous year, and about 6 per cent. over 1991–92 budgets. Over the past two years, standard spending will have increased by nearly one third, or 19 per cent. in real terms. We estimate that local authorities plan to spend over £5 billion in the current year, which is about £400 million more than they spent last year. We are currently looking at the levels of resources which local authorities will require next year for social services.

This will, of course, be the first year of implementation of our community care policy. We are committed to resourcing the new policy fairly. We will be transferring to local authorities the resources that we would otherwise have provided to finance care through social security payments to people in residential care and nursing homes. We will make that transfer transparent and separately identifiable. I am happy to acknowledge the valuable contribution made by the voluntary sector in the provision of local services for mentally ill people. Voluntary organisations are noted for being user-friendly and for providing flexible services to meet individual needs. Because of their independence from mainstream services and generally closer contact with grass roots opinion, voluntary bodies are often at the forefront of innovation and service development.

In the mental illness field, we are supporting more than 20 voluntary organisations at a total cost of over £2 million. MIND receives £415,000 a year towards its headquarters administrative costs and the National Schizophrenia Fellowship receives £173,000—a core grant of £91,000 plus two project grants. We are also contributing £150,000 over three years towards the running costs of SANE's telephone advice service, the launch of which I attended during my first few weeks at the Department of Health.

The three-year core grants awarded to MIND and NSF in 1990–91 expire on 31 March next year, but these organisations are eligible to apply for renewal of grant aid. I cannot at this stage predict the level of grant that might be applied for or agreed for next year, but I can tell the House that we will give full consideration to the continuing needs of these organisations within the constraints of our grants budget.

I assure my hon. Friend that the Government appreciate the cycle of despair and deprivation which affects homeless mentally ill people. I am glad that my hon. Friend recognises the work done in London during the past couple of years. We have now increased the money to be put into the homeless mentally ill initiative to over £20 million by 1994–95, which will provide for four community psychiatric teams and up to 150 short-term specialist hostel places.

We are not taking the responsibility for providing care for homeless mentally ill people from local health and social services authorities, where it rightly lies, but we recognised that central London had particular problems because of the concentration of people sleeping rough and traditional difficulties in securing inter-agency cooperation in the capital.

At the beginning of last year, we announced a £3 million scheme to stop young people drifting into central London and to develop innovative ways of supporting them in their own communities. We have a further £3 million plan over three years to get doctors out to hostels, night shelters and day centres to make sure that homeless people have the health care to which they are entitled. The rough sleepers initiative by the Department of the Environment to help people sleeping out in London will cost £96 million over three years. The vital role of voluntary agencies in this area is fully recognised, and the Department of the Environment will pay £20 million in grants over the next three years under section 73 of the Housing Act 1985.

The sum of £6.1 million has been allocated in the current financial year, supporting 147 projects around the country, which give practical help to single homeless people. My hon. Friend may know of two projects undertaken by the Bournemouth Churches housing association in south-east Dorset, which are assessing the needs of homeless people in the area, developing a strategy for helping them, and providing resettlement for people at the south-east Dorset night shelter.

The duty to prepare and revise the code of practice is laid on the Secretary of State by section 118 of the Mental Health Act 1983. The code's purposes are defined in that Act as the guidance of doctors, hospital managers and staff, and approved social workers in relation to the admission of patients under the 1983 Act; and the guidance of doctors and members of other professions in relation to the medical treatment of patients suffering from mental disorder.

That makes it clear that the code is intended not just to explain the meaning of the Act but to serve as a guide to good practice generally. Doctors and social workers are expected to have their own first-hand knowledge of the 1983 Act as part of their specialist training. A separate publication, "Memorandum on the Mental Health Act 1983", helps them in that.

In contrast, the code quite properly can and does deal with matters beyond the strict scope of the statutory requirements. It must of course be fully consistent with the letter and the spirit of the 1983 Act, but, as my hon. Friend pointed out, the code cannot create rights or bestow freedoms that are not in the Act itself.

When the present code was introduced in 1990, we announced that we were asking the Mental Health Act Commission to monitor the operation of the code and to propose amendments. Earlier this year, the commission reported on its monitoring and submitted a number of proposed amendments. Generally, the commission reported that the code had been well received by those concerned.

In April, we wrote to all interested bodies to seek their comments on the proposed amendments. The commission told us that it will be submitting further proposals. When they have all been fully considered and consulted on, we shall be laying a revised code, as the 1983 Act requires.

My hon. Friend's first criticism related to the discrepancy between paragraph 2.6 of the code as originally drafted and the wording of the 1983 Act, which allows a patient to be detained in the interests of his own health or safety or with a view to the protection of other persons. As my hon. Friend pointed out, that paragraph has been amended, and I confirm that the amendment came into force on 13 January. That amendment is now part of the code, and carries precisely the same weight as the rest of it.

I am aware that the terms of the amendment attracted some criticism, including, as my hon. Friend said, his own prayer. I am glad to report that the terms of the circular published with the amendment last February were endorsed by the National Schizophrenia Fellowship, which issued a press release welcoming it.

My hon. Friend's second criticism was the emphasis, as he referred to it, in paragraphs 18.23 to 18.28 on the patient's

freedom to dismiss himself from treatment". We asked the Mental Health Act Commission to consider that passage along with other points that were criticised when the code was introduced. The commission did not agree that the paragraphs in question would necessarily lead to inappropriate laxity in supervising detained patients.

The commission undertook to monitor that part of the code, and in particular to assess the reaction of units to the practicality of the advice it contained. Rather than address the substance of that point, I will say that the proposals for amending those paragraphs are being considered together with the other comments that we receive in the current consultation exercise.

My hon. Friend's third point concerned the right of a patient's nearest relative to make an emergency application for his admission to hospital. We fully agree with my hon. Friend that the words "where necessary" and "if necessary" are misleading. In the circular to which my hon. Friend referred, we say: The words 'where necessary' in paragraphs 2.27 and 2.30 are ambiguous. They should he interpreted as meaning that where a nearest relative is unaware of his or her rights under the Mental Health Act 1983, then either the approved social worker or the doctor(s) involved in the patient's assessment should positively draw the nearest relative's attention to the existence and substance of these rights. I take my hon. Friend's point about the relative weight of the code and the covering circular, but the circular is printed as part of the same volume as the code, and arguably that gives the nearest relative's rights more prominence that they would otherwise have. The circular that we published last February with the amendment to paragraph 2.6 took the opportunity to remind users of the code of their obligations to the nearest relative—so that point was rubbed in yet again.

Even if a code technically outranks a circular, in this instance the circular relies on the 1983 Act, which trumps them both. In any case, I assure my hon. Friend that the offending words "where necessary" and " if necessary" will not appear in the revised edition of the code that will be introduced when we have completed consultation.

As to the very sad case of my hon. Friend's constituent, Miss Helena Thompson, I have carefully considered what he had to say, but I do not believe that the blame for that tragedy can be put entirely at the door of the code of practice. I know that my hon. Friend has received several reports on the case from the director of social services and, from the information I have, it appears that both the social services department and the medical staff concerned discharged their duty in a highly conscientious and professional way.

The case, as my hon. Friend has recounted it, seems to reflect the coincidence of two tragic circumstances. It is the case of a mentally ill mother with a daughter who was bedridden and starving to death in circumstances that remain somewhat mysterious. As far as I can ascertain, the real failing arose not from any misunderstanding about the powers available under the Mental Health Act or other legislation, but simply because Miss Thompson was not known to be in the house and in such a desperate state. When that was discovered, action was taken—as my hon. Friend reported—to remove her to hospital under the National Assistance Act 1948. I must underline that, if her presence had been discovered any earlier, that would not in itself have made any difference to the judgment about whether her mother met the statutory criteria for detention under the Mental Health Act.

There is no question of the social services having been misled by anything in the code of practice about the scope of their powers. or about their obligations to Mrs. Thompson's other daughter. The reason why they could not take action earlier to secure her admission to hospital was that the doctors concerned did not consider that she was suffering from a mental disorder of a nature or degree that warranted her detention under the Act. Therefore, neither an approved social worker nor Mrs. Thompson's nearest relative could have made an application under section 2 or section 3 of the Act.

My hon. Friend mentioned the delay in arranging Mrs. Thompson's eventual admission to hospital. I am satisfied that that was not a result of any doubt about the powers available to the local authority. In fact, it was arranged to remove Mrs. Thompson at a time agreed between all the parties concerned—the consultant psychiatrist, the GP, the approved social worker, the community medical officer, the police and the ambulance service. After they had entered the house under the section 135 powers, Mrs. Thompson was immediately admitted to hospital under section 3 of the Act.

As I have said, we are considering very carefully all the amendments that have been proposed to the code of practice, and will he laying a revised version when the process has been completed. I hope it will be some reassurance to my hon. Friend that I do not believe that the present wording of the code has contributed to the very sad death of his constituent.

Question put and agreed to.

Adjourned accordingly at twenty-nine minutes to Eleven o'clock.