HL Deb 04 December 1985 vol 468 cc1307-76

Lord Mottistone rose to call attention to the needs of mentally ill and mentally handicapped persons, with special reference to community care; and to move for Papers.

The noble Lord said: My Lords, I am indeed most honoured to move the Motion standing in my name. I am also deeply grateful for the fact that there is not going to be a Statement so that we can get on with the business, but a lot of the advantage thereby gained has surely been lost by the rumbling on of Questions a good deal more than they normally do. Therefore, I hope that perhaps we can get on with it quickly.

This debate is a stage in a succession of activities both in this House and another place to ensure that proper care continues to be available for mental patients of all sorts at all times. In general there is agreement among all the public and private bodies concerned about that somewhat obvious main aim. However, there are many differences of opinion about whether the actions being taken, or proposed, or indeed some of the actions that are not being proposed, are always the best to achieve that aim.

There has been much useful contribution from the other place, especially from its Select Committee on Social Services, in studying community care, and indeed in the Government's response to that report which recently appeared. But in order, in part at any rate, to make sure that the debate does not range too widely so that we keep within compass, I propose to concentrate on the work that has been done in this House, and hope that perhaps other Members might think that an advisable line of attack.

My knowledge stems mainly from being advised over the years since the passage of the Mental Health (Amendment) Act 1982 by the National Schizophrenic Foundation. This is a body of close relatives of schizophrenic patients formed in response to an article in The Times 15 years ago by the late Mr. Pringle. The NSF has now grown to have members all over the country.

It is thus truly a grass roots organisation of people with real practical knowledge of the impact of a particular sort of mental illness on families. My emphasis will thus be mainly on the problems of the mentally ill, though I have some knowledge of mental handicap through being the patron of the Isle of Wight Branch of Mencap. I should add that I have also had many helpful letters from a wide range of people too numerous to mention whose views I shall, in part, reflect.

I am most grateful to the many distinguished persons, who know far more about the problems of mental patients than I do, who are taking part in this debate. I am particularly grateful to my noble friend the Minister Lady Trumpington for sharing with me the introduction of this Motion, and I fully understand why she will not be able to remain throughout the debate. I am particularly pleased that my noble friend Lady Hooper will be winding up for the Government, and I am sure that with her past experience in another other place she will do it extremely well.

I should particularly like to thank my noble friend Lord Renton, the past President of Mencap, and the noble Lord, Lord Allen of Abbeydale, the present president of that body, for contributing. They will be able to fill any gaps of knowledge of the problems of the mentally handicapped that I shall necessarily omit. I should also like especially to thank my noble friend Lord Colville of Culross, the Chairman of the Mental Health Act Commission, for joining in the debate. The first biennial report of that body was recently published and is most encouraging. Your Lordships will have seen that I have arranged for copies of that report to be available in the Printed Paper Office.

I am also most grateful to the noble Lord, Lord Ennals, the President of MIND, for taking part. I hope that he will be able to clarify for us the attitude of MIND to certain activities of doubtful helpfulness. In particular I am grateful to the noble Earl, Lord Longford, for contributing to this debate. His Unstarred Question in March 1981 led to the excellent Richmond Fellowship Inquiry, copies of which I have also arranged to have available in the Printed Paper Office.

The noble Earl, Lord Longford, was joined in that inquiry by my noble friend Lady Faithfull who is taking part in this debate and will be contributing from the point of view of social services on which she is so expert. Another member of the inquiry team, I am delighted to say, is my noble friend the Minister Lady Trumpington. Accordingly, I hope we can look forward to a very helpful contribution and indeed commitment from the Government.

The third paper in the Printed Paper Office is a pamphlet entitled Cart Before the Horse? which is a reprint of correspondence between the National Schizophrenia Fellowship and the Minister of Health more or less continuously between Lord Beswick's debate on the Richmond Fellowship inquiry almost two years ago and this year's summer recess. It is my purpose in this debate to impress on the Government the vital importance of correcting what still appear to be errors in the implementation of their policy.

Before doing so, I should like to turn briefly to the problem of schizophrenics. The Richmond Fellowship inquiry tells us that the mental illnesses most likely to lead to prolonged residence in hospital are schizophrenia and paranoid psychoses of which schizophrenia is much the most prevalent. About one person in a hundred can be expected to suffer from such a condition at some time during their lifetime. At any given moment three people in every thousand are receiving treatment or care for schizophrenia: that is 165,000 people in the population of the United Kingdom. Schizophrenics are also most prone to suicide and to destitution if not properly cared for. Their close relatives are therefore particularly concerned that suitable care at appropriate levels continues to be available for them all the time. I suggest to your Lordships that as such a large proportion of our fellow citizens are likely to be involved in that illness, it behoves us all to support that aim of the families.

In recent years, especially since the foundation of the NSF in 1970, close relatives have come to see that their problems are better handled if shared with others. From this has come a greater understanding of the need to persuade the public that all mental illness is a sickness which does not deserve its social stigma but requires sympathy. Sadly, though, the social stigma remains; and it remains not only in the attitude of those of us who are fortunately spared such an ailment, but also in the families themselves who are all too often shy about admitting that they have relatives who have a mental illness of any sort. Therefore it is important for us all to try to work together to get a general understanding of this illness, and of the others, so that we can overcome this very unfortunate attitude of social stigma.

With that point in mind, a schizophrenia campaign to educate the public is shortly being initiated both in the press and on television—-the latter being a two-part programme each of which will start at 10.30 p.m. on Tuesday, 21st and Tuesday, 28th January. In the meantime, your Lordships will see very well informed articles in most of the major elements of the press during the coming month or so.

In addition, there is a need to know more about the origins of the illness. In recent years it has become more commonly accepted that schizophrenia has at least a partial organic base—that is, physical, biological or chemical—linked with a genetic predisposition. There is thus a need for more research. One body with which I have been acquainted is the Schizophrenia Association of Great Britain which is conducting investigations into the probable biochemical cause of the illness. I have been in correspondence with the Minister about that and perhaps she may have a word to say; but if not, I shall look forward to further correspondence.

I come now to the main points which I want to make to the Government. These can be summarised under four headings. First, there is great concern whether protective care in mental hospitals, or in special wings of general hospitals, will always be sufficient for those mentally-ill patients who at any one time really need such care, either voluntarily or compulsorily. The awful warning of the Italian Psychiatric Care Act 1978—which, if your Lordships are not familiar with it, is mentioned in the Richmond Fellowship inquiry—must ever be present in our minds when considering this factor.

Secondly, there is great concern that where it is agreed that the number of hospital beds for the mentally ill in a particular National Health Service district can be reduced, the necessary community care is not being provided in advance (I repeat "in advance") of any such reductions. A recent statement by the Minister for Health talked about complementary action. That is really not good enough because it is no good having the number of beds reduced before there is full care facility to take the patients the moment the number of beds are reduced. I should therefore be grateful for a reassurance from my noble friend the Minister that her department truly understands the need for advanced community care preparation, and that such care has to be of satisfactory quality.

The third matter for concern relates to families The families are, with the National Health Service, the social services and the voluntary organisations, the fourth caring arm for all mental patients. Their contribution is all too readily taken for granted. In the Isle of Wight, where your Lordships know I come from, I have discussed the matter fully. I am reasonably satisfied that the 10-year plan of the district health authority and the social services department of the county council will meet the first two matters of concern to which I have referred. Furthermore, the local members of the National Schizophrenia Fellowship seem happy with the arrangements so far as they have gone. What the local members are concerned about is the lack of understanding of mental sickness by some general practitioners, the lack of sympathy for the families and their sometimes desperate problems by some psychiatrists and the apparent failure of all concerned to appreciate that parents also grow older and become less able to cope. Thus there is concern that the problems of the families are neither adequately understood nor satisfactorily catered for in the longer term.

The fourth matter for concern is that so-called patient power may develop as strongly in this country as it seems to be doing in the United States and certain European countries such as Holland. In this connection, the support apparently being given to this totally erroneous movement by MIND much concerns me. I hope that the noble Lord, Lord Ennals, will be able to reassure me on this point. I apologise to the noble Lord that I have been so frightfully busy this morning with two other appointments that I never got round to warning him of it in a letter, which I fully intended to. If he cannot answer it here and now, perhaps he can do so in writing later on.

The problem is that mentally ill people can sometimes be incapable of deciding on the best treatment for themselves. There have to be arrangements for their care in the hands of people professionally qualified so to do. If such arrangements are not made, the persons concerned may well be driven to suicide or destitution, and their families will suffer much hardship in the process. Bodies like the Campaign Against Psychiatric Oppression are not only misguided: they are evil.

To conclude, I trust the Minister will reassure me about the Government commitment to keep sufficient hospital care for all kinds of mental patients, as well as developing efficient and sufficient community care in advance of any closures. I trust also that the Minister will convince me that future plans are not too heavily based on extrapolated statistics of doubtful origin. In addition, I hope that my noble friend will convince me that general practitioners are being encouraged to learn more about mental illness and that psychiatrists are being encouraged to learn more about the sympathetic treatment of families. My Lords, I beg to move for Papers.

3.32 p.m.

Lord Ennals

My Lords, may I firstly say how very much I appreciate the decision of the noble Lord, Lord Mottistone, to choose this subject, and the manner in which he has introduced it. As he has said, it is a very wide subject. Bearing in mind that the noble Lord, Lord Renton, and the noble Lord, Lord Allen of Abbeydale, will be speaking mainly on mental handicap, I, like the noble Lord, will probably say more about mental illness, bearing in mind, as he said, that I am chairman of MIND. However, I shall comment on what I suspect he may have meant by "the strange allegations". We shall deal with that a little later. I am most grateful to him.

The subject for debate could not have been more timely, coming as it does just after the Government's (I fear) very negative response to the report of the House of Commons Select Committee on community care, with special reference to the mentally ill and the mentally handicapped. I make no apology for dealing quite considerably with the Select Committee's report, because it took them a year to produce it. It was a major study, with some major recommendations. Though it was produced in another place, I think it is an absolutely basic document which should be considered.

This debate is also timely because it comes the day after the publication of the report of the working party of the right reverend Primate the Archbishop of Canterbury on the inner cities. The latter is an authoritative report from what I think is a distinguished, independent and balance committee. Without touching on the recommendations except to say, "We cannot afford it", the chairman of the Conservative Party, Mr. Norman Tebbit, has concentrated his attention on personal denigration of its membership. I think this is extremely unfortunate. I suppose it is a terrible allegation to say that until 10 years ago the chairman was a member of the Labour Party. What a terrible thing to have been! What a sin! Of course, it could also have been said that he was appointed by the same Mr. Norman Tebbit as chairman of the Manpower Services Commission—and a very distinguished chairman he was—and we all know how high one can rise if one becomes chairman of the Manpower Services Commission.

One may ask: what has this report to do with community care? It has a great deal to do with it. The misery, neglect and degradation of the inner cities is the same misery, neglect and degradation as that of our system of care in the community, but written large. We are not dealing, in the inner cities, with something that does not apply to other parts of our society, but it applies more to the inner cities. In my view community care has become a misnomer. It has become almost a myth, a delusion. I am afraid it is community neglect in far too many cases. Community care is facing a deep crisis of underfunding, as the House of Commons Select Committee very clearly recognised.

The chair of the Association of Metropolitan Authorities social services committee recently strongly criticised the Government's response to the Select Committee's report and to its recommendations, particularly the part in relation to funding. I was interested to receive today a letter from the Association of County Councils, which is of a different political balance, which referred to their general disappointment. It said: the Government's response to the Social Services Committee is obviously disappointing. It has to be said that there appears to be very little in it to recognise the problems identified by this Association"— that is the ACC— and others, and the response appears to be unduly complacent in dealing with what are very real needs". I shall not take it further, but it is a very condemnatory letter of the Government's response to a very important document.

The Social Services Select Committee faced up to the crisis with a package of 101 recommendations. Yes, of course many of them would cost money. "Crisis? What crisis?" seems to be the Government's response in the document that they published a few days ago. They are talking about tax cuts a little nearer the election, tax cuts which presumably would affect people who can afford to pay it. However, they are really saying that there are no additional resources available for the mentally ill, the mentally handicapped, or the elderly with senile dementia. Certainly there are not many votes there. I think these are people who, almost above all in our society, need care and sympathy, and, more than anything, the finance to enable that care and sympathy to become a reality.

The difference between the view of the Government and that of the Labour Opposition is on the matter of the degree of urgency as to the failure to provide effective care in the community. In replying to correspondence from the chairman of the National Schizophrenia Fellowship, referred to by the noble Lord and referred to in the document that he has also very thoughtfully arranged to be in the Printed Paper Office, Kenneth Clarke, in May 1984, when he was then the Minister of State for Health, repeated and gave his support to the objectives of the 1975 White Paper, Better Services for the Mentally Ill. I shall read the section which he cited in his letter: We welcome this oppportunity to stress that our aim is not the closure or rundown of mental illness hospitals as such; but rather to replace them with a local and better range of facilities. It will not normally be possible for a mental hospital to be closed until the full range of facilities described in chapter 4 has been provided throughout its catchment area and has shown itself capable of providing for newly arising patients a comprehensive service independent of the mental hospital. Moreover, even then, it will not be possible to close the hospital until it is no longer required for the long-stay patients admitted to its care before the local services came into operation". That was 10 years ago. I must say that as we look at what progress has been made in the last 10 years I think more and more of us are convinced that we want to see real progress made in closing old psychiatric hospitals provided, as the noble Lord rightly said, services are available in the community. No patients should be discharged from these old hospitals until a plan has been carefully worked out, with the psychiatrists, the social workers, the patients themselves and all the professions involved, to ensure that there is a proper provision for their welfare. There is no use dumping people into a society which does not have the provision to look after them.

I believe that the Government have been very long in words and very short in actions and resources. To quote from the report commissioned by the BMA, the Royal College of Nursing and the Institute of Health Service Management: In services for the mentally ill the local authority role remained relatively small accounting for only 3½6 per cent. of the total spending in 1983–84. Within the NHS the pattern of increased spending which was evident from 1978 to 1982 was not present in later years. Total NHS spending was £963½3 million in 1981–82, £962½7 million in 1982–83 and £965½1 million in 1983–84". Going down each year in real terms. This must be seen as a matter of concern in a service where there is a clear requirement for major new programmes to replace the hospitals". The mental illness percentage of local NHS expenditure is also marginally declining although mental handicap is on a very slight upward trend.

The second report from the Social Services Committee of the House of Commons, which was published in January 1985—and I shall quote two sentences from it—says: We are at the moment providing a mental disability service which is under-financed and under-staffed both in its health and social aspects. Joint finance, they said, as a means of transferring further responsibilities from the HNS to local authorities is now virtually played out. They said that the pace of removal of hospital facilities for mental illness has far outrun the provision of services in the community ro replace them. This is a very serious charge with very serious problems created for those who have been discharged from hospitals and who may not have found their place in the community.

The Social Services Select Committee, as I have said, made 101 recommendations. Your Lordships will be pleased to know that I am not going to go through all of them. I want to pick out just five which, I think, are fundamental. Mental illness hospital provision must not be reduced without the establishment in advance of demonstrably adequate alternative services; secondly, community care must not be done on the cheap; thirdly, genuine community care policies are only achievable in the context of a real increase over a period of years of expenditure on mental health services; fourthly, the DHSS should create a central bridging fund to assist the development of community mental health services. I shall repeat that: a central bridging fund. I think that is essential; fifthly, any growth in staff numbers directly attributable to the policy of community care should be exempt from manpower targets.

I am afraid that the Government in response had very little to say. On the central bridging fund, they said that the recognised need for transitional financing in some form and the resource implications are being borne in mind. Being borne in mind nine months after the Select Committee made its report does not suggest any sense of urgency, let alone any sense of a bridging fund. On manpower targets, they said the Government take account of community care needs in looking at changes in total local authority and health service manpower statistics. They take account of it. On greater parliamentary consideration of mental health policies, the Government will welcome informed debate. That is good. But there really is no sort of promise of any new steps to be taken to deal with what I think most of us here will see as a very urgent problem. The response published, I think, is depressing almost beyond belief.

The crisis is not just due to the fact that the social service departments are screwed down in terms of expenditure, cuts in the rate support grant, grant penalties and the rest which have been put before your Lordships' House on so many occasions; there has been the collapse in the housing programme and the dramatic increase in single homeless people, many of whom have a history of psychiatric problems and many of whom are being driven towards the brink. I believe that there are several factors which we should note in looking at this worsening situation.

Perhaps I may give one or two examples. I referred to the housing programme. The housing investment programme has been slashed by over 50 per cent. in real terms since 1979. Housing subsidy has declined seven-fold, yet housing, decent ordinary housing in hostels, is a major component of community care. Housing is a right everyone should have but the most disadvantaged are being denied this basic right. If we look around, we know that there is a steady and frightening increase in homeless people, many of whom have had a record and a background of mental illness or of mental handicap. It is very distressing. If I may say so, the new DHSS board-and-lodgings regulations which compel young people to move from area to area and push existing claimants into still more sub-standard accommodation can exacerbate mental illness or delay recovery, especially as many ex-patients may get trapped in board-and-lodging establishments because of the difficulty of obtaining furniture grants or other single payments once they are offered council accommodation.

The lack of government money to fund alternatives to the huge institutions is leading to a rundown in beds in those institutions without appropriate alternative care being provided. Here, I am very much talking about accommodation, places where people may live; and although local councils should accept homeless people vulnerable through mental illness as in priority needs under the Housing (Homeless Persons) Act 1977, many fail to do so. Even if they provide accommodation, it is often housing of limited quality and no support is really provided.

There are two other points that I want to make in my remaining few minutes. First, with inadequate professional support and cuts in domiciliary services such as home helps, meals on wheels and care assistance, an increasing burden is falling on the carers. We have to ask whether society is caring for the carers. The vast majority of people who have suffered a mental illness or are suffering a mental handicap live within the community; and they are often much more likely to live in the home than in any sort of institution.

Just over 1¼ million people in our society are caring for a relative or a friend who is severely or very severely disabled, mentally or physically. As many as 5½ million people are supporting a person who could not live safely or comfortably without their help because of age or illness—and 100,000 carers have been doing this for 10 years or more. Some have been doing it for more than 30 years. We have to recognise that those who have been caring for the carers—and the noble Lord, Lord Renton, knows very well about this—carry a very heavy burden. Often they carry it alone and often their lives are hampered by the fact that their first responsibility has to be for the person for whom they are caring.

More women now care for an elderly sick or disabled relative than care for a child under 16, and most of the carers—four out of five of them—are women. So we have an enormous problem of our community lacking in organised community services where the family is having to bear a very heavy responsibility. And not only a very heavy responsibility; they are of course carrying the financial burden. If just 1 per cent. of those caring for an elderly relative gave up, the health and social services budget would have to increase by 20 per cent. overnight. So we see that they are the basis of care in the community, and we have to ask whether we are supporting them enough. I look at their financial problems: for some of them there should be cash payments to compensate for extra costs and the loss of earnings. Carers save the state enormous sums of money. The invalid care allowance—the only benefit available for carers—is not payable to any married woman, no matter what her relationship is to the disabled dependant. It is payable currently only to married men of any marital status, and to single women. I do not think this is any longer acceptable. Perhaps it made sense when it was introduced—it was at least a step forward—but the time has now come to put this injustice right. I believe this is one of the essential tasks we have to do.

My last point was dealt with in a two-day national conference organised last week by MIND, under the heading "Patients become People". Whether somehow or other that is linked with the concerns of the noble Lord, Lord Mottistone, no doubt in his brief wind-up he will tell me. I know nothing about "patient power" but most patients have no power at all and those whose only residence is a mental hospital do not even have a vote, let alone political power or any other sort of power. This is quite different from patient power, or whatever the noble Lord, Lord Mottistone, has heard. I believe that people who are patients must be consulted about their own future. They are people as well as patients. Let me say there is nothing more demoralising than to suffer mental illness. It can be humiliating and destabilising. It can undermine a person's self-confidence and can devalue that person as an individual.

People become patients, and all sense of responsibility can be undermined. There is little joy in being a patient in a mental hospital. There is little joy in being in the community if the facilities are not there. I think the feelings, the hopes and fears—and I say this of mentally handicapped people as well as of the mentally ill—should never be ignored.Sometimes they are ignored or inadequate attention is paid to them. As patients are treated and cared for and go through the process of rehabilitation and resettlement too often they feel that others are programming their future or ignoring their problems. Often, they say, we do not even listen to them. There is no question of patient power. It is saying that patients are people. They should be consulted about their own future. Often of course they are in no position to decide their own future, but they should be consulted about it. I say this with a depth of feeling which I want to convey to your Lordships' House.

I should like now just to finish with 10 quick one-sentence points as a programme. I notice the noble Baroness shaking her head; perhaps she was not, perhaps she was nodding off to sleep—no, she was not nodding off to sleep. Quite often it is said that from this Bench people do not put forward practical alternatives or positive programmes, and so I should like to give now, for the benefit of the noble Baroness, 10 points which I think should be borne in mind:

First, Government must recognise that inadequate community care is no substitute for inadequate institutional care. Secondly, the Government must make money available to fund the transition from hospital care to a local comprehensive mental health service with a central bridging fund or other earmarked funding. Thirdly, regional health authorities must guarantee that the proceeds from all sales of psychiatric and mental handicap hospital land will be retained within mental health and handicap service budgets.

Fourthly, a substantial increase in the housing investment programme must be made specifically to provide ordinary housing in the community for mentally ill and homeless people. Fifthly, disincentives such as rate capping and manpower targets on local government and health authorities to provide comprehensive local mental health services should be removed. Sixthly, an agreed vision for a new service must be formulated by all professionals, consumers, informed carers and volunteers involved in service provision. Seventhly, models of good practice must be developed and disseminated to demonstrate to staff and consumers the feasibility and value of community mental health services.

Eighthly, partnership between health authorities, local government and the voluntary sector and multi-disciplinary collaboration must be the keynotes in developing local community services tailored to individual needs. Ninthly, full consumer particu-pation in service planning and delivery should take place as of right. Tenthly, the invalid care allowance should now be extended to married and cohabiting women, at a cost of £85 million, which is what it would cost the nation.

I believe that that is the sort of programme—very similar to that which was outlined by the Select Committee after its year of deliberation—that the Government ought to take on board if they are to face the challenge of community care which is really utterly failing the mentally handicapped and the mentally ill in our society.

3.56 p.m.

Lord Winstanley

My Lords, I must hasten to join the noble Lord, Lord Ennals, in thanking the noble Lord, Lord Mottistone, for giving us an opportunity to debate a matter which really is of the utmost public importance. The noble Lord, Lord Mottistone, has shown a close interest in this matter over many years. It was a great pleasure to me personally, as a vice-chairman of the Parliamentary Mental Health Group, to welcome him to our meeting last week. It was also a pleasure to note that he came to that meeting not to tell all the professional workers who were gathered together how they should be running their affairs; he came to listen—and the fact that he listened very carefully was evident in the speech he has made to us in introducing this debate.

Like other noble Lords who have expressed an interest in this subject over the years, or those whom it was known were to speak, I have received a great many reasoned and lengthy papers from a great many organisations—professional organisations, voluntary bodies of one kind or another which do such immensely important work in this field. I think that most of your Lordships will have received the papers and documents which have been prepared for us. Obviously it would serve no useful purpose for me to go through all of them, but I think it would probably be useful if I said to all those people who have taken the trouble to compile these various papers that they really have been studied and read very carefully by us all, and the points made in them will not be forgotten and, indeed, will be brought to the notice of those concerned.

I was particularly interested to note that many of the papers, documents, pamphlets and letters that I received came from organisations in Scotland. They said substantially the same thing as the others, but it occurred to me that the administrative structure of the National Health Service and of local government in Scotland was perhaps more suited to making the kind of community arrangements about which we are now talking. In Scotland there is not the same division between hospital and domiciliary medical services as there is in England and Wales, with a total separation of the family practitioner committee services.

For example, it ought to be possible to do as the noble Lord, Lord Ennals, suggested. Let us suppose that an old mental health hospital is sold or, as is more important, some of the very valuable land around the building is sold, raising a great deal of money. Of course that is one of the attractions of the closure programme to the present Government. It is an attraction that I understand and I do not in any way quarrel with it. In such circumstances we want to see the money raised by the sale of those assets transferred to the community services, which are so important in terms of making the closure programme work. I would have thought that could have happened more readily in Scotland, where the regional health boards and the local authorities are much more contiguous and where the relationship is closer than is the case in England.

I want to mention in particular one of these papers to which the noble Lord, Lord Mottistone, referred; namely, Cart before the Horse, which has been produced by the National Schizophrenia Fellowship. It seems to me to summarise most of the anxieties which we have in this field—there are certain things which must be done before other things are done, and I do not think we are satisfied that that is actually happening.

In addition—and again saying that I was much impressed by the unanimity of the comments of all these various bodies, professional organisations and voluntary bodies—it seemed to me that nowhere is the case more clearly summarised than at the very opening of the paper we have all received from the Royal College of Psychiatrists, which is a highly influential and very important body indeed. It merely states this at the outset: The Royal College of Psychiatrists is enthusiastic about the current philosophy of care for psychiatric patients which shifts the focus away from the large psychiatric hospitals. We particularly welcome the concept of treatment and rehabilitation close to the patient's own home". It goes on: We are concerned, however, that psychiatric hospitals are being closed in various parts of the country without prior establishment of alternative facilities". That is the absolute crux of the whole problem and it is to that that we must address our attention, as indeed the noble Lord, Lord Ennals, did.

Let me just from my own professional experience mention three cases which have come to my personal knowledge and with which I have been professionally and personally involved. They are cases which I think illustrate some of the difficulties with which we have to contend. The first of these cases concerns a young man who was a patient, and had indeed been a patient for, I think, 15 years, in Winnick Hospital up in the northwest and that young man was scheduled, if that is the right word, for discharge into the community. I talked to him, and others talked to him, and it appeared that he was satisfied that in the end this was probably for his benefit; that it would be better for him to cease to be institutionalised and to become accustomed again to life in the community.

But he was very worried about the arrangements which were being made. Inquiries were made into those arrangements and proper residential accommodation had been found. There was no doubt that people had been laid on to care for him when he went home. But the anxiety expressed was: how would he manage in a rather frightening world when he had been living in an institution, somewhat protected, for a very long time? The unhappy fact is that before that young man was actually discharged, which was due only a week or two later, he hanged himself. That case illustrates as much as any that we are concerned here with some very vulnerable people indeed.

We all know that in our urban areas there are many frightened people—frightened with good reason—but there are no people who are more frightened, and who perhaps have more reason for fear, than mentally ill patients who suddenly find themselves in a community and in an environment to which they have become totally unaccustomed. If we realise how vulnerable those people are, I think we will make sure that the proper care and services are provided to look after them.

I am sure that we are all looking forward to hearing the maiden speech of the right reverend Prelate the Bishop of Saint Albans. He may very well refer to these matters. I do not always follow all the advice that is given to me by the Churches, but on this matter we would be very unwise indeed if we did not listen very carefully to what the Church has to say to us.

I move on to the second of these three cases. This is a case with which the noble Baroness, Lady Trumpington, is familiar, because she has already dealt with it in Answer to a parliamentary Question of mine some little time ago. This case concerns a social worker in a mental hospital, a girl by the name of Isobel Schwartz, whose father, a professor at the University of Manchester and a microbiologist, is a friend of mine. This unfortunate girl working in a hospital had established a very close relationship with a schizophrenic patient who was subsequently discharged, rather against her will, into the community and into accommodation which proved to be rather unsatisfactory.

The social worker, who had established such a good relationship with this patient, was sent later to move the patient to another place to which the patient did not wish to go. Understandably, in a patient who has come to depend upon and trust a social worker and finds that the social worker is doing something which the patient does not particularly like, that patient developed a resentment of a very deep and pathological nature. Subsequently, as the noble Baroness knows, the patient, who had had no community care at all, in the sense that she had not been seen by a psychiatrist and had not been visited by social workers, although she had been out in the community for many months, marched into the hospital where Isobel Schwartz worked and stabbed her to death. That shows that the workers in this field are people who are also very vulnerable indeed and are people who need protection.

Finally, I would refer to a family to whom I was the general practitioner for some years, and a member of that family—a schizophrenic youth—I sent into hospital. More recently, since I finished active medical practice, that youth was discharged back into the family and I can say from my personal knowledge of the case, which was in Salford, that the family would have been glad to have him back and were welcoming him back, provided that they had the necessary help and support with which to cope with him. In that case that necessary help and support was not available.

The consequences were catastrophic. The young man quarrelled with his siblings, his brother and his sister, and with his sister's husband, who was living with the family because of housing problems. They were all assembled together. The family broke up. He attacked his brother, who left home, the parents quarrelled, the mother became ill and had to go into hospital and, in the end, the young man had to be returned to hospital. That is a case, which was referred to by the noble Lord, Lord Ennals today, in which we had not given enough thought for the carers, the unpaid people in the community, mostly women—perhaps it should not be so, but it is—who do an immense amount of work. But that work can be done only if they receive the professional support and help which they need. That family has virtually been broken up, because the necessary steps were not taken in advance of the discharge of that patient, and the necessary steps were not taken on a continuing basis once the patient had been discharged.

I do not wish to go on longer than is necessary, because I know that noble Lords in all parts of your Lordships' House will be saying the same things. We are going to say that we welcome the general policy of community care. We recognise that it is not a cheap option. It may well be a much better option for the patients, but it can be a very expensive option, and it is an option of which we should avail ourselves only if we are prepared to pay the price in terms of laying on the necessary services and resources within the community.

I should like to see set in the community targets each of which has to be reached before the next step in relation to the discharge of patients is taken. There is a difficulty here. It is that the large mental hospitals and institutions, to which we are referring in this debate, do not recruit from one locality. One hospital does not take all its patients from the nearest town. It takes patients from all over England and Wales or all over the United Kingdom. Therefore, when you are closing a hospital, those patients are not all going into one town. They are going into communities up and down the United Kingdom, which makes it very difficult indeed to harmonise this targeting process, because you cannot merely focus on the nearest town to the hospital which is scheduled for closure.

But what are these targets? First, there is the establishment of adequate hostel accommodation with care and proper supervision, of the kind so admirably provided by the Richmond Fellowship, to which the noble Lord referred, as well as by MIND, many other voluntary bodies and many local authorities, but not all. We need to be sure that there are adequate home helps. That may seem to be a simple thing, but in the community community work of that kind is necessary. When an invalid comes home—and a mentally ill person is an invalid—we need to be sure that the community nursing situtation is adequate in terms of recruitment in the different localities.

We also need to make sure that there are effective links maintained between the community services and the hospital services so that there is a full exchange of information between those responsible for the patient in hospital, and those who later take over the responsibility when that patient is discharged from hospital into the community. The patient should not be moving suddenly from care by one group of experts to care by another group, who have never set eyes on the first group. There must be some kind of communication and some kind of continuing contact between the two.

Finally, I underline once again that we need to ensure that there is effective support for the carers before we lay these additional burdens on them by closing down these institutions.

4.10 p.m.

The Parliamentary Under-Secretary of State, Department of Health and Social Security (Baroness Trumpington)

My Lords, I should like to begin with thanks and with an apology. The thanks are to my noble friend Lord Mottistone for providing us with the opportunity to debate this important issue at a particu- larly opportune time. I refer of course to the publication on 20th November of our response to the Social Services Committee Report on Community Care for Mentally Ill and Mentally Handicapped People. I thank my noble friend for his kind remarks with regard to the Richmond Fellowship Inquiry. I must say with all honesty, and much to my regret, that I was more of a sleeping partner than an active participant in any of the decisions. I greatly admire the work done by the Richmond Fellowship.

The apology is that, as I have explained to my noble friend, I have to leave before the end of the debate. I am most grateful to my noble friend Lady Hooper for agreeing to reply in my absence, and I shall read with great interest those speeches that I miss this afternoon. I look forward very much to listening to the right reverend Prelate the Bishop of Saint Albans when he makes his maiden speech.

Care in the Community as a philosophy is now widely accepted. We have tried in our evidence to the Social Services Committee, and in our response to its report, to say what we mean when we speak of care in the community and why we support it. It is not an exercise in cutting costs, either in theory or in practice. What we are concerned to do is to redirect resources currently concentrated in large outmoded hospitals towards a better quality of life for mentally ill and mentally handicapped people in more appropriate forms of care. I was astonished by the remarks of the noble Lord, Lord Ennals; and perhaps I may remind your Lordships of the support given by the Social Services Committee and by the overwhelming majority of those who gave evidence as to community care as a philosophy and as a practical proposition.

In the words of our response, community care is, a matter of marshalling resources, sharing responsibilities and combining skills to achieve good quality modern services to meet the actual needs of people, in ways those people find acceptable and in places which encourage rather than prevent normal living". In meeting "the actual needs of people" we must recognise that there is no one package for community care that is equally appropriate in all circumstances. If we are moving individuals out of hospitals, it must be to appropriate alternative facilities that already exist. For those who still need to be in hospital we need appropriate hospital care. The means have to be willed as well as the ends. Meeting the actual needs of people also means that those who are actually involved—the consumers and their families—must whenever possible have their views and wishes taken into full consideration as part of the planning process. This Government's emphasis on management reflects our firm view that we need imagination, dedication, and effective management if aspirations are to become realities. The changeover is not easy, and we cannot afford to get it wrong by leaving gaps and inconsistencies. It is only too simple to tackle the easy problems and the easy cases, and ignore special needs and minority groups. Special needs are just as real as ordinary basic needs, and we are paying particular attention to these. We want services to fit people, not services that fit only theories.

One job my department can do is help disseminate good practice. I should like to mention one or two examples. I would commend to your Lordships the initiative of the City and Hackney Health Authority in providing a comprehensive range of psychiatric services, in association with local authority and housing associations, without in this case any reliance on large mental hospital services.

As regards mental handicap services, going north this time, there is the work being done in Bolton, funded by the DHSS as a Care in the Community pilot project. Eighty mentally handicapped people are being transferred from hospital to a variety of community settings. The moves are related to their degree of disability, with accommodation comprising a staffed group house, sheltered living accommodation, family placements, and independent living. The support of the local neighbourhood is being encouraged and developed—and that is enormously important if we are to have real integration in the community

Let me illustrate. In Devon and in Norwich there are different forms of locality planning which seek to relate services to natural communities and build on the strengths and resources of those communities. In some urban areas there may not be a great deal of community identity; but I was encourged recently to hear that two local residents who initially campaigned against a unit for mentally handicapped people being established in their neighbourhood subsequently changed their views so much that they are both now pillars of the management committee. That is the kind of thing we really want to see. I have myself visited a number of schemes that make a deep impression—from homes for mentally handicapped children to flats for former regional secure unit patients. Such schemes involve very ordinary places in many ways, but provide something special for special people.

Throughout the country exciting innovative and beneficial schemes are underway with the aim of supporting people in the least restrictive setting possible. These schemes are devised and run by thoughtful and dedicated people with a concern for improving the quality of life for those in their care. Governments carry the responsibility for providing the means. I dealt with the funding aspect to some extent on 20th November in your Lordships' House when I spoke about the significance of the Chancellor's Autumn Statement. Then there are the mechanisms of co-operation between various statutory bodies which we have developed; and the guidance and dissemination of ideas which we can and do promote. By these means local enterprises can go ahead as part of a co-ordinated and planned network consistent with national policies.

Living as ordinary a life as possible in the community involves some risks, but I was concerned to learn, when I visited the Spastics Society last week, that in one of the recent riots some severely disabled spastic children had been living in the midst of the violence and were at risk from it. We must encourage the community to help handicapped people to live ordinary lives, and I hope that we and the rising generation will respect the most vulnerable people among us and give special help to meet ordinary needs.

Real progress can be achieved only if there is wholehearted collaboration and co-operation between the different statutory agencies and the voluntary sector. An individual may require health and social service support, access to education, training and leisure activities, housing and income support. Service providers tend to think within their own boundaries and responsibilities. The person they are helping sees things rather differently, and does not want—may not be able—to knock at seven doors to get the sum total of what he needs. As one exasperated physically handicapped "client" put it: being disabled is a full-time job.

Access to services and movement between services must be carefully managed so that individuals or their families are not left in the gap where a service ought to be. I feel I must spell this out yet again—people leaving places where their lives have been organised for them need help in coping with unfamiliar situations. For instance, there is the board and lodging situation, to which the noble Lord, Lord Ennals referred. He knows very well that people returning to the community will not be subject to time limits. This House has discussed the supplementary benefit regulations more than once and I do not propose to go over them in detail now. I will just emphasise that, in line with our policy of support for the voluntary sector, supplementary benefit can be paid to support people in homes up to a limit. It is of course right that there should be a limit to protect the interests of the taxpayer. However, from 25th November the limit for those in residential care is £130 in the case of mentally ill people or £150 per week for mentally handicapped people.

I am encouraged that quite a lot of the central initiative funding or local resources have been used to establish community teams of link workers, which make genuine co-operation possible and help to secure an access point for those needing help. Thus key workers have been found helpful in putting a human face to the comprehensive service—giving people a particular person they can trust and to whom they can relate.

Central Government have, as the Social Services Committee report remarks, a responsibility for seeking consistency across departments in their own planning and in the messages they issue. We shall continue to impress upon statutory authorities their responsibilities for joint planning and the joint use of resources. Nobody argues about that principle—the practice is not always what it might be. We have switched from confidential to open reports from the Health Advisory Service and the National Development Team for Mentally Handicapped People, and have completely reshaped the role of our own social work service, to make it a social services inspectorate, to encourage and disseminate good practice, including joint working and planning. Where the statutory authorities are concerned we do not accept the notion of a single body providing a "total service"—for all its seeming attractions.

I find that concept unattractive. Such a service would be subject to the criticisms directed at the old all-embracing institution concept. Co-ordination and co-operation are feasible, and there are places where, with goodwill and sound organisation, they are being secured. I am always encouraged, for example, by initiatives such as that of the North Western Regional Health Authority in sponsoring a community care conference jointly with the Central Council for the Education and Training of Social Workers.

My noble friend Lord Mottistone spoke from his great knowledge of the Schizophrenia Association of Great Britain. To take up one of his points, I and my colleagues agree entirely with the association in the desire to expand research on mental illness, including schizophrenia. However, the sort of grant which the department is able to make to certain voluntary bodies cannot be given for research purposes. The grants are given under Section 64 of the Health Services and Public Health Act 1968, and are given to voluntary bodies which are primarily engaged in providing services to patients or clients in the field of health and personal social services. What we and the Medical Research Council do is to fund actual research studies, and we have funded a number of research studies in the field of schizophrenia. It is undoubtedly a problem of the greatest importance, and it is exciting that some information relevant to its origins is now being revealed by research.

My noble friend asked for an assurance that we mean to keep sufficient hospital care for all types of mental patients—I take that as meaning mentally ill people—as well as developing community care. I readily give him that assurance. Indeed, I think he and the noble Lord, Lord Ennals, will find such an assurance contained in the correspondence the fellowship had with my right honourable friend the then Minister for Health which has been published in the Royal College of Psychiatrists bulletin.

I know of the Schizophrenia Fellowship's worries about statistics being used to justify an unreasonably low number of beds. As noble Lords will know, we are pressing health authorities to see that every district has its own comprehensive psychiatric service, instead of the previous pattern where patients often travelled to a distant hospital. In our policy paper we stress that districts should make their own estimate of local needs, but we provide some information about current good practice in meeting the in-patient needs of different groups. Very broadly, it suggests a need for rather more than 200 beds for the average district, or, adding in the few specialised units such as the regional secure units, rather more than 50,000 for the country as a whole. Well over half of those are for elderly people.

Current statistics show that numbers of beds occupied by most groups of patients are remaining about the same, but the "old long stay" patients, left from an earlier pattern of care, are growing steadily older and reducing mainly through death. We think that from this cause the present in-patient figure—66,000 at the end of 1984—is likely to fall over the next 10 years by more than 5,000, and we also believe that current initiatives towards care in the community for long-stay patients will reduce numbers by something under 5,000. These are extrapolations, but they are pretty straightforward ones, and again they suggest a need for more than 50,000 beds. I share a dislike of calculations which assume that, because there has been a trend in the past, we necessarily want that trend to continue in the future. But noble Lords will see that in this case an approach based purely on good practice gives much the same result.

I must add, too, that there is a very general hope that we shall find when we have provided such local community-oriented services that they in fact reduce the need for in-patient care. If experience justifies the claims made, I hope—as we must all hope—that the need for in-patient care will fall lower. But I stress that we shall not lower our good practice advice unless and until that becomes not merely a hope, but a fact.

I want to say a word about that difficult subject—money. The spending on mental health services (mental handicap and mental illness) was £1,657 million in 1983–84—the latest year available—for health and social services; an increase of about 18 per cent. in real terms over 1978–79. That does not cover social security, housing, general social services not attributed to particular groups, etc. Financial management strategies are being designed at regional and district level to allocate resources in line with service priorities; for example, from some large hospitals to services provided in the community. The department has encouraged health authority treasurers to share their views and experience. Central finance has provided extra support for mental health services. For example, for the elderly there has been £6 million to encourage development of comprehensive local services.

We recognise that property represents one of the National Health Service's most valuable assets and that efficient management will maximise the resources available to health authorities for improving services to patients. Earlier this year, therefore, we lifted the restrictions on the sale of NHS surplus land and property, so that redundant mental hospitals can be sold on the open market, thus releasing the maximum amount of money to develop better community-based services for mentally ill and mentally handicapped people. So, for example, Rotherham Health Authority has released resources through the closure of Aughton Court Hospital, and North-East Essex Health Authority through the closure of Essex Hall. Both hospitals are of course small. The closures and sale of those hospitals have released money for the more effective implementation of community care. I gladly repeat that which I have already told the Schizophrenia Society—that money raised from the sale of land and buildings will be used for care in the community and will not go into the compartments of other purses of the National Health Service.

The Social Services Committee has expressed a lack of confidence in the effectiveness of joint finance arrangements to facilitate and encourage the discharge of long-stay patients and to bring about the establishment of matching services in the community. I would answer the committee by underlining the many considerable achievements so far under joint finance arrangements, which have enabled authorities to launch jointly planned schemes which would not otherwise have got off the ground.

One hundred and five million pounds has been allocated to health authorities for spending in this way in 1985–86 and, judging from past experience, about 40 per cent. of this money will be spent on mental handicap and mental illness services. The takeup rate for money available under joint finance mechanisms has been 98 per cent. over a nine-year period, and in the most recent year was at the same high level. The money is available and it is being used.

Transfer of funds within the RHAs and from the RHAs is providing bridging funds for the Care in the Community initiative, and helping to provide, for example, staff and capital investment for adult training centres. These arrangements are both flexible and long-term. Nearly all regions now have explicit strategies for funding community care, including inter-district transfers of resources with responsibilities, and the build-up of bridging funds.

We have, through Care in the Community funding, also made available £16 million for pilot projects. In terms of central funding £10 million has been made available to help relocate children into appropriate settings with appropriate services away from large mental handicap hospitals. This has had considerable success, with the number of children in NHS hospitals and units falling from 7,100 in 1969 to 1,070 at the end of 1984. Some of the children have simply grown up, but the money has secured good quality homely units for many others. Children need to grow up in a place where they can be cared for as children. We are chasing health authorities to achieve this as quickly as possible—by using ordinary houses and families to the maximum extent.

I turn briefly to social security. We have said in our response to the Social Services Committee that we recognise the importance of social security for mentally ill or mentally handicapped people living outside hospital, with either no earned income or with some income but with special needs. The payments for residential care places, for example, have been set with this in mind; and in our review of social security we have taken into account their other needs. The Green Paper proposes that those disabled by mental handicap or mental illness will be covered by the new higher income support rates proposed. One small but significant example of our concern is the proposal contained in the Green Paper to increase the supplementary benefit earnings disregard for people receiving the disablement premium from £4 per week to £15 per week, giving increased scope for incentive payments in adult training centres. We are also concerned to provide clear information about benefit rights, and ready access to those rights both in hospitals and in the community.

There is, as the Government response acknowledges, a price to be paid for the new pattern of services. The cash price is reflected in the increasing mental health service expenditure in recent years, to which I have already referred. Quality and flexibility cannot be bought cheaply. The big gain is that we shall be paying for services that we do want instead of ancient buildings that we do not want. We are not closing hospitals without alternatives being provided. I cannot repeat too often that not a single large mental hospital has yet been closed and that many of those for which there is now a closure timetable are already half empty. If we wanted to go for simple relocation of patients we could close a substantial number of hospitals without discharging a single patient. That is not what people need.

The other obvious price of change is the need for an enormous adjustment in training, attitudes and responsibilities. Community care is about consumers, and that was not always true of the old service. Change is not easy to handle, and we all owe a great debt to the pioneers—not least the nurse pioneers—who led the way out of a hospital-dominated service into a radically new way of doing things; a way which recognises that in many places 95 per cent. of the consumers are outside the hospitals and 95 per cent. of the resources within them. We also owe a great debt to the many dedicated people working within the older institutions, often under less than ideal circumstances, discharging a very high standard of care to those whom they look after.

We cannot afford to be complacent about what is still to be achieved. We must continually review the services we provide and ask ourselves at all times whether what we are providing is appropriate for the people who are receiving it. We do not yet have all the answers. Some of the questions are not yet entirely clear. We shall certainly study most carefully the various points which arise from today's debate. We are always ready to accept new ideas. Progress sometimes seems painfully slow, but it must not be rushed; and I say that deliberately in response to the accusation sometimes made that we are rushing. Seeking commitment to firm timetables is not the same as rushing. What we are seeing is planned and responsible progress. The encouragement lies in people living fuller lives in the community, in some cases after very many years away from the community—people who would not ever want to go back into the great institution that was their home for so long. There are out in the community people who need a good deal of support but who now have the confidence that they will not have to go into hospital to get it.

I think it would be a great pity if this subject in any way turns into a vulgar political brawl. We all have the same end in view. We know that Care in the Community can work. It is the business of all of us to make quite sure that it continues to do so in the very best way possible for consumers, families and all those involved in caring for both those groups.

4.37 p.m.

The Lord Bishop of Saint Albans

My Lords, this is my maiden speech and I wonder at my temerity in making it so soon after my introduction into your Lordships' House just six weeks ago today; but I am given to understand that there is a tradition of tolerance, even of indulgence, to maiden speakers and I am relying on that to sustain me.

Before I became a Bishop and discovered that I was joining the ranks of Marxist theologians, I had spent virtually all my ministry on the London Underground. I began in a parish on the Northern Line. I proceeded from there to the Piccadilly Line and then eventually to a living on the Central Line; and I finished up as Archdeacon of West Ham. I confess that just occasionally I prayed to the good Lord that he would move me a little out of range of the North Circular Road. When I received, five years ago, a most gracious letter from the Prime Minister inviting me to become the Bishop of St. Albans I almost heard the Lord say, "I did hear you, but only just"; for instead of the North Circular Road I now have the M.25, which represents not just an excellent modern ring road (which will be even better when my bit has been completed) but also marks out the ring of mental institutions built by our Victorian forefathers some decent 10 to 20 miles away from their respective catchment areas.

No less than six of these are found within five miles of St. Albans. That is why the temptation to speak in this debate initiated by the noble Lord, Lord Mottistone, has proved irresistible. Of these six major hospitals, three are for the mentally ill and three for the mentally handicapped. They all deserve good publicity and I cannot praise them too highly for the heroic work they do.

I should like to restrict my remarks this afternoon to the latter group, represented by Cell Barnes Hospital in St. Albans, by Harperbury and by Leavesden. Between them they cater for nearly 3,000 mentally handicapped patients, ranging from those who probably never needed to be sent there in the first place but have now become chronically institutionalised, a high proportion of them being geriatrics, to highly disturbed adolescents who have to be protected from the consequences of their own strength and occasional violent outbursts, and embracing patients who combine physical and mental handicap to such a degree that they need total round-the-clock care.

The avowed strategy of the North-West Thames Regional Health Authority in pursuance of the policy dictated by national Government is that: All Districts should over the next decade develop increasingly comprehensive local services for mentally handicapped people … with the aim of ending the provision of residential services in hospitals.". Two priorities are outlined: first, the establishment of new homes in the community for children and young people wherever possible, and secondly, the running down and closure of one of those hospitals—Leavesden—within the next 10 years. I am not here to bore your Lordships with arguing a particular case, or describing a particular location, but I have spent some time visiting these institutions and perhaps I may be permitted to make some general observations arising from my visits.

First of all, let me say on behalf of the Church of England that of course' we wholeheartedly welcome and support the Government's policy of restoring the mentally handicapped to community care. This reversal in the 1980s of what was done in the 1890s by a body described as the National Association for the Care and Control of the Feeble-Minded, whose aim was the lifetime segregation of defectives, is much to be applauded. The policy is right in principle and the Church wants to play its part in ensuring that it comes out right in practice.

In a very moving debate in the General Synod in July last year, a report of the Board for Social Responsibility was received on The Local Church and Mentally Handicapped People and resolutions were passed welcoming the development of policies aimed at enabling a greater number of mentally handicapped people to live in the community; noting that fresh resources need to be made available if these aims are to be realised; and commending the consideration of the subject to dioceses for study and action.

In the Churches we are slowly waking up to the needs of the mentally handicapped. I guess that throughout the dioceses of the country at present this is firmly on the agenda and I have already received responses in a similar supportive vein from as far afield as Portsmouth, Devon and Manchester and from other parts of the Church.

But what can the Churches do to help? First, they can play a significant role in joining with what has to be a quite massive educational campaign to help ordinary people in our communities not to be afraid of the mentally handicapped but to treat them as human beings and welcome them as neighbours. Such education is still sorely needed. Far too few people have ever met, let alone related to, those with either mild or severe abnormalities. I can still vividly remember as a child walking in the local park with my family and seeing a crocodile of mentally handicapped men and women stumbling along on an organised walk, grunting, waving and grinning at all and sundry. I remember being told sharply, "Look the other way, John". I am sure my mother was more concerned to prevent me standing and staring in the roadway; but looking the other way has been the conditioned reflex of generations of Englishmen, and I sometimes reflect on that episode and wonder which was the greater handicap—the handicap of their brain damage or the handicap of those of us who, for all our health and strength, did not have the resources to look into their eyes and give them back a friendly wave.

Secondly, the Churches can enlist the support of volunteers who can help in the hundred and one neighbourly acts which such homes for the mentally handicapped will require, offering transport, companionship, acceptance and social life for those who come to live in the community. This we shall try to do, but I hope that such voluntary service will never be regarded as a substitute for, but only as a supplement to, the statutory care to which the mentally handicapped are entitled. As all those who are engaged in voluntary work know only too well, if too heavy burdens are laid on voluntary shoulders the supply of help sometimes dries up.

Thirdly, the Churches are already developing meeting places with the mentally handicapped through such organisations as the L'Arche communities or their satellite Faith and Light communities, which owe their inspiration to the Roman Catholic church. I hardly need to tell your Lordships that L'Arche is French for "the Ark". These "arks of acceptance", which are becoming increasingly ecumenical, are built on the principle that "We are all handicapped. For some the handicap is external. For others it is the handicap of selfishness and pride". Their charter goes on to say that, "each person, handicapped or not, has a unique and mysterious value". The L'Arche community brings together the mentally handicapped and those who care for them in a residential setting for living, working and praying together. Faith and Light communities invite the mentally handicapped, their families and friends, to a regular monthly meeting for sharing, celebration, social activities and prayer. As their founder, Jean Vanier, put it: The important thing is to meet, to listen to the man, woman or child who is mentally handicapped, to get to know him or her so that real bonds are created between us. In this way … nobody feels left out. We try to carry one another's burdens and to encourage each other on our journey to Jesus". In these and in other ways, the Churches will continue to do what they can to support these mentally handicapped treasures of our society in the changes that are properly taking place, thanks to Government initiative. But there are anxieties and I should not be honest if I did not voice them and ask for appropriate reassurances, while at the same time thanking the noble Baroness, Lady Trumpington, for all that she has already given.

Others before me have voiced the need for greater resources if care in the community is to be a success and not a nightmare. I shall not labour the point, but on Sunday afternoon I visited a ward at Leavesden Hospital where 23 pathetically incapable, mentally handicapped adults were being nursed by only two members of staff. It is a ward which, for 24-hour care, seven days a week, has a total staff complement of only six full-time and one part-time nurse and I know that no community care for that number of patients in that kind of condition would be possible without at least double that staffing ratio.

So let me simply plead that the pace of change from hospital to community is never allowed to outstrip the provision of adequate resources. Furthermore, if dispersal is to take place, it must be done with an eye to the needs of the patients. What is their community? Most of them come from London boroughs but their London borough of origin may mean nothing to them after 25 years in an institution. There are no family or friends in Ealing or Hillingdon to take an interest in them. Their community is the hospital. That is where their friends are—the staff, the social club, all their security. If they move out of the building, may they never by wrenched away from the only relationships that currently mean something to them.

For some of them, their community may be in Watford, where they will probably be placed. Yet, how sad it is that Watford Borough Council, which will need to give planning permission for the establishment of group homes, and the local community health council have both complained that they were not fully consulted about the proposal to close the hospital and so have pledged to fight the health authority's closure plans. How important it is, therefore, without taking any sides in the matter, to ensure full and widespread consultation if these plans are to succeed.

Finally, I have been asked by those who are devoting their lives to this work to make a plea that Her Majesty's Government combine with their enlightened policy of community care a determined, long-term programme of research through the Medical Research Council into the factors that produce mental handicap. I was quite astonished to be told—whether on good authority or bad—that only about 15 per cent. of all mental handicap could be identified as to its cause and origins. I may be wrong. But, if this is indeed so, community care must be regarded as only an interim solution on the much longer road of research that leads to greater success in the prevention of any handicap that can possibly be prevented.

4.52 p.m.

The Earl of Longford

My Lords, it is a privilege to follow the right reverend Prelate and to congratulate him on his very moving and very well-informed maiden speech. The noble Lord, Lord Winstanley, who is himself well qualified in this field, said that we did well to listen with special interest to anything that the Church had to say. I agree. The speech of the right reverend Prelate will perhaps send us back once again to the Gospels, where we shall read the story of the miracles. The right reverend Prelate will be able to tell us offhand what proportion of those miracles were miracles of mental healing and what were of physical healing. Some may be considered to be on the borderline. At any rate, in the Gospels mental illness and handicap and physical handicaps of all kinds are placed on an equal footing. That has never been so in society. Everything that the right reverend Prelate has said will help us in that direction.

I should also like to thank the noble Lord, Lord Mottistone, for initiating this most timely debate and for the kind things that he said about the Richmond Fellowship and their report which emanated from a committee of which I was chairman. I shall concentrate on those aspects of this subject which I believe are usually assigned to a Back-Bencher, rather than cover the whole field. I am glad to think that I shall be followed by the president of Mencap, whose name will always be honourably associated with mental handicap. I was once chairman of the National Society for the Mentally Handicapped. I am glad to think that he will be dealing with that subject, as no doubt will the noble Lord, Lord Allen, when he rejoins us.

As the noble Lord, Lord Mottistone, said, I initiated a debate nearly five years ago. I am sorry that we have lost the services of the noble Baroness, Lady Trumpington. Did she have to leave us?

Baroness Hooper

My Lords, yes.

The Earl of Longford

My Lords, I was going to say one or two things in reply to her, but the noble Baroness, Lady Hooper, in her debut in winding up a debate, will no doubt dispose very effectively of anything that I say about the noble Baroness, Lady Trumpington. Nearly five years ago, I initiated a debate on this subject in this House, and that led on to the Richmond Fellowship Committee. That, in turn, led on to the debate started by my noble friend Lord Beswick, who has made such a notable contribution to the work of the Richmond Fellowship Committee.

It is interesting, glancing through the report and looking at the names of members, to find—not only the name of the noble Lord, Lord Winstanley, of the noble Baroness, Lady Faithfull, who will be speaking, and of the noble Lord, Lord Beswick, but also that of the noble Baroness, Lady Trumpington. Although she has said that she did not play a large part, she was a most valued member. Apart from anything else it was important to have two leading Conservatives as strong and unchallengeable as the noble Baroness, Lady Faithfull, and the noble Baroness, Lady Trumpington. It is impossible for Mr. Norman Tebbit to say, in view of their memberships of our committee, that we were just a lot of Marxists. Perhaps he did not say that. He may have said something worse. I forget exactly. At any rate, it is impossible for him to criticise the composition.

I was going to say, had the noble Baroness, Lady Trumpington, been present (but I feel bound nevertheless to say it in her absence) that there is a sentence in the report which, although it is true that it was written by myself, is something for which she must be thought to share responsibility. I said: We all share"— that is the whole committee— a profound conviction that this sphere of social need has been hitherto scandalously neglected". If it was scandalously neglected in 1983, no-one can pretend that it is anything else but scandalously neglected now. So when the noble Baroness, Lady Trumpington, says that she hopes there will not to a vulgar political brawl, I must make plain that many people outside the Government circle consider that the present provision for the mentally ill and the mentally handicapped is grossly inadequate. That is just a conviction. It does not involve any comment on the sensitivity or lack of it among those who are responsible for Government policy.

It stems, I suppose, from the Government's peculiar economic policy. Mr. Lawson, the Chancellor, has said that we are having a boom and that the whole country is going ahead fast economically: yet at the same time we are undergoing a period of such extreme stringency that we are unable to provide very much to help the mentally ill. It is true that Mr. Lawson was once my pupil at Oxford. He may have picked up this sort of double talk from me. If so, I apologise.

Lord Ennals

Shame on you!

The Earl of Longford

My Lords, it is no doubt all my fault. Wherever it came from, this is what we are told by our rulers. They are making a great success of the economy, but nothing much can be done to improve the lot of the mentally ill. I do not wish, however, to speak in a controversial spirit. I wish to deal with a few points that arise from the Richmond Fellowship report.

The House must not be frightened if I say that I shall allude to seven points. I shall only have about a sentence to say on each. I shall therefore remain within reasonable limits. Our first suggestion was a designated Minister with special responsibilities for mental health. I do not want to quibble over this. One can argue as to whether or not we have one at the moment. The noble Lord, Lord Glenarthur, did a very good job in his time. He certainly took a special interest in mental health. The appointment of the noble Baroness, Lady Trumpington, is very welcome, not only because she is so popular but also because she is very forceful. I feel that if anyone in her particular situation will be able to make an impact it will be her. But it remains unclear at this moment whether the noble Baroness, Lady Trumpington, can be what I called in 1983 the designated champion of the cause of the mentally ill and the mentally handicapped. I do not think that at the moment that point has been clarified. I hope that as time goes on she will establish the same kind of influence as, shall we say, Mr. Alf Morris had when he was Minister for the Disabled. That is what I have in mind.

Secondly, the establishment of a development fund for care in the community initiatives was proposed. The development fund has not yet been established, but the Government have indicated that they may put extra resources towards providing for people who are moving from hospital into the community. Let us be hopeful—perhaps not too hopeful—about that.

Thirdly, we suggested a DHSS planning board on which the voluntary sector was represented. As far as I can see there has been no move to establish a planning board with a voluntary sector representation. This is most unfortunate because of the immense contribution which the voluntary sector can make. One or two nice and very well-justified things have been said about the Richmond Fellowship, which has done such great work in the voluntary sector over all these years under the auspices of that amazing woman, Elli Janssen.

Fourthly, it was proposed that co-ordinating mechanism should be established in every district with representation from local, statutory and voluntary interests. I understand that there has been a little movement here but the overall picture is still very unsatisfactory.

Fifthly, it was proposed that a monitoring mechanism along the lines of the schools inspectorate should be established. Again, there has been a little progress here. Plans are afoot to extend the work of the social services inspectorate under the Registered Homes Act. The Richmond Fellowship, despite some criticisms of that Act, welcomes the Registered Homes Act as a positive move. Therefore, I do not want to be churlish; I would say that one should be grateful.

Sixthly, there was the recommendation that coordinated care should be available at grass-roots level for all identified as being in need by reason of severe mental illness or disability. In a sense, that is the core of the whole discussion and I cannot do better than endorse what has been said by the noble Lord, Lord Ennals, who has a unique, double-barrelled kind of experience in this field.

Lastly, the inquiry asked that in-service training schemes and specialist training courses should be set up in centres of excellence. I shall give one example before I close. The Richmond Fellowship College has been developing staff training in this field for 25 years. It should be actively involved with the statutory agencies in planning for the training needs of staff during the next decade. I would hope that the Government would accept that submission and act accordingly.

Much could be achieved by administrative changes, some of which I have outlined. The temptation must be resisted to believe that the switch from institutional to community care automatically solves the problem. It could do more harm than good. I do not say that it is doing more harm than good but that it could, as explained by the noble Lord, Lord Ennals, and other speakers.

I said earlier that the Government refused to provide larger resources because of their sincere economic beliefs. Because of that particular kind of economic doctrine they are refusing to do what is necessary to provide an adequate service in this country for the mentally ill. Much could be done, as I say, by a more intelligent use of the resources. But in the long run we must be prepared for a much greater provision of resources and in that clear sense, therefore, to sacrifice ourselves, to tax ourselves much more boldly than we have done hitherto, if we want to provide a service for the mentally ill and the mentally handicapped that is worthy of a Christian country.

5.4 p.m.

Lord Renton

My Lords, first, I should like to join with the noble Earl in congratulating the right reverend Prelate the Bishop of Saint Albans. I am sure that all of us were extremely impressed by the depth of knowledge that he has already acquired of the mental hospitals and other places in his diocese.

I should like to endorse what he expressed as a mere hope, but which seems to me already to be fact; namely, the work done by the Church in improving public understanding of the character, the personalities and the needs of mentally handicapped people. My own experience of it was in his own cathedral because I was once invited to open an exhibition there of art by mentally handicapped people, some of whom could not even speak. I can only say that I wish that I had been able to do as good paintings as they did.

Perhaps I may say on a personal note that I have always had a great affection for St. Albans because, from about 1938 onwards, it was for family reasons my home from home. My sister-in-law lived close by and I got to know the place so well. I wish the right reverend Pelate well in his new diocese. I am sure that he will have a most fruitful time of service there

It is always a pleasure for me to hear the noble Earl and a privilege to follow him. I think that your Lordships should be warned that you have a kind of Mencap hat trick on your hands this afternoon. Your Lordships have heard the noble Earl who is a past chairman; I am a past chairman and president: my noble friend Lord Allen of Abbeydale is now chairman. We are all speaking in I hope fairly quick succession.

I am glad that my noble friend Lord Mottistone chose this subject today. If I may let the cat out of the bag, this was the day on which a Conservative Back-Bencher was entitled to choose the subject and I am glad that the noble Lord chose this subject of the problems related to mental illness and mental handicap because it is further evidence that Conservatives care just as much as other people about these problems.

We welcome the activities of MIND, of which the noble Lord, Lord Ennals, is the distinguished President, of the Richmond Fellowship, and so on. One must always allow the noble Lord, Lord Ennals, a little political licence; but I felt that the somewhat critical speech the noble Lord made of the Government's performance was well answered by the very impressive facts and figures about government action already taken and to be taken in this field given by my noble friend Lady Trumpington.

We genuinely welcome the support of associated pressure groups, but I think that we can claim that in Mencap we have used the resources available to considerable effect, as I shall show in a moment. Of course, as the Richmond Fellowship report mentions—and as the right reverend Prelate mentioned—it was with the best intentions that our Victorian predecessors built these vast institutions; spacious buildings in spacious grounds with farms and gardens and some opportunities of doing work.

I have been in four of these places myself—as a visitor, I hasten to add—and they were in a kind of way most imaginative. But they involved what the right reverend Prelate correctly called segregation from the rest of life; and that was the objective. It was intended to give protective surroundings and a protective existence for people who, it was assumed, could not lead ordinary lives. I am afraid that has to continue for many of them for some years. Those who went in when they should not have done, when they were young, become completely institutionalised. For those adults who could go into the wider world, of course, it is a tremendous leap in the dark; for those who have for many years, or even a few years, lived in an institution suddenly to try to lead an ordindary life. Goodness, we who call ourselves ordinary people have problems enough in managing our lives! The difficulties of transition for these people are very great. Therefore, those noble Lords who have referred to the need for improved arrangements to secure that transition does not take place too hastily or without proper advance preparation are, I suggest, dealing with the crucial point that arises in this debate.

It was not until the Royal Commission report in 1957 recommended that there should be a complete change from the institutional practice of having people in large mental hospitals that a move started. That was less then 30 years ago. Seeing my noble friend Lord Broxbourne in the Chamber—and I am very glad that he is speaking in the debate—reminds me that the first legislation to reverse the process was his Mental Health Act 1959. It is interesting that Part III of that Act used the then existing law. Residential homes for ordinary people run by local authorities and nursing homes, whether run by local authorities or privately, could under that Act be used for those who were "mentally disordered"—that was the phrase used—but the Act said that the numbers should be limited by the authorities. Under the 1959 Act it became a criminal offence for anyone to take more people than the number allowed into any one of these nursing or residential homes. At the time we felt that that was right and I was one of the junior Ministers who had to help my noble friend with regard to that Act, and I was proud to do so. If the scheme were thoroughly thought out again, we would probably not make that a crime.

However, that was the start of this new system which so many of us have been discussing today. As my noble friend Lady Trumpington pointed out, it is a system in which the health service, the local authorities, and above all the voluntary bodies which provide services, have an important part to play. The noble Earl, Lord Longford, and I are both patrons of the Ravenswood Foundation which has done wonderful work establishing a home for about 140 people, but they are not herded together in one building. It is a very open plan, with separate chalets and a number of separate buildings for training; it has a magnificent heated swimming pool, and so on. That has mostly been built without government funds. Public funds are used to support people when they are there, but the capital was generously raised by the Jewish community. Several million pounds were required to provide the home for those 140 people.

I come now to deal with the contribution made by Mencap. After the White Paper of 1971, which was an attempt to deal with the situation, it was found that the position was not quite satisfactory and the kind of complaints about which we have heard today were already being made—namely, that people were being discharged from mental hospitals without proper alternative provision being made. That worried us a great deal at Mencap. In 1980—and I am necessarily jumping the years because of time—my right honourable friend Mr. Patrick Jenkin was Secretary of State for Health and Social Security. He attended a Mencap conference and said that he wanted to encourage the voluntary bodies to provide further accommodation. He offered us £1 million, spread over four years, on a pound-to-pound basis. In other words, for every pound that we contributed towards this development, he would contribute a pound up to £1 million spread over a period of four years. It sounded splendid and we rejoiced, but we found that conditions were attached which made the money unacceptable.

However, we were not daunted by that because we already had our own housing association. By the time Mr. Patrick Jenkin became Secretary of State for the Environment we found that we were able to get large sums for our housing association to develop these small residential homes and hostels for the mentally handicapped who were being discharged from large institutions. We have already provided 40 small homes at considerable expense to ourselves as well as to the public purse. Each of these places holds between five and eight mentally handicapped people, all of whom are adults. To provide 40 such homes in the past four years is not a bad start.

I am pleased to be able to tell your Lordships that we have 78 more projects under way which we shall get built with housing association grants amounting to £5 million from the Department of the Environment. We do not keep this a dark secret, and I mention it in the debate in case other voluntary bodies can jump on that rather valuable bandwagon. So it goes on.

However, from the figures I have given of 78 places with an average of seven people in each, your Lordships, by quick mental arithmetic, will see that a very large amount of money is needed just to start these homes going. We in Mencap furnish them and then we have to staff them. So far we have succeeded in doing so despite the problems to which people have referred about staffing. We have found the staff, and I hope that we shall continue to do so.

Other voluntary bodies are making similar progress. It is progress mainly with regard to adults. I was greatly heartened to hear my noble friend Lady Longford—I apologise, I mean Lady Trumpington; I hope that both my noble friend and the noble Earl will feel complimented by the confusion in my mind—point out (and this is very fundamental) that in the past four years the number of children in mental handicap hospitals who did not need medical attention but who were just there because there was nowhere else for them to go at the time, has been reduced from over 7,000 to just over 1,000. That shows that this process is moving in the right direction.

One could go on and say much more, but I just want to conclude on this note: I think that my noble friend Lady Trumpington was quite right in saying that we do not want to make this into a vulgar party squabble. Indeed, the fact that so many Members of your Lordships' House take a deep and caring interest in this matter is further evidence of the proposition that a civilised society can be, and should be, judged partly by the way in which it treats those of its citizens who have the misfortune to be mentally ill or mentally handicapped.

5.21 p.m.

Lord Allen of Abbeydale

My Lords, it seems to be no secret that I am currently chairman of Mencap, but I suppose I ought also to say that I have the special interest of being president of the League of Friends of Broadmoor. Although these are interests, I may hasten to add that they are by no means financial interests.

Like previous speakers I am grateful to the noble Lord, Lord Mottistone, for choosing this important subject for debate today. It is a subject which is difficult and, as he said, wide-ranging; so wide-ranging, indeed, that in the time available I myself propose to pick out just three salient points. I do so the more readily as the major issues have already been well covered earlier in the debate. We are particularly fortunate in that the debate has been illuminated by so notable a maiden speech as that delivered by the right reverend Prelate.

I have just one preliminary point. I notice that the House of Commons Select Committee, about which we have heard so much, said that it was a mockery of community care if mentally disabled people were dumped on the prisons simply because there was nowhere else for them to go. I was greatly tempted to go back to the long-running and rather deplorable story of the regional secure units, safe in the knowledge that if I did so I would at any rate have the sympathetic support of the noble Earl, Lord Longford. But I decided to resist that temptation and simply to express the hope that this is a topic to which we shall revert in another debate at a fairly early date.

Instead, this evening I should like to begin with a hard, practical issue, that of mobility allowance; an allowance which is payable to those who either are unable to walk or are virtually unable to do so, however "walking" may be defined. I do so in particular on behalf of those mentally handicapped people whose walking abilities are erratic and unpredictable and who cannot move towards a desired destination.

In a debate in another place just over a year ago—the reference is to col. 925 of Commons Hansard for 16th November last year—Mr. Tony Newton, the Minister for Social Security, said that a good deal turned upon a forthcoming judgment of the House of Lords Judicial Committee on an appeal by a blind person who had directional problems, but that the Government were conscious of the difficulties and that when the result of the appeal was known they would consider whether any further guidance was needed, and whether the regulations should be amended—and the relevant regulation-making power is most astonishingly wide.

In the event the House of Lords dismissed the appeal, I think last March, and it is not difficult to see why this conclusion was reached on the terms of the regulations as they now exist. But when the Select Committee asked that sympathetic consideration be given to extending mobility allowance to those mentally disabled people who were in practice unable to walk unaided, the Government's recent and rather belated reply was silent about further guidance or about new regulations, but said that the committee's proposal would be "kept in mind", with the inevitable accompanying murmurings about difficulties of finance and principle.

I wonder whether the noble Baroness, when she winds up, could elaborate a little on what being "kept in mind" means in this context. Are the Government still brooding about further action? Are we likely to see amending regulations? Or is this a formula designed to conceal a resolve to do nothing? The answers to these questions are of great practical significance to a number of families facing real difficulties.

Lord Ennals

My Lords, would the noble Lord give way? Just to show that there is no party controversy whatsoever, the term "will be kept in mind", in my experience, from whichever side of the House or whichever party is in power, means that it is not at the moment planning to do anything at all.

Lord Allen of Abbeydale

My Lords, I understand, on a technical point, that the phrase to which the noble Lord referred earlier was "borne in mind". Whether there is some subtle distinction, I do not know.

My second topic concerns the care of the elderly. I am not at all sure that, as a nation, we have yet come to grips with the increasing problems of the care of the elderly in general, but I am in no doubt that we have a long way to go before we can claim that sufficient help is being made available to enable ageing mentally disabled people to achieve as satisfactory a quality of life as the rest of the ageing population.

Medical skills have led to a most remarkable increase in the longevity of the mentally handicapped, but specialised facilities in the community simply have not kept up. Many of the elderly mentally handicapped have an increasing need for help and support, for advice, and for opportunities to be active; and for them any adjustment they may have to make late in life to new surroundings and new people around them is especially traumatic.

All I seek to do today is to emphasise that this is an increasingly important issue which I hope the Government will take very seriously indeed. I know that the noble Baroness, Lady Trumpington, referred to a specific grant to help the elderly, but it did not seem to be on a scale to go very far, and certainly this was not a topic on which the Government chose to spread themselves at any great length in their reply to the Select Committee.

My third point inevitably brings me back to the one word which underlies so much of what has been said already, and that is money. Let me say straightaway that at Mencap we are grateful for the grant towards our administrative expenses—although we could certainly do with some more. But the point I want to make—and here I am only repeating what has been said by several speakers already—is that it is really no good going in for community care unless adequate plans have been made in advance, and I am afraid that I, for one, have not been totally reassured by what has been said about preparations of this kind.

I know that Mr. Kenneth Clarke, when Minister for Health, told the Select Committee that he believed that going in for care in the community was cost-neutral and that cost was therefore not a major consideration, but I fear that the findings of the York University study, and our own calculations, confirm the suggestion that to carry through the policy of community care on a worthwhile scale is indeed going to need more resources.

I think only a limited dependence can be put on the local authorities for a major effort if, for all practical purposes, they are limited to their present resources and to future uncertainties. If some sort of bridging finance could be provided from the centre—this is a point which the noble Lord, Lord Ennals, touched on—there is at least the prospect of recovering some of the money in the end from the disposal of sites of unused hospitals. I gathered from the noble Baroness that there was a guarantee that the money raised in this way would be reserved for these purposes.

We awaited with some eagerness the Government's reply to the Select Committee on this crucial issue of resources so that we could get a clear impression of whether additional resources were to be made available. Alas, to put it kindly, that reply did not remove all doubt. I should like to read to your Lordships a short extract from it. After explaining that for some individuals community care would be cheaper and for others more expensive, the paragraph goes on: Authorities are jointly assessing individuals; costing care options … and, where further resources are thought necessary, determining the effective priority for these developments, taking account of national policies and local circumstances. Specific central initiatives have been and are being undertaken, and can be further considered as appropriate. The Government is keeping the situation under review, and ensuring that community care needs are reflected in public expenditure discussions, and that the use of resources by health authorities and the match between their resources and their plans is monitored closely in accountability reviews and in the scrutiny of plans. As a former civil servant I can speak of that passage only with admiration. One can just picture the scene: the loving care with which a proviso was suggested here and a qualification put in there, and the result a beautiful bit of prose. But I wonder what it actually means? I think I am not overstating it if I say that the conclusion does not emerge with crystal clarity.

I looked for a much more detailed explanation from the noble Baroness this evening, but the fact is (I say this with great regret) that she went too fast for me. I shall read Hansard with great interest to see what she said. Whether she was saying we are to get more money, I do not know. We had a list, a cornucopia of goodies, but what they amount to will require further study.

There is one point which the noble Baroness will be able to make when she winds up, and that is to explain (perhaps at a pace which I, at any rate, can take in) what the present thinking of the Government is about bridging finance from the centre.

In the light of what the right reverend Prelate said there is just one other point I should like to touch on which underlies so much of what we are discussing, and that is the attitude of the community. As he said, there is a great deal of ignorance about the mentally disabled and too ready a tendency to assume that they must all, without distinction, be behaviourally disturbed and must of necessity be bad neighbours. Experience suggests that once a move has taken place, public resistance tends to die away. I cannot help thinking that if it were now proposed for the first time to site Broadmoor in the middle of Crowthorne there would be a most enormous howl of objection, whereas in practice this long-established hospital is well accepted in the town and the local residents do a simply marvellous job in supporting the hospital and the patients. The problem—and it is admittedly not an easy one—is how to break down initial prejudice and get a more informed public opinion. Some of this can be done by the voluntary organisations, but there is scope for the Government to do much more to try to get their policies understood. I know that could be said of other things they do, but I shall let that pass.

The issues we are discussing this evening are of great significance to a considerable number of the less fortunate members of society. It has been said that one must never forget the burdens falling on families as well as the wellbeing of the mentally disabled themselves. At times one's predominant feeling is simply one of humility. It is an area where greater public awareness and rather greater public resources can result in real help for some of our fellow citizens who deserve our sympathy and our compassion.

5.36 p.m.

Baroness Faithfull

My Lords, inevitably in a debate such as this there is repetition. I make no apology for I propose to repeat a good deal of what has been said before, but perhaps in different ways simply to underline the importance.

My first point is to refer to children, as have my noble friends Lady Trumpington and Lord Renton. Everything starts in childhood and it is a great sorrow to many of us and to the organisation called Exodus that we have so many handicapped children living in large, long-term mental hospitals and big wards. I pay tribute to Her Majesty's Government for the partnership which the Government have taken on with voluntary organisations. The noble Lord, Lord Renton, has mentioned one at Ravenswood, and the noble Viscount, Lord Tonypandy, will know of others in his capacity as president of the National Children's Homes. From the point of view of Barnardo's, of which I am a council member, in concert with Her Majesty's Government Barnado's are slowly helping to find alternative accommodation in the community for mentally handicapped children.

Last year residential care was found for 299 children in small group homes in the areas where the children lived so that they could be near their families. At the same time 426 children received what is called "respite care": that is care at the weekend or perhaps during a holiday giving parents a rest; and 70 children were placed in foster homes. We look forward to having further co-operation with the Department of Health and Social Security so that ultimately we and other voluntary organisations will be able to remove children from hospitals for the mentally handicapped.

I now come to points which have been touched on by many noble Lords, especially the process of moving a person from a hospital into the community. First, I should say that I hope that we will not adhere slavishly to the principle of community care because some patients do better with hospital care. There must be choice. I should refer to the right reverend Prelate, who said that every person, however handicapped, is valuable. They have to some extent a choice and if not a choice, at any rate, as other noble Lords have said, consultation. I have dealt with many such cases. The transference does not only lie in the preparation of the patient: it lies in the preparation of the family; it lies in the preparation of the community.

Perhaps I may just say that last Christmas I visited a patient who now lives in a three-room-up and a two-room-down house with four other patients. I took him my Christmas presents on Christmas morning. While I was there, the front doorbell rang, and I heard my friend (who is now a man of 30, and for whom I have been responsible since he was six) go to the door and then slam it. He returned with a big box of chocolates. I said, "Where has that come from?" He said, "The lady next door brought it in". So I said, "Well, didn't you say 'thank-you'? Didn't you ask her in? Couldn't we give her coffee?" He said, "Why should we? We have been here for two years and that is the first time she has ever been near us!" So I flew to the woman next door, brought her in and we all had coffee. Now she is a great friend. But she should have been prepared before that home in the community was ever opened.

That brings me to another point, which is the position in relation to the people who do the work: the hospital staff, the doctors and the social workers. I, like many others, as has been mentioned by the noble Lord, Lord Winstanley, have also had a letter from the Royal College of Psychiatrists. Dr. Bewley writes: The Royal College of Psychiatrists is very concerned that the run-down of the mental hospitals is happening up and down the country already without adequate alternative provision being made by the local authorities.". If one is to make adequate provisions, there are the bricks and mortar but there are also the people. The people about whom I mainly wish to speak this afternoon are the social workers. I wonder whether your Lordships will bear with me if I just go into a little bit of history. Before the 1970 Local Authority Social Services Act, the medical officer of health had two departments: he had a department for mental health and a. department for those people caring for the elderly and the handicapped. Those two departments came under the aegis of the then Department of Health. At the Department of Health there was a most remarkable social worker called Dame Geraldine Aves, who was responsible for setting up a two-year training programme for mental health officers and those working with the elderly. It was two years' training simply in the fields of mental health and the elderly. Running alongside that, in the local authorities, were children's departments, and the children's departments were at that time the responsibility of the Home Office.

The Home Office set up a training unit within the Home Office and there was a two-year training programme for children and families only: nothing else. Furthermore, there were refresher courses after training and there was retraining for anyone who wished to take it up. Then, there was the probation department. The Home Office was responsible for probation. The probation officers had their training. Then, in 1969, the Chronically Sick and Disabled Persons Act was passed. Of course, up to that date, there had been no training for the physically handicapped under the Chronically Sick and Disabled Persons Act.

With the passing of the Local Authority Social Services Act in 1970, the Council for Education and Training in Social Work was set up. This is a kind of independent quango body. It was their responsibility to lead training for the new social services department throughout the country. The Council was made up of no fewer than 64 people. My Lords, can you imagine it? It was big, it was unwieldy and an enormous number of people serving on that council really knew nothing, if I may suggest it, about the professional training of social workers.

Can your Lordships believe this? It was then arranged that there should be one training programme for all social workers, and, believe it or not, for two years. By my reckoning, it should have been for six years. I see the noble Lord, Lord Winstanley, shaking his head and I am sure he has experienced difficulties in this area. How could that council have set up a training programme for social workers in the fields of the mentally ill, the mentally handicapped children, the chronically sick and disabled and the elderly and expect to train them in two years? It was not possible. It should never have been thought of, and it should never have been carried out.

Baroness Seear

My Lords, will the noble Baroness agree that some of the so-called "scandals" in connection with social work, which are doing no good at all to the profession of social work, probably derive from this unfortunate change in training?

Baroness Faithfull

My Lords, I am very grateful to the noble Baroness. Of course, coming from the London School of Economics, she well knows what I am talking about. In fairness to the trainees, to my fellow social workers, I say that society has served them ill. To carry out the kind of work that we have to carry out, with a training of only two years, is an absolute impossibility.

I mention this because of course it was recommended in the Mental Health Act of 1981 that there should be approved social workers for dealing with the mentally ill and mentally handicapped. They were to have a special training within their departments and a special assessment before they could receive their warrants. As your Lordships will know, under Section 4 of the Mental Health Act, for which my noble friends Lord Broxbourne and Lord Renton were responsible, compulsory admission to a mental hospital was not dealt with under that Act except as a kind of helping hand by the social workers. However, under a later Act, the social workers were there at the admission, together with the doctors, to decide whether patients should or should not be admitted. If it were at all possible to prevent a patient being admitted statutorily, it was the social worker's business to know and help, and to work with the doctor. But that needs training.

Perhaps your Lordships will bear with me while I read the relevant comment of the Mental Health Act Commission in their first annual report. The report reads: The provision and training of sufficient Approved Social Workers … have been particular difficulties during the period in question, mainly due to industrial action"— and I shall come on to this— This matter has been consistently pursued by Commissioners, in view of its significance for the admission of detained patients. Fewer than 1,000 social workers passed the necessary examinations for [Approved Social Workers] and at least some English counties have no fully qualified [Approved Social Workers] at all". Therefore, the Act of 1983 is not being carried out. It cannot be carried out because the training is not yet adequate. There are other problems, I am bound to say this. I am a member of NALGO. I have been a member of it all my working life, except for when I was in the Civil Service and then belonged to the Civil Service Union. I am still a member of NALGO. However, I should suggest that NALGO has prevented people from training, by laying down certain conditions which I consider to be professional conditions and I do not think it was right of NALGO to scupper, if I may use such a word for it, the training of the social workers. I make a plea to NALGO to re-think its role in social work, to re-think what is its social duty in social work. It is to help those who are members of NALGO, but I should suggest that it is not to interefere with professional practice in a profession. I beg NALGO to re-think what it is doing, and to realise that if it proceeds with its present action, there will be more patients admitted to mental hospitals than there should be, and then we shall have more difficulties in getting patients out of hospital.

I would just say this. To put extra bits of training on to basic training is expensive. I need hardly say that your Lordships will have read in yesterday's newspapers the report of Mr. Blom-Cooper on the investigation on behalf of Brent Council into the Jasmine Beckford case, where the child died. In his report he recommended a three-year training course for social workers, instead of two. Personally, I think that three years is not enough; but then I think it would be possible to train social workers, on the initial course, to do mental health and not need to have extra bits added all the time—a bit for mental health, a bit for child care. This is not sensible.

I suggest that there should be a three-year course, at least, for social workers. I suggest that the first 18 months of the course should be generic; and I believe that it is necessary for social workers to be taught philosophy—the reasons why they are doing what they are doing. Very few courses that I know of have philosophy in their curriculum. In the course that I did, way back in the 1930s, we had a philosophy lecture every week for the duration of our course. Until social workers know and think about what they are doing, they will not get their work in perspective.

Secondly, it is quite shocking that social workers are taught so little law. You cannot do social work unless you are working within the confines of the law. I hardly dare tell your Lordships that there are some courses where the social workers have one lecture on law in two years. This may be rare, it may not happen in every case—I am sure that it does not—and I know that the Council for Training and Education in Social Work is repairing this. Here, again, when I trained I had a lecture in law from an eminent QC every week for the duration of my training. This is not happening at the moment. I believe also that it is impossible in the first 18 months of generic training to learn economics and the social background of the country.

The Earl of Longford

My Lords, would the noble Baroness who speaks with such authority on these matters agree that where students, potential social workers, have actually taken a university degree in some of these subjects that should shorten the course?

Baroness Faithfull

My Lords, if you have a degree you can take a social work course in one year. It is not enough. You cannot learn all that you need to learn of social work in one year.

I have two last points to make. First, I must touch on the Council for Training and Education in Social Work. This independent body, as I said earlier, was set up in 1970 with 60 council members. I think we must congratulate Her Majesty's Government for reconstituting this body. I think it was reconstituted a year ago under the very able chairmanship of Miss Joan Cooper, and it now has 26 people on the council. I still think that that is too many.

My last point is this. I think that the tutors and the people who run courses are in very great difficulty because the Council for Training and Education in Social Work is asking now for a three-year course—but, I regret to have to say, not until, I think, 1999. I would think that it ought to come much sooner. But what is the rub? The rub is that the universities say that they have not got the money to put on three-year courses, and so we have an impasse. What are Her Majesty's Government going to do about this? I ask this very seriously and would like to pursue it at a later date.

Finally, a great responsibility lies on universities and on the tutors and lecturers. I say with very great regret that some of the courses offered, short as they are, have such a party political bias and concentrate so much on politics that they get away from the central professional points and training which should be given. Also, I would say that all the training in the world, all the laws in the world, will not make a ha'p'orth of difference unless only people of character, integrity and quality are accepted for training as social workers.

5.54 p.m.

Baroness Masham of Ilton

My Lords, most people, I am sure, would agree with the concept that mentally ill and mentally handicapped persons should be treated and rehabilitated as close to their homes as possible. But the move from the large institutions to smaller units or care in the community is no cheap option. I am sure that this message has truly gone out from this House today. It is a mammoth task needing the greatest co-operation and organisation between health and social services departments with the help of the voluntary agencies as well as education and training departments.

It was good to hear from the Minister's speech of some of the progress which is being made. It sounded hopeful. There have been some excellent voluntary initiatives for mentally handicapped people recently. Horticulture, for one, and dance and drama and art as well. These are encouraging signs. The maiden speech of the right reverend Prelate the Bishop of Saint Albans was also a message of hope, because attitudes are so vitally important. I should like to congratulate him on his most moving speech.

Before a decision is taken to close a large psychiatric hospital and to sell off the surrounding land, plans for the patients should be made. We should look at the quality of life of the patients, what they have now and what they may have in the future. The large psychiatric hospital can be frightening and daunting for people who are not used to them, but over the last few years their interiors have greatly improved.

In some hospitals the quality of nursing care is superb. Patients are taken for outings by the staff, and there are recreational and occupational facilities. There are often social clubs, and some of these have bars. In one Birmingham hospital I visited patients who had moved out into the community preferred to come back to the hospital for these social activities which they enjoyed among their friends and people who understood them. They had not found this sort of community life outside the hospital. There is a real fear by many people that psychiatric patients of many different handicaps could become isolated and very lonely in a society where they are not understood or wanted.

If the move to the community is to be successful, then the services must also be decanted. There must be occupational therapy support, sheltered workshops and social activities. The big stumbling block is the cash. There will have to be a reallocation of resources. More people with expertise in mental illness and handicap will be needed to be spread throughout the district. The increase in numbers of trained psychiatric community nurses working in health districts over the past two years has been a great step forward. They not only understand the needs of patients, but they also support and advise the families.

I should like to ask the Minister how the fostering schemes for the mentally ill and handicapped persons are developing. The idea is excellent, but in practice are these schemes working? The replacing of specialised social workers by generic social workers has not helped in the care given to mentally ill and handicapped persons. In fact, is this not one of the tragedies of our present child abuse problem? Perhaps, as the noble Baroness, Lady Faithfull, and the noble Baroness, Lady Seear, have mentioned this, it could be looked at very urgently. The world has become a place for specialisation. Doctors work in very specialised fields, as do scientists; yet the social worker is expected to understand a multitude of very complicated problems. No wonder vital signs are missed or that many social workers themselves have breakdowns.

There is another problem with regard to social workers when there are regional secure units, because these units deal with some of the most disturbed and difficult patients. Although the units cover the whole region or even supra-regions, the social workers belong to the local social service departments, which do not see why they should support patients from outside their area. Therefore there is sometimes a shortage of social support in this much needed specialised field. I worry when some of the small hospitals are sold off throughout the country because when the large psychiatric hospitals are disposed of there will still be a need for hospital care for some patients. That must not be forgotten. Planning permission for new units is sometimes very difficult to obtain. Small, institutional units will be needed for the severe organic braindamaged patients; for instance, those with severe head injuries, and some stroke patients.

I have just been dealing with a tragic case where the husband had a stroke which changed his whole personality. At times he got very aggressive. His elderly wife could no longer cope. She was herself twice admitted to a general hospital with exhaustion and breakdown through stress and strain. The daughter had her own family to bring up and her own husband to look after; she found it very difficult to help and was desperately worried. When at last this man was admitted to hospital the terrible pressure was taken off these people. The man was visited regularly by his family in hospital, and I had a letter from the daughter full of admiration for the hospital staff who could manage him and understand his ways when his wife just could not cope.

Many people were shocked when recently a deaf mute person who had committed minor crimes was sent to prison. If we do not have adequate specialised units, more psychiatric patients will be sent to prisons, which are not the correct place for them, and of course it increases the overcrowding of prisons and means that they are bursting at the seams.

We have a large and growing population of elderly people, some of whom develop Alzheimer's disease and senile dementia. Many of these patients outlive their families, their mental faculties decline and they have to be looked after. We must look ahead and ensure that this problem is not shoved under the carpet. With many unemployed young people we should be training some of them to care for these unfortunate people in the future. I have written to the noble Lord, Lord Young of Graffham, about this and I hope he will include this need in his youth training scheme.

In regard to a recent Question in this House on lifting Crown immunities on hospital kitchens, the noble Baroness, Lady Trumpington, said this would not be practicable, as some of the kitchens might have to be closed immediately since they would not pass the test by the inspectors. My Lords, some very frail and vulnerable patients reside in hospitals with such kitchens. I was surprised when I read the noble Baroness's defeatist Answer in Hansard. This is not her usual style; she is one to stand up and be counted. I come from Yorkshire, from a county where, sadly, many patients died last year in a psychiatric hospital from an outbreak of salmonella poisoning. Would it not be possible, while the kitchens were upgraded and modified to reach the required standard, to bring in a mobile kitchen? When troops were fed in the Falklands or when they are fed elsewhere, are not mobile kitchens used? I am sure that where there is a wish there is a way. I feel that the overall provision of good and adequate health facilities throughout the country is the wish of the majority of people.

6.5 p.m.

Lord Broxbourne

My Lords, after two such admirable consecutive speeches from noble Baronesses it now falls to me, however inadequately, to implement the principle of non-sex-discrimination. I feel privileged to take part in this debate, which has been characterised by so many interesting and informative speeches. I should like to start by congratulating my noble friend Lord Mottistone on his initiative in bringing this matter before the House in such an interesting way. I should like to thank him also for the speech in which he propounded it.

The Motion makes special reference to community care, a concept which I have long advocated. It is now rather over a quarter of a century since I introduced what became the Mental Health Act 1959 into the House of Commons. My noble friend Lord Renton made a very kind reference to that, and I should like to thank him for it and to repeat also my thanks for the great help and invaluable support that I received during the passage of that Act from my noble friend, as a Home Office Minister. That was a mammoth Act, drawing inspiration from the Royal Commission which preceded it and replacing what The Times of the day called, the jungle of existing mental health law, with a new pattern, simpler to understand and apply, and in line with contemporary thinking and medical advance.

Nearly 20 years passed before it was reviewed in the White Paper of 1978. Then, with certain amendments in the Acts of 1982 and 1983, it has stood up well to the test of time. I am glad to see my noble friend Lord Renton back again in the Chamber. Perhaps he would be good enough to read in tomorrow's Hansard what I said of him with great appreciation a few moments ago.

I am of course now referring to the Mental Health Act 1959, to which he made such a kind reference. Mr. Sorenson—and I am sure that the noble Viscount, Lord Tonypandy, remembers him well as an amiable and respected Member on the opposite side of the House from me but on the same side as the noble Viscount—said that the Act would no doubt become known as the "Walker-Smith Act". It is no surprise to your Lordships that it never has been known by that name. In fact, the naming of Acts after the Ministers initiating them went out. I believe the "Butler Act" was the last example—and when one reflects on the content of some of the intervening legislation perhaps it is just as well for Ministers that the practice has fallen into desuetude.

The underlying philosophy of that new approach in 1959 was the desirability of shifting, so far as possible, the emphasis in mental health from institutional care to care within the community. This involved, of course, an appropriate role for local authorities with a supporting base of professional skill and popular understanding.

That philosophy is now generally—perhaps universally—accepted, and in the words of the most recent White Paper, The practice is now visibly beginning to catch up with the preaching.". The same White Paper observes, however, that, a great deal of effort, skill and imagination", will be required to achieve the best possible results in the future.

There are, of course, many problems, as your Lordships have heard, evidenced by over 100 specific recommendations in the report of the House of Commons Select Committee and by the weight of testimony, oral and written, submitted to that committee by many who are expert and active in this field.

I propose to refer to only very few of these matters. Having regard to the amount of parliamentary time I took up in putting the Mental Health Bill on the statute book, the least I can do by way of amends is to try to economise on your Lordships' time today. That desirable objective is easier to achieve by reason of the excellent speeches which we have heard and in particular, if I may so make reference, to the speeches of my noble friend Lord Renton and the noble Lord, Lord Allen of Abbeydale, who are distinguished representatives of Mencap, cugus minima pars sum.

I refer, first, to the aspect known as the "cart before the horse" aspect, which is, of course, a phrase taken from paragraph 30 of the House of Commons Committee's report. That has been, I think, referred to by your Lordships, but perhaps I may just remind your Lordships of what it says: Everybody must be aware of the need for appropriate community services to be in place before the process of hospital run-down races ahead yet further.". That is a concept which has attracted considerable support among your Lordships this afternoon, and it indeed must be the logic of the matter and the key requirement. The run-down of hospital treatment for mental disability is not an end in itself, but an ancillary to its replacement by suitable care within the community.

There will always be a need for some mental health care and treatment in hospitals. There will always be some for whom, unfortunately, the outside world is not suited and for which they are not equipped—sufferers from what in the Mental Health Act we called severe subnormality; that is, people in the statutory definition, incapable of living an independent life". The Select Committee's report acknowledges this and states: We must face the fact that some people need asylum", and it recommends the department to, draw on the experience of existing hospitals with a view to producing practical guidance for future provision of asylum care". I support that view.

Increasingly, however, for those not in this category alternative provision will and should be made in the community. That depends not only on having the right climate of opinion, but on having the right facilities and opportunities. I wish particularly to mention opportunities for work and employment. This, again, is stressed in the recommendations of the Commons Select Committee, in Recommendation 52, which deals with this matter and states: We recommend that the DHSS, together with the Department of Employment and respresentatives of employers and trade unions, now explore the practical possibilities for expanding the narrow base of sheltered employment". The Government have good news as to this at paragraph 59 of the White Paper which refers to the sheltered employment scheme.

Of particular interest is the Mencap Pathway Employment Service, designed to place persons with a mental handicap who could benefit by it into open employment. That is a scheme which I commended to the Secretary of State for Employment last Wednesday and I trust that, with his characteristic energy and drive, he has already taken my words to heart and given effect to them. I see the noble Baroness looks around, whether in acquiescence, in inquiry or simply in doubt, I am not sure. So I say to her just this. If by unhappy chance that is not so, she must jog his elbow and it would be an obdurate and insensitive colleague, indeed, who was not responsive to having his elbow jogged by so charming a person.

My third and last point is money. There is nothing surprising in this. One cannot be a Social Service Minister for long, without getting the impression that you could solve most, or perhaps all, of your problems but for the money. I am not preaching the bottomless purse heresy. Before being a Social Service Minister, I was for a time a Treasury Minister and a Trade Minister and there is something to be said for interchanging these roles, which is beneficial in both respects. Nevertheless, I think that mental health is perhaps a special case when it comes to claims on the public purse. Certainly, it has a strong case.

May I remind your Lordships of what the Select Committee said at paragraph 21 of its report. It stated: We are at the moment providing a mental disability service which is under-financed and under-staffed in both its health and social aspects". That is a judgment, coming as it does with the authority of an all-party committee, which Ministers can hardly be expected to welcome. But it is also a judgment which they can hardly ignore or brush aside. The Government's response is somewhat muted. I need not read it, because it has already been read in a charmingly teasing fashion by the noble Lord, Lord Allen of Abbeydale. The Government's reponse is that they are "keeping the matter under review." Those are cautious words, indeed, bearing, one would think, the unmistakable stamp of Treasury Chambers.

In conclusion, I would just say this to Ministers. There are many Members in both Houses, and many thinking and responsible people outside, who, while not subscribing to the economic heresies of the bottomless purse, nevertheless consider that mental health and its problems have by their nature particular facets which give it a special claim on the nation's resources. Provided that such resources are properly directed and prudently applied, the dividend in terms of social progress and human happiness could be great indeed.

6.19 p.m.

Viscount Colville of Culross

My Lords, I was grateful to my noble friend Lord Mottistone for giving me a character reference in his speech, which makes my entry into the arena on this subject a little more respectable than might have been supposed. It is now nearly four years since this House helped to set up the Mental Health Act Commission, although it has been operating for only two years. I may say that my chairmanship of it is not only an honour but a matter of pleasure and very great interest at the same time. The subjects that have been discussed this afternoon are really the daily fare of my colleagues, our staff and myself, because they are at the forefront of so many of the problems that we have to deal with. I shall say a few words about Care in the Community but I believe that the subject matter of the debate is wide enough to go a little further, and that is the way in which my noble friend has framed it.

First, I was very pleased indeed to hear my noble friend Lady Trumpington talking about the least restrictive setting possible for the treatment of a mentally disordered person. That is certainly the philosophy that we understand to underlie what is now the 1983 Act. There is in the discussion of Care in the Community a double aspect, with only one of which, I am a little surprised to find, most speakers have dealt. I think it is equally important. My noble friend Lady Faithfull did deal with it and she dealt with the whole system whereby the caring services in the community may adequately deal with a mentally disordered person's problems so that the whole question of going into hospital never arises in the first place. For that, of course, the necessary training and the necessary resources are all too essential.

The other aspect which has been widely discussed this afternoon is that of the proper ability to take those who are and have been in hospital back into the community again. In the biennial report of the commission, to which two noble Lords referred, we have at the end set out a collection of priorities for our work over the forthcoming year or years. The first of these is an examination of the care services in the community both, so far as we can, in relation to admissions and in relation to discharge and aftercare. We do not perceive it as being in any way indicative of Parliament's interest in the whole question of aftercare that the whole subject is dealt with in only 16 lines in Section 117 of what is now the 1983 Act. We believe it has been very much reflected this afternoon that Parliament recognises it as being a major subject.

Nevertheless, in the course of our work over our initial two years, the emphasis has not been so much on finding out what is going on in social service departments, because there has not been time for that yet. We now propose to set about this in earnest without, I hope, detracting from the work that is being done in visiting patients and hospitals and seeing what is going on on that side of it. We believe that, for both the period before anybody is being considered for admission and indeed afterwards, after they have been in there and are being rehabilitated so as to go out into the community again, we need to study very carefully the whole way in which the social services are doing their job and the way in which—this was one of the points made by the noble Lord, Lord Ennals—they are working in collaboration with the health authorities. It may be comparatively easy in the Isle of Wight, because I imagine that the social services department and the district health authority cover exactly the same area, but that does not always happen elsewhere in the country. That is the kind of thing that needs to be looked into. I do not in any way disparage—very far from it—the aspect of the voluntary services in this respect, although perhaps they do not so much come into our remit.

We have been concerned about a corollary of the whole exercise of trying to get as many patients as possible back into the community. It is one that has been mentioned this afternoon, first by the noble Baroness, Lady Masham, and again just now by my noble friend Lord Broxbourne, It is quite evident that however much the policy may stand to try to get people out into the community, there will be patients who will not be able so to be discharged, and they will have to remain in hospital. We have focused to some extent upon those in that category who are mentally handicapped, the exact point of my noble friend Lord Broxbourne.

It was, I think, largely the responsibility, or at any rate at the urging, of Mencap, whose trinity of speakers this afternoon has so enlightened us, that in 1982 the whole area of detention for persons suffering from mental handicap was very greatly reduced. This was a matter of policy and it was done among other things in order to avoid stigma. But there are at the same time very considerable disadvantages—at least I think there are—for people in that category. I do not wish to overblow the trumpet of the commission but certainly in the same Act we were given some very strenuous duties to look after patients who are detained. At the same time we are not allowed to interfere in any way with those who are in hospital on an informal basis. Given the rights of the detained patient to information, to talk to visiting commissioners, to complain, to go before mental health review tribunals on a regular basis—those are only some of them—we have a feeling that the powerlessness—to take the point of the noble Lord, Lord Ennals—of some of the informal mentally handicapped patients who may have been in hospital for a very long time is something that may not have been fully considered when Parliament was reviewing the 1959 Act as it did three years ago.

My commission has therefore decided—this is possible without primary legislation—to ask the Secretary of State to extend the powers of the commission to do what it does now in relation to detained patients so that it may also look after informal patients who are, although not technically detained, physically in detention. It is a very strange thing that commissioners go to a ward in a hospital for the mentally handicapped where there are perhaps one or two detained patients and 28 or 30 informal patients, all living in identical circumstances, but that we can take into account only those who are detained. It seems a strange paradox that these new protections in the interests of the patient and his family should have been introduced into legislation while at the same time they are denied to some of the very people who perhaps most earnestly need the attention of people who could come and see them and take an impartial interest in their condition.

Lord Renton

My Lords, I am most grateful to my noble friend for giving way. He has raised a very important point. He has said that he has asked the Secretary of State if something can be done about it. Does he consider that it would be unnecessary to have legislation to do this and also to do the things which his commission wisely recommended on page 10 of the report with regard to the mentally handicapped?

Viscount Colville of Culross

My Lords, it would certainly be unnecessary to have primary legislation to do what I have just said, because there is a power in Section 121(4) which would enable the Secretary of State to do it. There is rather a lot on page 10. Perhaps I may tell my noble friend afterwards which parts of that could be achieved without further legislation and which might not.

There are two other things which seem to us to be desirable which certainly would need legislation, and I cannot remember whether or not they come on page 10. The first relates to the new system that has been brought in to provide for second opinions for either ECT or long-term medication. It is probably in relation to the mentally handicapped long-term medication that this is most important. What has been provided is a system whereby, after three months of medication, if a patient either cannot or will not consent to the medication that his doctor wishes to give him, that doctor cannot administer any further medication at all without obtaining a second opinion from a doctor appointed by my commission. I should say that that is not a second opinion in the recognised technical or medical sense, because we do not wish the doctor who comes to advise to substitute his own opinion for that of the consultant who is directly responsible, but merely to say whether or not he thinks that, in the condition the patient is in, the line of medication proposed and the plan of treatment as a whole are in accordance with good medical practice. I believe that we have managed to get a consensus among the medical profession that such is a respectable thing to do. It was not immediately apparent that that was going to happen but it so emerged.

There are many mentally handicapped patients who are quite incapable of giving consent to medication. The introduction of a whole system of second opinions for detained patients has tended to throw doubt in the minds of doctors and other staff about the extent to which, by common law, they can continue to administer medication to the incapable but informal patient. A certain amount of confusion is beginning to emerge as a result. We believe that Parliament may like to consider an extension of the second opinion system into the circumstances which I have just described and similarly, for people of that character, an extension of the ability to go before a mental health tribunal for an independent but well-advised report and decision as to whether or not they should stay in hospital. Sometimes it is very difficult for such people to have their case brought before the managers in a way that will enable the managers to take a decision to discharge them.

Those two latter proposals would require legislation, and I do not of course envisage that that will come out of our debate today. Nevertheless, I put them before the House as being two matters worthy of consideration for people who I believe are very much in the minds of those who are here this afternoon and taking part in this debate. I say in parenthesis that I hope it will not be thought that we are trying to empire-build. That is very far from being the case. We believe that we could deal with the, as it were, reception within our ambit of the informal patients in the comparatively narrow category which I have described without any undue extension of staff, personnel or resources. I daresay that the two other proposals would have resource implications and might therefore have to be judged accordingly.

The commission has in addition to producing its biennial report, which I hope some interested people may read and comment upon—for it is not an anaemic document but is intended to provoke response from those concerned—written a draft code of practice. It is due for imminent publication by the department for consultation. It contains a very large amount about Care in the Community at the stage where admission to hospital is being considered; the very area that was being discussed by my noble friend Lady Faithfull. We have paid a great deal of attention to that aspect because in the code of practice we are not confined to detained patients. Therefore we have put all our energies in our multi-disciplinary exercise into describing what we believe to be a suitable method of setting about that very difficult exercise, the philosophy at the back of one's mind all the time favouring the least restrictive method of treatment possible.

We have also adopted some new targets for next year. As I said before, the first of them is community care. I wish to mention only one of our other new targets at this stage because there is so little time in a debate of this kind. It concerns a matter that was touched upon by the noble Lord, Lord Allen; that is, the mentally disordered offender. I will only mention it this afternoon because I realise that it is a much larger subject and one which, as the noble Lord rightly said, needs a larger debate of its own. However, there is one aspect of it that is worth mentioning now. It is one on which everybody needs some help and ideas.

There is a vague feeling of disquiet abroad—it may be more than vague and may be rather acute disquiet—that there are people who come before the courts and who are in prisons who ought not to be there but who should instead be in hospitals for the mentally ill. The difficulty is that nobody really knows how many such cases there are, whether the people concerned really ought to be in hospital, and if they should be, why they did not get into hospital. In other words: what was it that went wrong? In the case of the prison service, the Home Office has been doing a great deal under the powers that it has to transfer into hospitals prisoners who have become mentally disordered. I know that that is a priority for the prison medical service and indeed for Ministers. My noble friend Lord Glenarthur is as anxious as anybody to carry on with that process.

The question which it is much more difficult to deal with is whether or not anything goes wrong in the courts. There are powers for both magistrates and Crown Courts to make hospital orders with or without restrictions. They can do so if they can find a hospital bed to which the offender can be sent. Nobody knows over the length and breadth of England and Wales—and I do not deal with Scotland in this capacity—whether or not that system is working. We are starting an exercise with the senior judiciary and with the magistrates which I hope will meet with the approval of the House, to try to obtain some basic statistics. That exercise will produce only a partial response but I hope that it will at any rate begin to produce something in the way of hard facts for the first time.

Baroness Faithfull

My Lords, I apologise for interrupting my noble friend, but in dealing with such cases my difficulty has been that the court would have liked to send an offender to hospital but that the superintendent there is entitled to refuse a patient. That is where the difficulty lies.

Viscount Colville of Culross

My Lords, if I thought the problem was as simple as that then I should not have embarked upon a fairly elaborate exercise. If one examines the problem in detail one finds that it is usually a good deal more complicated than the simple point to which my noble friend has referred. Certainly it is sometimes the case that the reason is that which my noble friend has mentioned, but there are many other reasons too. We have compiled a questionnaire that might help to identify what is the impediment.

There is a footnote that is worth mentioning. One has to be extremely careful that in the course of one's enthusiasm to see the mentally disordered offender sent to hospital rather than to prison, one does not deal in that way with someone who will turn out to be medically untreatable. One will then be faced with a dilemma which is probably infinitely worse than any other dilemma; someone who can neither be detained in hospital nor has been sentenced to prison—particularly if the offence is a very serious one. Therefore we are playing with a subject—and I do not use the word "playing" in any jocular sense—and dealing with a subject that can be very sensitive We need to be sure that we have got it right.

I mention the matter today partly in the hope that it may receive a little encouragement, if not from my noble friend on the Front Bench then at any rate from others who are interested. I also do so in order to invite anyone who has ideas about how that project may proceed to contact the commission in order to help us with it. I believe that both the judiciary and the magistracy really are interested in the subject. We certainly are. I believe that our colleagues from all the various professions represented on the commission are only too anxious to collaborate and that there might be some movement forward in a very difficult area in this respect.

Those are two courses of action which we propose for the future. I am sorry that they are not entirely on the main line of our debate but perhaps that main line has been fully covered. I will leave it at that for the moment. I hope that noble Lords will read our report. If it provokes any response or reaction of any kind, then I hope that noble Lords will contact the commission at the address shown in the report, because we are trying to fulfil the remit that was given to us by Parliament when the commission was estabished by the Act of 1983.

6.39 p.m.

Lord Rea

My Lords, I should like to congratulate the noble Lord, Lord Mottistone, for introducing the Motion. It is very gratifying when a Motion dealing with the needs of a very disabled group of people comes from the Government side. It helps us to move the Front Bench more when some pressure comes from behind it as well as from this side of the House.

Many of us will have made some critical remarks about what is going on. I hope that none of those who is undertaking the devoted and excellent work in hospitals and in the community throughout the country will feel that those remarks are directed at him. The noble Baroness, Lady Trumpington, described some of the good that is going on; some of the imaginative and encouraging things happening in many different places throughout the country. Some regions have gone ahead faster than others—Devon and Cornwall, for example—but they do not have some of the intractable problems of other regions. There is no lack of willingness on the ground to make the ideal of Care in the Community a reality, given the means, but as almost everyone who has spoken said, the means are too often lacking.

I should like to centre my comments around six points. First—and this speaks for itself—we want progress, not regress. As the Social Services Committee says, we must ensure that people receive care which is at least as good as that which they at present receive in hospital, and preferably better. The fact that the committee felt the need to even record that statement says something in itself.

Secondly—again, many other speakers have said this—funds must be adequate, reliable and related to need. The earmarking of funds, or its equivalent, is in my view a vital part of this. I was pleased that the noble Baroness reiterated that funds from the sales of National Health Service property which is used for mental illness care will be retained within the mental health service.

Thirdly, innovation and experiment should be encouraged and supported. As the noble Baroness said, there is no single answer, no universally applicable blueprint, to solve the problem. Another point is that most mentally disabled people cannot be cured. They will continue to need long-term support. Again—I think the noble Baroness, Lady Masham, pointed out this—most of the mentally ill are already in the community and better services need to be provided for them as well as those who are to be discharged from long-stay hospitals.

Finally in the provision of care, as the noble Baroness, Lady Faithfull, pointed out very clearly, people are more important than buildings. This has cost implications because of course people imply a revenue cost rather than a capital cost.

Before discussing these points in more detail, I should like to comment briefly on the Social Services Committee report. I found it a most valuable and helpful document. It should be pointed out that its composition reflected the proportion of the parties in another place. That is a point that should perhaps be borne in mind by the noble Baroness who is to reply. The official Government response to the report—as I think a number of speakers pointed out, particularly my noble friend Lord Ennals—was cautious, defensive and complacent in comparison with the calls for action and many recommendations in the report.

Once again the chairperson, Mrs. Renée Short—I notice in the report that she has been given the male gender—has assembled a complex body of evidence into a document which is worthy of one of our biggest social issues. The evidence was collected from a very wide range of organisations and people. It makes fascinating reading, although I have been able only to dip into it. I was delighted to see that one source of evidence was Professor Tom Arie, the psychogeriatrician from Nottingham, who once had the brilliant idea of citing your Lordships' House as an ideal model for a psychogeriatric day centre.

The single issue which most concerns us all of course is the provision of finance for the exercise. Many people have spoken about this and I do not want to get involved in the details; but what seems clear is that additional money is required not only for the transitional period but also to upgrade the service. Several noble Lords have quoted the Social Services Committee's statement that we are at present providing a service which is under-financed and under-staffed.

A figure for the sum that might be required was quoted by the Association of County Councils' booklet Strategy for Community Care: a sum of £500 million needs to be transferred to local authorities for mentally handicapped people alone, not including the mentally ill. MIND suggests the same sum for expanding services to priority groups. The actual figure is of course very difficult to calculate but it might well amount to an increase of about 5 per cent. in the total overall costs of the Department of Health and Social Security. Some of this money will go to health, although much of that can be redistributed. Most of the extra money needs to go to local authorities to be used by their social service departments and housing departments. Some of it will need to go to voluntary organisations. A great deal will also have to go to social security to pay for the people now living in hospital but who will be entitled to benefit while living in the community.

All this may seem very difficult with the current financial stingencies which seem to be so necessary to provide the tax cuts which are supposed to be coming in March. However, it should be remembered that we spend only 6 per cent. of our gross domestic product on health, which is much less than nearly all other industrialised countries with the same age structure as ours.

I now turn to "earmarking" which I presume was originally an agricultural term. It is something which must be considered. It is only too easy for local authorities, regions or health districts to absorb funds into other areas with more immediate priority. I gather that is one reason why we have so few regional secure units. One crude possibility perhaps would be to tag each patient. I do not mean actually putting a clip on the ear, but an £11,000 credit representing the share of hospital costs to be spent in the provision of housing, subsistence, and care in the community.

Some interesting proposals for financing community care are put forward by the Association of County Councils in the booklet I mentioned. The Social Services Committee report says: The Government should now accept that genuine community care policies are achievable only in the context of some real increase … in expenditure". In response, the Government say—and here I quote a slightly different part of the report from the noble Lord, Lord Ennals, and the noble Lord, Lord Allen: The Government is keeping the situation under review and ensuring …that the use of resources … is monitored closely. I very much hope that the noble Baroness will be perhaps a little more positive in her reply, although I doubt that she will be allowed to be.

Leaving aside the provisions of finance, it is important that we get good value for money—whatever money we spend—and that the community care it buys is appropriate and helpful. A large range of services is required. There are few districts where what is provided now even approaches the ideal. I work in Camden, which has well above average provision for an inner city, but I find that a number of my mentally disabled patients are not adequately or appropriately provided for. Most of them are not discharged patients from long-stay hospitals. Some of them may require intermittent, inpatient treatment at times of crisis. However, these disabled people do not receive adequate support despite the existence of a day hospital in the area, day centres, good social work coverage and better than average provision of, and collaboration with, community psychiatric nurses. Admittedly, some of these people are very difficult personalities, but that is the challenge. They do not much care for what is at present on offer. We still rely—perhaps too much—on drugs, particularly the major tranquillisers which some would say are a substitute for the caring, therapeutic community which might enable the drug bill to be cut and readmissions to hospital to be reduced.

Many of my chronically ill patients live in isolated flats and are only just coping. Some of them are still living with their families who, as the noble Baroness and other speakers have mentioned, bear a heavy burden. Some patients are so disabled that they need help not only from nine to five o'clock when day centres are open but also in the evenings and at weekends. In the best situations, there are group homes consisting of compatible patients who provide self-help and help for each other and thus a small therapeutic community develops. I feel that we should be moving more rapidly along these lines and the Richmond Fellowship has shown us one way in which this can be done. We need the provision of more community mental health centres, more sheltered employment with workshops and more adult training centres. We need more social centres that are open all day and at weekends. As many noble Lords have said, we cannot expect all patients to be integrated fully into the community.

In answer to the question of the noble Lord, Lord Mottistone, about general practitioners being adequately trained for mental health work, I may say that now all general practitioners must have a mandatory vocational training period, six months of which consists of residence as a senior house officer in a mental hospital, and that training in general practice itself is now much more orientated toward care of the mentally ill section of the practice.

As a possible source of ideas for future developments, I think that the Social Services Committee saw a rather one-sided picture of the situation in Italy. Certainly in 1978 the sudden closure to admissions there of large, old mental hospitals caused many problems, but equally very encouraging new developments have taken place, particularly in Trieste, where local, 24-hour staffed mental health centres are handling all the mental health problems of the city in a very caring and yet confronting approach, which has led to a dramatic fall in the need for medication and of course the drugs bill. Some noble Lords will have seen the very interesting television documentary which looked at the Italian experience.

In conclusion and to summarise, it is clear, both from my own experience when working in the community and from the evidence in the Social Services report, that there is much enthusiasm to do the job well and plenty of ideas, but the Government need to do more than make encouraging noises. Rather than thrust mentally disabled people out of hospital and into a community which is ill-prepared for them, it might be kinder to leave them in the institutions, with their water towers, tending their extensive gardens and taking part in occupational therapy—and this is not just making baskets; occupational therapy in mental hospitals is now often extremely effective and involves the patients in a range of activities.

To move forward will need new money, and I am not sure that the Government fully realise it.

6.55 p.m.

Lady Kinloss

My Lords, today's debate quite rightly centres on the needs of the mentally ill and the mentally handicapped. An aspect which is frequently overlooked is that both mental illness and mental handicap not only cause suffering to the sick or handicapped person but place a great burden on their families. So far, though professionals have long been aware of the pain, guilt and stress in families where one or more members become mentally ill, yet the health care services still concentrate wholly on the patient. The need for appropriate help for relatives who are looking after a mentally ill member of the family is vital if they are to help that person make a full recovery. The love, commitment and stamina of the relatives are pegs on which the patient's survival and recovery depend.

In one case which was reported to a voluntary organisation, the Richmond Fellowship, a wife was told by her husband's psychiatrist simply that he had a personality problem and that she had to live with it. No suggestions were made as to where she could go for support or how she could make their lives more bearable. This could have resulted in two people becoming ill had not a friend told her of the Richmond Fellowship. If both had become ill the state would have had two people to care for. Adequate advice and support for the healthy partner are needed to make life more bearable for both.

I am sure that everyone is aware of the worries and the concern felt by ageing parents who have adult sons and daughters suffering from chronic mental illness or handicap, as to how best they can arrange for their future. The Richmond Fellowship, realising this, advertised offering help in a national newspaper. Within three weeks two hundred replies were received, often with long, heart-rending stories of people who felt that they had no one to whom they could turn. Helping the families of the mentally ill or the mentally handicapped has two primary aims: prevention of mental and emotional deterioration and support in the management of daily life, both of which are vital to care in the community. They cannot be achieved on a sufficiently large scale without a radical re-thinking of priorities in the services that can be offered by GPs and the training of health service professionals, who are often the first to be consulted when families are under strain.

When parents are under stress they will often consult their GP, and though he realises the strain and stress suffered by his patients he often does not have the facilities to refer the patient and his family appropriately. If each GP had a psychologist, trained social worker or trained counsellor available to the practice, families under stress could be helped without feeling stigmatised and labelled. Parents looking after their sick children can feel very isolated in our modern society where extended families have been split up. The psychological battering of children and adolescent breakdown can so often result from this situation. Support at the right time for young parents in difficulties is the most important contribution which can be made to the mental health of future generations.

The second aim in family work is the support of families who care for chronically ill relatives. Paradoxically, this may consist of helping families let go of the sick person. Families need to be able to see their involvement with the sick person in the generalised context of others who are undergoing similar experiences. They need to be helped not to overprotect the sick person or to prevent that person from taking more responsibility for his or her life. In the past, when parents became unable to cope with a sick person that sick person became a permanent patient in a mental hospital. This option is rapidly disappearing.

There are schemes which offer families both psychological support and practical help in finding a realistic and homely alternative to the family home as a permanent residence for their chronically ill sons and daughters. Voluntary organisations in the mental health field and the major children's charities, though they are doing all they can, cannot be said to be doing more than scratch the surface of the problems at the present time. It is the proper function of Government to support such initiatives with finance as well as encouragement. The planning and strategy needed to deal with the problem as a whole can only come from central direction. It seems to me that the social worker or welfare officer is crucial in helping families with their problems.

In the case of some parents they feel that they should look after their sick children because it is their problem. A widowed mother, especially, can feel that her husband wanted their child looked after at home, and, therefore, though she is getting older, she feels that she must continue to do this, even when there is suitable residential care available. Perhaps the noble Baroness who is to reply will give special attention to this problem and to the guidance of social workers and welfare officers when visiting families where there is a suspected problem of this sort. It would be helpful if there was an informative leaflet in post offices and sub-post offices explaining where parents might obtain advice. This could be of great help, especially in rural areas. And this is, after all, a well recognised way of passing on Government information

As the noble Lord, Lord Mottistone, said in his opening speech about Care in the Community, the National Schizophrenia Fellowship, in its pamphlet on its corespondence with the Minister of Health, called it "cart before the horse". I hope that this will not happen and that the horse will be put firmly in front.

Lord Kilmarnock

My Lords—

Noble Lords


7.1 p.m.

Baroness Macleod of Borve

My Lords, I am trying to slim, but I did not know that I was invisible. Like other noble Lords, I should like to thank my noble friend Lord Mottistone for raising this very important issue at this time. I say that it is very important not only from the point of view of the patient but also from the point of view of people on the ground. As we know, the Government are quite rightly urging hospitals to encourage their patients to live in the community. That is right. I agree entirely with it. But, as we also know—I hope that this is the reason for the noble Lord bringing it to our attention—the people in whose community the patients are likely to live are full of concern, full of anxiety and are being thoroughly tiresome and obnoxious. I hope that this debate, if it is given enough publicity, will go some way to quench their fears.

I thought that the right reverend Prelate was going to steal completely my tiny speech. He talked about some hospitals in an area to which I wish specifically to refer. Luckily, my hospital was the one that he left out, and so I am all right. I intervene in this debate because, for many years, I have been a member of the National Association of Leagues of Hospital Friends and for the last 11 years its national chairman. In that capacity I have travelled the length and breadth of the country visiting all sorts of hospitals to see what the voluntary workers are doing. The hospital to which I wish to draw your Lordships' attention especially is Napsbury, in the Barnet health authority area. This vast hospital was built in 1905 for 1,000 patients. In the 1940s-1950s it had 2,300 patients. In 1975 the number was down to 1,000 patients. Now, luckily, we have fewer than 800 patients, principally as a resutl of the introduction of new drugs. The only reason that I single out this one hospital from all those in the country that I have visited is that it has what I consider to be the best on-going plans that I have encountered anywhere in the country for helping patients to go out into the community. I should like briefly to give your Lordships what I hope is a pen picture of what it does. It is, I believe, a pioneer in community care.

Although a big push was started in 1960 to get patients into the community, it was in 1974 that the people at Napsbury really started to get things going. They realised that it would take time. The work still requires time. But so long as adequate training is given it is felt that the patients can live almost a full life out in society. Naturally, one agrees with those noble lords who say that some patients will always be too ill to be on their own in society. I intend, however, to talk about those who can go out and who are encouraged to go out by the medical and nursing staff at Napsbury.

We have flats where certain patients are taken and helped to live by themselves, not in wards but in their own rooms. They are helped to take care of themselves and are gradually being trained for outside life. All these facilities are located in the grounds of Napsbury Hospital, near St. Albans. Out of a figure of just under 800 patients, 500 work daily at occupation and industrial therapy training, so that their lives are busy. I had the privilege of opening what is called a horizon centre the other day. This is a big house in the grounds of the hospital where 24 patients are being trained to do the laundry, to cook, to look after themselves, to do the cleaning and to do their shopping—all the social skills that are needed outside. There is, in addition, a training house where six live in quite ordinary, almost boarding house, and one might even say, home conditions. It is a charming house, beautifully furnished. Everyone is very happy there.

In both cases the hope is that patients will stay there for only six months before they are found somewhere else to live outside the hospital. At another house near the church patients are entirely on their own without any supervision unless it becomes necessary. As president of the housing association that has made it possible, I am particularly proud of eight group homes in various boroughs within the catchment area. In these homes about six people of both sexes live. They are entirely self-supporting. They go out to work. They do not work within the hospital. They have their own latch keys. They are ordinary members of society. Obviously, people keep a watchful eye in case there is need for those involved to go back into hospital for a short time.

I was told by telephone this morning that there is another house that is going to be run by the Institute of Social Psychiatry which will take 20 ex-patients. This is within the hospital grounds. It is hoped that there will be a sheltered workshop, probably in Barnet, where ex-patients who are not able to do ordinary everyday work, which most of us think we are privileged to do, can go. The most important step taken since 1974, under the aegis of the Barnet health authority, is the introduction of what is called crisis intervention. This consists of two teams permanently on call for 24 hours, seven days a week, consisting of a doctor, a nurse and a social worker. They go out at a moment's notice to any home where there is a problem to assist those who might be helped by someone from the psychiatric hospital. This prevents, in many cases, a patient whom they have seen having to go into hospital. It seems to me a brilliant method of trying to cope with those who may temporarily have a mental illness before there is any question of admission to hospital. Those teams are not always busy, but they are always on call.

Although discharged patients are often very vulnerable and have to be dependent on someone in the world outside, one of their problems is I believe, the social stigma. That needs education among the public. But it also needs the goodwill of people who perhaps are not themselves in the medical or nursing profession.

I am very much concerned, and spend a good deal of my time, with voluntary organisations, as other noble Lords do. I should like to close with a tribute, which I feel they so richly deserve, to the medical profession, the nursing profession, and the voluntary organisations, mostly, if I may say so, MIND and the leagues of hospital friends for all that they do to help people not only in hospital but outside as well. Without them I think that we might still have vast hospitals full of people, who, as other noble Lords have said, need not be there and who could lead ordinary lives. There is a big part for everybody to play in this sphere and I should like to hope that the quality of life for discharged patients is as happy and as fulfilled as possible.

7.10 p.m.

Lord Kilmarnock

My Lords, may I begin by apologising to the noble Baroness, Lady Macleod of Borve? I should like to assure her that I was not intending to steal her thunder. There was a confusing exchange of messages as to who had cancelled. It was the noble Baroness, Lady Elliot of Harwood, and not herself. Could I also say to the noble Baroness, Lady Hooper, in congratulating her on her first appearence in a winding-up speech, that if she cannot hear me—as happened when I spoke from this place in the last health debate—will she please let me know and I shall move up higher? There is a gap between the microphones here.

Before going any further I must express my thanks to the noble Lord, Lord Mottistone, for giving us the opportunity to hold this extremely important and I think very illuminating debate. One of the things that I have found most striking is the sheer scale of the problem of mental illness and, I fear, the inadequacy of the response. The noble Earl, Lord Longford, said that it was grossly inadequate—those were his words. At a time when the number of hospital beds has declined from almost 100,000 in 1972 to around 69,000 today, the throughput of patients with mental illness has risen from 175,000 to 183,000. As the Social Services Committee report of another place tells us "Mental illness is certainly not diminishing".

With a reduction in the number of hospital beds, there has been some rise in the number of day-care places provided by local authorities, voluntary bodies and the private sector, but the increase has been much less than the fall in the number of beds. The local authority role has been particularly slow in getting going. As Table D of the recent York Centre of Health Economics report shows in its appendix, all local authority gross expenditure on residential mental illness places has risen merely from £16.6 million to £20.2 million over the last six years, which means that it is declining in real terms, as I think the noble Lord, Lord Ennals, said.

Local authorities are not complacent about their performance. The Association of County Councils has, I believe, written to a number of your Lordships. The noble Lord, Lord Ennals, also quoted from them. They say: The Government's response to the Social Services Committee is obviously disappointing. It has to be said that there appears to be very little in it to recognise the problems identified by this Association and others, and the response appears to be unduly complacent in dealing with what are very real needs". I am not sure whether that is the exact passage that the noble Lord, Lord Ennals, quoted, but it can certainly bear repetition.

When we turn to mental handicap, the picture is rather different. There has been much more response from local government, and the overrall share of spending going on these services is rising, albeit not spectacularly. However, these statutory and other services do not complete the picture, as we also have to build in the very large number of people with severe mental handicap who are already being cared for in the most genuine sense of all in the community, that is, by their families. I think the noble Lord, Lord Mottistone, called this the fourth caring arm, but I think I am right in saying that numerically it is the first. It is estimated that 200,000 of these have parents who are ageing and who will not be able to continue full-time caring much longer. This has very important implications for social security and, indeed, for the burden falling on Government if these people are forced to give up.

This is an area in which Government can do a great deal. How well are we and the Government responding to a scene that is more characterised by clouds than sunshine? The Social Security Committee of another place does not give the Government very high marks. It points out in paragaph 21: The proposition that community care could be cost neutral is untenable". This has already been mentioned, but I think that it is worth repeating. It goes on to say: We are at the moment providing a mental disability service which is under-financed and under-staffed both in the health and the social aspects. Proceeding with a policy of community care on a cost neutral assumption is not simply naïve: it is positively inhumane". I think that the noble Lord, Lord Broxbourne, quoted some of that, and I think that that, too, bears repeating.

This is fully confirmed by the report published by the York Centre of Health Economics, Public Expenditure on the NHS: Recent Trends and the Outlook, from which I quoted on 20th November. The Government, in their response to the Social Security Committee in another place, say that they are "costing care options". I think that came in the studiously impenetrable paragraph that was read out by the noble Lord, Lord Allen of Abbeydale. The Government go on to refer to work being done at York, precisely on this. Since they appear to pay serious attention to the York Centre of Health Economics—and rightly, I think—can the noble Baroness say whether they accept the centre's recommendation in that report that national health expenditure as a whole must be increased by 2 per cent. per annum in real terms if the Government's own objectives are to be met? That is important "if the Government's own objectives are to be met", not additional ones. It is not the Government's objectives that are wrong. I think the right reverend Prelate said that they were to be applauded. The trouble is that the resources are not there to meet them.

The centre also said: It may be that in the long run community care will prove a cheaper option but in the initial stage costs are likely to be higher as the investments are made in the new system at a time when much of the old is in being". Have the Government finally come to accept that this now has the backing and authority not only of the Social Services Committee but also of the York Centre of Health Economics, a widely respected body?

Other speakers have covered most of the areas in which there are serious shortfalls and shortcomings and I do not want to be repetitive, but there are a few specific points that I want to raise. I have given the noble Baroness advance notice of them; I hope she received my note. First, the Social Services Committee in another place recommended that the Government analyse the likely effects of the social security reviews—that is to say, the Fowler reviews—on the benefit entitlements of mentally handicapped and mentally ill people. Can we have an assurance that that will be done, and that something dealing with that will be included in the White Paper? They also recommend the extension of mobility allowance—this was referred to by the noble Lord, Lord Allen—to those mentally disabled people who are in practice unable to walk unaided; and the extension of invalid care allowance to married women as soon as the resources are available—a proviso that I would not have added.

What do the Government say? They simply say that they will keep the former proposal in mind—a phrase of which the noble Lord, Lord Allen, was suspicious. On invalid care allowance, they seem to be prepared to allow the European Court once again to rule against us for unequal treatment of men and women in a social security scheme. Do they want to invite that humiliation and find themselves forced to take the action that they could take voluntarily now? The estimated cost is £85 million. It is a large sum, but it is not huge, especially if a large number of carers become unable to cope with their present charges. It would be an enormous help to those caring for mentally handicapped relatives.

We would go further. The SDP has formulated a "carers' charter", which has been widely acclaimed. The main proposal is to establish a specific carers' benefit to which the extension of invalid care allowance to married women would be a first step. If the Government would only take that step, which would be widely popular, we would be only too happy for them to take the credit. We would do the rest in due course, but this is urgent. It requires action now.

I turn to homelessness. A terrible situation is developing here. The Royal College of Psychiatrists is extremely worried about the growing population of homeless psychotics who, shuttle between short admissions to psychiatric hospitals, prison sentences for minor offences and doss houses". On the subject of doss houses, which I have raised before in your Lordships' House, I want to ask the noble Baroness about the progress of the review of the resettlement units, to which many of these unfortunate people not unnaturally gravitate. There is supposed to be a replacement programme for Victorian facilities, such as the Camberwell Resettlement Unit, but what is the current state of play? Are voluntary bodies in a position to take over, even if funds are provided for that purpose?

At paragraph 165 the Commons Select Committee suggests that there may be up to 8,000 fewer bed spaces of this type in London alone in five years' time. Is this not alarming? These facilities are not marvellous, but in the current chronic state of the housing stock they are better than nothing. The Government claim that the Camberwell closure has been accompanied by an increase of places. Can the noble Baroness say where these are and what will be the net effect after other closures have taken place? Do the Government accept the Social Services Committee's recommendation that the replacement scheme be accompanied by a published evaluation of its results?

On the important question of training of social workers I shall say very little. It appears to me that the Government's response sidesteps the Social Services Committee's concern about insufficient training to enable social workers to meet their new responsibilities under the Mental Health Act and other legislation. However, the noble Baroness, Lady Faithfull, has covered this field so authoritatively that I shall not pursue it any further. I shall simply go on to my next point, which is the sale of mental hospitals and their grounds.

On Wednesday, 20th November the noble Baroness's noble friend Lady Trumpington said at col. 569 of the Official Report that: money received from the sale of mental hospitals would be used for care in the community purposes and would not disappear into other NHS pockets". At col. 573 I asked the noble Baroness to confirm that at the end of the debate. Indeed, at col. 643 she acknowledged that: in some areas community care may become more expensive, particularly where the standard of the service needs to be improved. The resources we are making available, authorities' own improvement programmes, and income from the sale of old mental hospitals will help to do that". It seems to me that the noble Baroness's second assurance that day was slightly less explicit than her first, and neither of them, nor her further assurance today, which I listened to carefully, make any mention of the sites on which the buildings stand. The Royal College of Psychiatrists have expressed fears of asset stripping. They say: We are convinced that in some parts of the country asset stripping is occurring. No directives have been given to ensure that the sale of (often valuable) land that surrounds mental hospitals is ploughed back into the mental health services. There is sometimes an unseemly haste to close (large) mental hospitals with considerable savings on the substantial running costs before arrangements have been made by a local authority to provide for the care of the inhabitants". The Social Services Committee makes the point in paragraphs 207 to 208 that these sites, which were provided by earlier generations for a specific purpose, do not belong to an authority but are entrusted to that authority for the benefit of mentally disabled people. They recommend that no mental hospital site should be disposed of without explicit consideration being given to the possible redevelopment of suitable parts for mental disability services, perhaps as part of a housing redevelopment. At paragraph 209 they also say that if a site is sold, it should be a binding obligation on the authority to show that the proceeds are devoted to mental disability services for those who would otherwise have been inpatients. At present there is a general understanding that this would be the case. There is, however, no mechanism for ensuring that the money is retained in these services. Although it may involve no more than a one-off capital gain, mental disability services have had to endure being Cinderella services long enough to be entitled to the proceeds when surpluses accrue. We recommend a clear ministerial directive to health authorities to retain the proceeds of any sale of mental illness or mental handicap hospital sites within these services". The Government reply at paragraphs 88 and 89 goes some way to accepting the inclusion of community mental health services in suitable redevelopments. At paragraph 89 they also confirm their view, that since the hospitals were established in the first place for the benefit of mentally disordered people, this must be the primary consideration in disposing of them". But "primary" implies other considerations as well, and frankly the line on sites as opposed to hospitals themselves is equivocal. Can we please have a clear statement of the Government's position in regard to this important source of funds? The Social Sen ices Committee say that there is no mechanism for their automatic switching into community care for the mentally ill and mentally handicapped. Will the Government create that mechanism and, if so, what will it be and when will it begin to operate?

Finally, I return to where I started. As the Social Services Committee remind us, it is no good imagining that community care will save money. They go on to say that the pace of removal of hospital facilities has far outrun—that is the phrase—the provision of services in the community to replace them. The stage has now been reached when the rhetoric of community care has to be matched by action. In the Government's response there is far too much about keeping things under review, with which the noble Lord, Lord Broxbourne, had some fun, or keeping them in mind, which the noble Lord, Lord Allen of Abbeydale, subjected to his wry humour. What is needed is action now, and I am sure that that is the overwhelming message to emerge from this debate.

7.28 p.m.

Lord Prys-Davies

My Lords, we are grateful to the noble Lord, Lord Mottistone, for introducing today's debate and for initiating the debate on this complex area of policy. It has given the House an opportunity to acknowledge advancement, where there has been advancement, and also to give expression to troubled reflections or, as the right reverend Prelate the Bishop of Saint Albans said, to give expression to our anxieties. I should also like to thank the right reverend Prelate for a contribution which showed his understanding of the human problems which are faced by the citizen in accommodating himself to a progressive policy for the mentally ill and the mentally handicapped.

We have been told that the debate has taken place against the background of this authoritative report from the Social Services Committee and the Government's very recent response thereto—a response which has not been warmly endorsed or received because, where we are able to understand the prose, it says very little that is reassuring.

Of course there have been other reports in recent years. We have heard about the 1983 report of the Richmond Fellowship, under the chairmanship of my noble friend Lord Longford. There is the important exchange of letters between the chairman of the National Schizophrenia Fellowship, supported by the Richmond Association, the Salvation Army and others, and the then Minister of Health between February 1984 and July last. Let it be remembered that the Schizophrenia Fellowship has a special interest in the second largest group of patients in mental illness hospitals. Therefore, its comments deserve careful consideration by the Government.

The noble Baroness, Lady Trumpington, was a member of the Richmond Fellowship Inquiry, so she has evinced an interest in the services for the mentally ill and the mentally handicapped for many years. Our hope must be that her voice will not be drowned within the department.

Since the Mental Health Act 1958, of which the noble Lord, Lord Broxbourne, can be truly proud, there have been advances and there have been achievements in implementing the policy of community care. What is rather interesting about the criticism we hear today is that this criticism has been around the place for 17 years, and it shows how difficult it is to take awkward decisions which have to be taken if we are to implement the policy.

Let me briefly note the achievements. If we look at the statistics of hospital care we see at work a policy of discharging patients from hospitals as soon as feasible, but allowing an easy return where necessary, and that the number of people resident in hospitals at the year end has been falling every year since about 1970. In our travels we come across this evidence.

In my own area there is the Hensol hospital for the mentally handicapped which accommodated 800 patients in 1970. By last year that had been reduced to 434. By 1988 it will be reduced to 334, and in about seven years' time it will be reduced from between 150 to 200. But this particular hospital requires heavy investment in additional staff, skills, and the upgrading of the building if it is to be a substitute home for those patients who cannot live an independent life in the community.

We welcome the development of the Community Psychiatric Nurse service—my noble friend Lord Rea has referred to the CPN—although its future role needs to be reconsidered. The noble Baroness, Lady Faithfull, with her immense knowledge of her subject, has described the task and the challenge which faces the Central Council for Education and Training in Social Work. But, as the noble Baroness, Lady Faithfull, emphasised time after time, this council is facing a task and a challenge which should not be underestimated.

Then up and down the country we have heard of local initiatives which are exciting and which are promising. The Minister drew our attention to three or four such initiatives. The noble Baroness, Lady Macleod, referred to such an initiative. Then the noble Lord, Lord Renton, and the noble Baroness, Lady Faithfull, described the progress made by the voluntary organisations, and no doubt my noble friend Lord Ennals could also have drawn the attention of your Lordships' House to many such initiatives undertaken by MIND.

These developments, all over about 20 years, represent the gains, the achievements; but I should like to emphasise that the mere statistics of a decreasing number of hospital beds cannot be allowed to be the complacent, sole measure of achievement. Those statistics have to be seen in their true context.

We must know whether the alternative model of Care in the Community has improved the quality of life for the discharge of patients. My Lords, has it? Where the necessary groundwork and facilities have been prepared, the evidence clearly indicates that the patient has gained. On the other hand, where the patient has been pitchforked into the community without the necessary groundwork, without the necessary supporting facilities, there is ample evidence that he has lost out.

This kind of evidence, which shows that the patient has lost out, is damaging to the policy of community care. It is also ammunition to those who, for various reasons, oppose the policy of transferring the main burden of care to the community.

The authoritative committee of the House of Commons concluded that, the pace of removal of hospital facilities for mental illness has far outrun the provision of services in the community to replace them. In speech after speech the attention of the House has been drawn to this major finding, or recommendation, of the committee. I think therefore that I am entitled to dwell on this main recommendation.

The recommendation is supported by the testimony of a large number of organisations which are not outside observers of the scene, and their testimony is not based on ignorance; it is based on the experience of their own eyes and of their own ears. The BMA, who know a thing or two about primary care, question whether the people who at present find themselves discharged from hospital into the community will, in the future, be properly looked after. Likewise, the Royal College of Psychiatrists are concerned that hospitals have been closed without alternative facilities.

The Association of County Councils conclude that there are many patients within the community often without adequate support services. The directors of social service, who have taken the lead in providing community services, were scathingly critical of the inadequate community facilities. In their own evidence the general practitioners drew attention to what they described as the reality of the situation; namely, that there had been no shift of resources to match the shift of patients.

In a joint statement the National Schizophrenia Fellowship and the Richmond Fellowship clearly warned that care in the community usually means that many patients without families, or whose families are reaching breaking point, get no care at all, and end up in prison or mental hospitals as vagrants, or commitsuicide. That is strong testimony. They are strong words.

I should like to refer to one other piece of supporting evidence which has not been touched upon this afternoon. A significant symptom of the situation is that parents of some mentally-handicapped children have recently been moved to petition the Social Services Secretary to halt the hospital closure programme until there has been an independent review of the community care available for patients.

Parents wish the best for their children. The needs of their children are at the heart of the lives of most parents. Accordingly, the call by the parents for the retention of the large hospitals for the mentally handicapped is a revealing example of a change of attitude on the part of parents. They are not prepared to accept community care as at present delivered.

In the light of this kind of testimony, I suggest that in the official response the department has shown an inadequate understanding of the practical problems in implementing the policy, a policy which we consider to be basically sound. Should not the Government be responding to this major finding and to the parents' petition by setting up an inquiry to study the relevant evidence, to consider the practical problems which are being encountered when transferring patients from hospitals to the community and then to form a judgment and, where appropriate, to make recommendations? If the Government are not prepared to concede this much, should not the department instruct every health authority in the land where there is a lack of community facilities to set up such an inquiry? It is simply not good enough to say that the closures are not being rushed, that the closures are planned. The planned run-down of the hospital must be rephased if the community facilities are inadequate. If the Government continue to ignore the volume of criticism, their conduct in this respect will come to be seen as complacent and will give ammunition to those who oppose the policy.

There are two questions that I want to ask the Minister as they have not been asked by any other Member of your Lordships' House. The first is that the main accountability within health authorities for implementing community care programmes will, from now on, be with the newly-appointed unit general managers of the mental health units. I understand however that the jobs have not been easy to fill, as has for long been the case. The general manager applicants have been attracted to the more glamorous sections of the NHS. Do the Government recognise this as a problem, let alone have a plan to resolve it?

Secondly, the Health and Social Service Journal commented adversely on the exclusion from the Government's response of any reference to the NHS management board or the supervisory board. Will the Minister tell the House to what extent are these bodies at the centre of the NHS aware of and addressing themselves to the 101 problems identified by the social services committee? I agree entirely with Members of your Lordships' House who have called for adequate finance to be made available and on a recurring basis. I agree entirely with the need to ensure public understanding and co-operation. We were immensely grateful for the message from the right reverend Prelate that the Church is interesting itself in this challenge. But I have concentrated on what I consider to be the major findings of the committee.

To conclude, central Government need to demonstrate that they are satisfied with the quality of community care schemes. Until it is demonstrated that the authorities are satisfied with the quality of community care programmes, then those who appeal for a period of stability before more hospitals are closed have a strong case which needs careful consideration. I trust that the Minister can inform the House that the Government will give such consideration to the problem.

7.45 p.m.

Baroness Hooper

My Lords, I should like to add my thanks to my noble friend Lord Mottistone for presenting us with this timely opportunity for sharing views on this important subject. These are views which must be taken seriously, coming as they do from so many experts and people who dedicate time and effort to the voluntary sector in this important area of mental health and care. I am encouraged that, time and time again, the view is expressed that we are moving in the right direction with community care. It is not an easy, cheap or convenient option. We feel it is simply the best way of offering a group of disadvantaged people the chance of living the best kind of independent life they can. Of course, there are difficulties to obscure the objectives themselves.

Noble Lords have expressed concern with the way in which community care is seen to be working, but many of the concerns expressed have been as much for the shortcomings of the existing service as for the expected or actual shortcomings of those which we are in the course of developing.

I was glad that the good things that are happening in the field have not been forgotten this afternoon and this evening. We can cite many good examples of good community care in action. The danger is that in citing just a few we may appear to overlook many other local schemes run by pioneering and dedicated people who will say that community care can work and that when it does it benefits both the carers and the cared-for.

My noble friend Lady Trumpington dealt fully with, and I think anticipated very well, the many anxieties and apprehensions which have been expressed in the course of this debate. She dealt with specific points raised by my noble friend Lord Mottistone and the noble Lords, Lord Ennals and Lord Winstanley, in their opening statements. My task therefore is to endeavour to cover any specific questions which were raised subsequent to her response or which may not have been covered by her.

Turning to the opening speech made by my noble friend Lord Mottistone with his knowledgeable references to schizophrenia, I was interested and pleased to hear about the forthcoming publicity campaign which will aim at educating the public about schizophrenia and what it really is. This should be a constructive and helpful step forward and I hope that the television programmes next January will reach a wide audience. We are aware that as more people are cared for in the community a greater part of their care will be undertaken by the primary health care team, and in particular, by general practitioners. My noble friend expressed a particular concern about this. We are conscious that there needs to be more training for GPs in recognising the early symptoms and signs of disorder; how and when to refer people to specialist care and how to support those families caring for someone who suffers from schizophrenia. Understanding, by both the public and the professionals, is crucial to a sympathetic response to the problems of the sufferer and his or her family which we ardently seek, and we must look to improved professional training. It is fortunate that the Royal College of General Practitioners is alert to this need and we hope to work with it, and, in particular, to increase the share of the substantial post-graduate education available to general practitioners which goes to psychiatric subjects.

The noble Lord, Lord Ennals, raised a 10-point plan. Since many of his preoccupations were covered by my noble friend's speech and I can reassure him that certain other points in the first nine are being taken care of, I need only add, in relation to the tenth point, which concerned the invalid care allowance extension, that, yes, it does cost £85 million and that was also a price that the Labour Government did not feel able to pay when they introduced the benefit.

Lord Ennals

But that was 10 years ago, my Lords.

Baroness Hooper

My Lords, the noble Lord, Lord Winstanley, referred also particularly to the Royal College of Psychiatrists and the treatment of unprepared discharges. We well understand the point, but I feel it is worth saying that we are glad that the Royal College recognise the difficulties because they themselves accept a crucial role in ensuring that appropriate facilities and care are available for patients before they discharge those patients from hospital. This individual case planning is absolutely essential.

Perhaps I may now turn to the remarks made by the right reverend Prelate the Bishop of Saint Albans. I know it is not customary in this House for more than one person to congratulate a maiden speaker, but as one who is fresh from that experience myself, perhaps I may welcome his helpful and well-informed contribution. I should also take the opportunity to pay a tribute to the part already played by Churches and church people inside and outside the hospitals. Chapels in hospitals are often sanctuaries in the best sense. In the community, acceptance by a local congregation can be almost the biggest single contribution to real community integration. I think this is an important contribution that local churches, as well as the larger churches, can make in this area.

The right reverend Prelate would also no doubt wish to be reassured on the topic of the avoidance of separating friends. Preserving relationships between friends is increasingly recognised as good practice—indeed, best practice—not least because of the research funded by the Department of Health and Social Security with the co-operation of the management and staff of Darenth Park Hospital.

The noble Earl, Lord Longford, challenged me to dispose of him effectively. I trust he will forgive me if I do not take him literally! However, I can dispose of the first of his seven points, which questioned the appointment of a designated Minister, because we do indeed have a designated Minister for mental health in the shape of our very own Lady Trumpington.

Turning to the references the noble Earl made from his considerable knowledge of the Richmond Fellowship inquiry, as we said when we met the noble Earl and the fellowship in 1983, we welcomed the report generally and took its thinking into our own policy thinking. I think I can say that we accept all the policy points it made and have been actively seeking to bring about services to match. However, I grant that we have not followed the fellowship's advice on the other side of their recommendations; i.e., the changes in management and finance, which they suggested as a means of a more rapid pursuit of the policy points. Here, we have thought our own judgment better and have made major changes of our own in the management of the health service over the last two or three years. For example, we have not set up the proposed departmental planning board, but we have set up a general management board for the health service.

We are not seeking a separate development fund for a mental illness service. Indeed, I think to do so would be divisive. I can imagine some cottage hospital for elderly people where those under the geriatrician were funded one way and their friends under the psycho-geriatrician were funded from an entirely separate pocket. However, we have clear statistics which unmistakably show that spending on mental illness, both by health Ministers and by social services, has risen in real terms, and further rises are planned. Thus I can confidently reply to the noble Earl, and indeed to other noble Lords who have been preoccupied with this point, that we do indeed value his initiative and the report of the Richmond Fellowship. We are working hard and, hopefully, successfully towards achieving its objectives.

My noble friend Lord Renton reminded us of the need for careful preparation for change. Indeed, this was a point which was also raised by other noble Lords. I agree that it is necessary to prepare facilities in advance and to prepare the individuals for radical change in their lives. This is being done. There are many examples, including the work at Ravenswood Village Settlement. I should also wish, in this context, to commend the work of Mencap, which has been enormously valuable in respect of both policy and practice. I am delighted that the Department of the Environment, as well as the DHSS, has been able to help, and I am glad to say that the DHSS pound-for-pound scheme has successfully supported some very valuable voluntary body initiatives for mentally handicapped children.

The noble Lord, Lord Allen, has given us the benefit of his expertise as a civil servant, as well as chairman of Mencap, this afternoon, particularly in relation to the mobility allowance extension. As the noble Lord says, these rules were considered by the Appellate Committee of your Lordships' House earlier this year in connection with a claimant who needs to be accompanied when out of doors. How their judgment is applied in other cases is of course a matter for the adjudicating authorities. In January next a tribunal of social security commissioners is to consider cases of a similar nature involving mentally handicapped children. When they have given their decision we shall certainly consider whether the qualifying conditions for the allowance are in need of further clarification. We are certainly not shelving this one.

The noble Lord, Lord Allen, also referred to elderly mentally handicapped people, as indeed did other noble Lords and the noble Baroness, Lady Masham, in particular. We recognise that mentally handicapped people are growing older and the needs of ageing people need to be understood in a special way. We are commissioning research at the Hester Adrian Research Centre, which should provide information useful to those providing services. The department's report on helping mentally handicapped people with special problems, published last year, referred to the needs of mentally handicapped people who are elderly.

My noble friend Lady Faithfull is, as so many noble Lords have acknowledged this evening, a great expert in this field. She quite rightly raised the subject of social work training in relation to the Mental Health Act. We do need specialist training for a core group of social workers who specialise in dealing with detention and the alternatives. This is a development from specialist training, under the old legislation, for mental welfare officers.

On social work training more generally, I am not going to venture to challenge my noble friend on her own territory. I shall take away what she says to share with my ministerial colleagues. I know that in doing so the question of funding will be seriously considered.

My noble friend Lady Faithfull made a number of points (and I think I can also select one other) which related to children in hospital, and expressed a general welcome and tribute to Government efforts here in partnership with voluntary bodies. I should like to acknowledge, in particular, the pioneer work of Barnardo's in the community care of profoundly handicapped children, not least in Liverpool, using a special support unit and ordinary families with necessary back-up.

The noble Baroness, Lady Masham, also raised a number of important points. I have already referred to her special concern for the elderly. I hope the noble Baroness will forgive me if we reply to her other questions in writing. However, concerning the question of brain damage, we are aware that brain damage through strokes and accidents presents a considerable problem. We look forward to considering what is said about this in reports on rehabilitation at present being prepared by the Royal College of Physicians and at a conference at one of our rehabilitation demonstration centres which is due to take place next April. We have this year introduced a grant for three years to Headaway, the voluntary organisation representing head injury sufferers. I hope this gives the noble Baroness some comfort.

My noble friend Lord Broxbourne also gave us the benefit of his considerable experience in this field. Indeed, I must say that some in your Lordships' House have long memories and long experiences; and my noble friend took us back to the Mental Health Act 1959, the forerunner of the current 1983 Act. The 1959 Act was indeed important as a landmark in many of the developments of policy and practice that we are now discussing. It played a significant part in ending excessive hospitalisation but we hope that we have learned from the mistakes as well as from the wisdom of our predecessors.

As far as the Mencap Pathway scheme is concerned, to which my noble friend referred, I shall make sure that my noble friend the Minister is reminded suitably. My noble friend Lord Colville of Culross reflected in his speech the concerns and insights of the Mental Health Commission. Perhaps I may take the opportunity of paying tribute to the commission's labours over the past two years and to assure him that my noble friend the Minister hopes to discuss with him shortly the various comments raised in his commission's recently published bi-annual report.

The noble Lord, Lord Rea, also raised a number of points. Perhaps I may tackle the question he raised in particular about earmarked funds to enable local authorities to provide care for people transferred from hospitals. This was a preoccupation raised by a number of noble Lords. The earmarking of funds is not considered necessary or appropriate in terms of central allocations. Parliament has not given the Secretary of State for Social Services power to give earmarked money to local authorities and they do not want earmarked money from the Government. The Secretary of State has enabled health authorities to transfer funds to them from their own allocations for as long as necessary for people coming out of long-stay hospitals.

The noble Lady, Lady Kinloss, commended the work of the Richmond Fellowship which was commended by many other noble Lords. I should like to volunteer an additional comfort to her about working with voluntary bodies by saying that the Government also support this, as evidenced by the Section 64 grants which amount to above £2 million a year for mental handicap and mental illness in cooperation with the voluntary sector.

My noble friend Lady Macleod, after her years of good work with the League of Hospital Friends, was able to cite as an example the Napsbury Hospital. This is clearly an excellent plan; and the experience there will provide very useful experience for the future. The noble Lord, Lord Kilmarnock, kindly forewarned me of the line of his misgivings. I hope that he will forgive me if I do not do more than pick out one or two points that he made, and I hope that he will be assured that we will deal with the other points separately; in particular in relation to the social security White Paper. I regret that it is not possible to predict the wording of the White Paper, but I can guarantee that, in preparing the White Paper, community care has been borne very much in mind. Perhaps I may take one specific case to which he referred. The Camberwell Resettlement Unit, which closed on 27th September this year, has been replaced by smaller units which are taking significant numbers of mentally ill men and women and providing hospital care of various sorts. In fact, the new places exceed the old places.

The noble Lord, Lord Prys-Davies, in summing up for the Opposition, was a little pessimistic. I am sorry that the noble Lord was not reassured about the cognisance that the Government take of the various reports that he quoted. But he noted the achievements as well as the criticisms and acknowledged the difficulty of taking the right decisions in order to bring in change most effectively. He may be assured that my noble friend Lady Trumpington will study carefully his comments together with those of all noble Lords. If there is any desire for further detailed responses, we shall be happy to give them in writing. I have no doubt that I may not have dealt adequately with all the points that have been raised, but, in concluding, I commend community care to your Lordships as being simply the best use of resources to provide the highest quality of life for mentally ill and mentally handicapped people. This Government are wholly committed to developing care in the community in a careful and sensitive fashion, so that the individual's needs are met fully. We are dealing with the real needs of people, whose needs will be best met by an individually tailored package of services provided by a range of statutory bodies and voluntary organisations. In seeking to bring about beneficial change, we cannot emphasise enough how much we owe to the dedicated families and carers of mentally handicapped and mentally ill people, to whom much tribute has been paid by many noble Lords, and we should ensure that they receive all the support they need. While we would not wish to deny the very real rewards that looking after even severely handicapped or disturbed people can bring, we should not underestimate the burden borne by relatives and other carers, even though it may be gladly borne.

I would underline again the increasing emphasis which is being given to the provision of outreach services in the home, providing support and advice to families looking after mentally handicapped and mentally ill people and respite care where needed. This is also an area, as has been said, where the voluntary sector can play a very valuable role. Again, I think that appropriate tribute has been paid to the numerous organisations which provide this very valuable service to the community. I think it is fully recognised—and, as a result of the debate this evening, even more so—that we cannot transfer people from institutions into the community overnight or without regard to the special needs of the individual. We must make sure that they as individuals are given the care they need to enable them to lead a worthwhile life. We are proceeding perhaps too slowly for some and perhaps too fast for others; but we are proceeding step by step and each step takes us further. The successes achieved so far, the people released from institutions and leading a full life in the community will remind us that we should never lose sight of the goals of community care.

My noble friend Lady Trumpington in replying earlier quoted our response and defined the aims of community care as seeking to achieve good quality and modern services to meet the actual needs of people in ways those people find acceptable and in places which encourage rather than prevent normal living. We must never lose sight of those aims.

Lord Mottistone

My Lords, I, too, should like to congratulate the right reverend Prelate the Bishop of Saint Albans upon what I though was not only a humorously introduced maiden speech which showed great quality but also a moving description of the problems of the mentally handicapped. I take issue with the suggestion of my noble friend the Minister that only one person may congratulate a maiden speaker. I think that as many people as may like to may do that. I should also like to congratulate my noble friend Lady Hooper: I think that, for a newcomer, she summed up this debate of ours better than I have ever heard it done before, covering just the right amount of what we had all said and doing it all in barely over 20 minutes—quite remarkable. I hope that all Front-Bench speakers old and new will take example from this in the future. If I may, I should like to take up what one might almost call a dissident point with the noble Lord, Lord Ennals, who invited me to comment further on the matter that I raised with him. I apologise for not having wrtten to him, but I have here the programme of the conference that he chaired last week. I must confess that the titles of the subjects spoken about frighten me. It seemed to be a conference more on the politics of civil liberties than on care for the mentally disabled. Perhaps we may leave it at that at this stage.

There is no need for me to do any summing up at all. I have to apologise to the noble Lord, Lord Rea—I have already done so in a note—for the fact that I had to rush away and change (and thanks to the superb job done by my noble friend the Minister, I shall get off in time.) What I should like to do in conclusion is to thank everyone who contributed to this debate, for so splendidly producing what can be described as "properly matching speeches", covering the ground so fully and so knowledgeably, and really making this a debate in which it was a pleasure to take part and, indeed, to have the privilege of moving. My Lords, I beg leave to withdraw my Motion for Papers.

Motion for Papers, by leave, withdrawn.

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