§ 6.31 p.m.
§ Lord Winstanley rose to ask Her Majesty's Government what steps they intend to take with regard to the recommendations contained in the Report of the Committee of Inquiry into the Care and After-care of Miss Sharon Campbell (Cm. 440).
§ The noble Lord said: My Lords, as will be apparent this Question is concerned with the care and the aftercare of Miss Sharon Campbell. Miss Campbell is a girl who it now a patient in Broadmoor Hospital. I am glad to say she is making good progress. She was at one time an in-patient in Bexley Hospital and later, having been discharged from that hospital, she stabbed to death a young and talented social worker with whom she developed a very close relationship by the name of Isabel Schwarz, who as a girl was once a constituent of mine when I was in another place. Isabel Schwarz was the daughter of Dr. Victor Schwarz who is a member of the academic staff of the medical school of the University of Manchester, with which I have close connections.
§ This long and sad story, as faithfully related by the committee of inquiry chaired by Mr. John Spokes, QC, has lessons for us all. It has lessons for doctors, nurses, social workers, for all noble Lords who take an interest in this subject, for voluntary bodies such as MIND and the Schizophrenia Fellowship, which are deeply involved in this field, and above all lessons for Her Majesty's Government.
At the outset I must say that I am delighted that at long last we have had a detailed and thorough inquiry into this tragic case. It took some time to have an inquiry held. Indeed on 30th July 1985, 12 months after the tragic death of Isabel Schwarz, I tabled a Question in your Lordships' House. Noble Lords will find it at col. 259. I asked Her Majesty's Government:
Whether they will hold a public inquiry under Section 14 of the Health and Safety at Work Act 1974 to establish the extent to which failures by Bexley London Borough, Bexley Health Authority, the South East Thames Regional Health Authority and employees thereof were responsible for the death on 6th July 1984 at Bexley Hospital of Isabel Schwarz, a social worker employed at the hospital".
To that Question I had an encouraging response from the noble Baroness, Lady Trumpington. My
information is that there was much resistance on the part of the authorities concerned to the holding of anything other than an internal inquiry. I suspect—no more than suspect—that the noble Baroness, Lady Trumpington, who took a close personal interest in this case after I alerted her to it, was responsible for overcoming that initial resistance.
I cannot help noting, that at paragraph 14.11 on page 61, the report states:
The death of Isabel Schwarz was reported to the Health and Safety Executive in November 1986, over two years after it had occurred".
The Health and Safety Executive is the body with statutory responsibility for matters of this kind. It is extraordinary that that body was not alerted to something over which it had statutory responsibilities until 24 months after this tragic event had taken place. It seems to me that that requires explanation.
I have no wish to comment in detail on such a lengthy and complex report. I can do no better than quote briefly from an article about the report, not the case, by Dr. Victor Schwarz who is Isabel's father which appeared in Community Care. The article says:
In 3,000 pages of transcripts one pathetic phrase repeatedly obtrudes itself—'with the benefit of hindsight"'.
Dr. Schwarz goes on to say that it is the business of professionals, doctors and so on, to exercise foresight, not hindsight, that foresight,
based on a thorough acquaintance with the established facts and with the detailed history of the patient".
What about the established facts and the details of this patient? I look for a moment—I believes it simplifies matters if I do, because Dr. Schwarz has pointed us in the right direction—at a paragraph later in his article. He quotes from the Handbook of Psychiatry by T. C. N. Gibbens (1983, vol. 1) which states:
Homicide often occurs in schizophrenics who have been ill for over a year. Strangers rather than members of the family were victims mostly when paranoid delusions suggested that they were responsible for persecution. Homicide by schizophrenics is more often a feature of those who have lost contact with the hospital, having received no after-care or follow-up treatment. Many homicidal patients had given prodromal evidence of impulsive physical violence.… In the majority of schizophrenic homicides the motivations are clear: anger, resentment or fear".
As Dr. Schwarz, the father of that unfortunate girl, Isabel, says:
There can be no clearer textbook description of Campbell's case".
I now turn to one or two matters concerning the relationship of Sharon Campbell and Isabel Schwarz which appear and are illustrated by the report itself. At page 28, paragraph 8.12 shows Isabel Schwarz as having recorded in her notes that,
Sharon Campbell had asked if Isabel Schwarz could continue to see her after she left Bexley Hospital. It appears that Sharon was nervous about leaving the hospital and going to live at a hostel".
That is a common phenomenon. I told your Lordships in a debate on an earlier case with which I had experience of a young man in Winwick Hospital who was institutionalised and had been there for a long time. He had schizophrenia, was under treatment and in control but was being discharged into the community. Detailed arrangements had been
made for his reception, but he was extremely apprehensive and very frightened about going. I recorded an interview on film with that young man but before the programme went out a week later on television he had hung himself in Winwick Hospital. It is something to remember that the anguish experienced by institutionalised patients and their fears are very real.
The report, still in paragraph 8.12, states:
Sharon Campbell was then offered a month's trial placement at the hostel and Isabel Schwarz took her there on the 19th November…Following Sharon Campbell's discharge from hospital on the 19th November 1982, Isabel Schwarz remained Sharon Campbell's social worker until October 1983".
In paragraph 8.20, it is stated clearly and rightly in my view:
The risk was indeed that Sharon Campbell might become too dependent on Isabel Schwarz and that, when eventually the case was transferred, Sharon Campbell might resent what she could see as Isabel Schwarz's 'desertion' ".
That is precisely what happened. Indeed that is what frequently happens. Patients of that kind become deeply dependent on their social worker or on anybody else with whom they are in close contact and that dependency can be turned on its head into total resentment and hostility if something happens to go wrong. The person on whom the patient is dependent becomes the person who is responsible for whatever in the mind of the patient has gone wrong. We have evidence to show that Sharon Campbell was violent. She brandished a knife and threatened to attack people in hostels in which she was resident. She once attacked Isabel Schwarz in a car while she was being moved to another hostel. She then had to be taken into hospital by the police and was sectioned. Isabel Schwarz was then moved from the case. However, the dependence remained.
§ Following that incident Sharon Campbell made a number of telephone calls to the hospital in which she repeatedly threatened to go in and kill Isabel Schwarz. It was not very long after the last telephone conversation before she did so. It is clear from the report that Sharon Campbell marched into the hospital with a knife. She was seen by a patient and was reported. But they were unable to do anything. I attach no blame in that connection. She marched into Isabel Schwarz's office and there stabbed her to death.
§ It is a fact that the panic button in the office did not work. That fact was established two days' later when it was tested. I know from my own inquiries that had it worked it would have made no difference because the person responsible for responding to a panic call was away sick and no one else had been put temporarily in the place of that officer. I do not wish to go into that matter but it is one of the sad facts about the case.
§ I have raised the issue because I believe that such a tragic case calls for some kind of urgent action. We have on the agenda the Griffiths Report. I do not expect the Minister to give the Government's response to that report here and now. I agree with the organisation called Community Care Now, which is representative of local and health authorities and voluntary and professional bodies. It regards the Government's delay in implementing the Griffiths' 457 proposals as shameful. I cannot now ask for a detailed answer and I do not expect one. I know that one of Sir Roy Griffiths' main recommendations was that responsibility for community care should be placed in the hands of local authorities.
Bearing in mind the Government's present attitude towards local government it seems extremely unlikely that that prescription of Sir Roy Griffiths will ever be dispensed. However, it does not mean that there is no need for action. With regard to action in this case, I shall do nothing more but turn to particular recommendations contained in the report. They are repeated at the end when its many recommendations arc summarised. On page 67, paragraph 16.5 states:
We recommend that the Secretary of State issue to health and local authorities a written summary clarifying their statutory duties to provide aftercare for former mentally disordered hospital patients". are, or have been, suffering from a mental disorder until those authorities decide jointly that the need no longer exists".
Surely that must be carried out. Paragraph 16.6 clearly states:
We recommend that the Secretary of State issues to health and local authorities a written summary clarifying their statutory duties to provide aftercare for former mentally disordered hospital patients".
§ If at the end of this short debate the Minister can say that action is being taken on those two issues, I shall be deeply grateful.
§ I say with no disrespect to the noble Lord, Lord Hesketh, who was to reply to the debate and for whom I have a great regard, that I am delighted that the noble Lord, Lord Skelmersdale, has taken his place. On many occasions the noble Lord has demonstrated his detailed knowledge of such matters and his sensitive approach to them. I am glad that he has the duty to reply.
§ The thanks of all noble Lords are due to Mr. Spokes and his colleagues who conducted the detailed inquiry. We now wait to offer thanks to the Government for having taken action in response to its recommendations.
§ 6.44 p.m.
§ Lord Mottistone
My Lords, I should like to thank the noble Lord, Lord Winstanley, for tabling the Question and for bringing to bear his personal knowledge of the subject both as a doctor and as someone who knew some of the people involved in the case.
I am advised by the National Schizophrenia Fellowship. It has suggested to me that the report throws up seven specific points which need urgent attention. First, general practitioners and psychiatrists should be more prepared to commit themselves in diagnosing such appropriate mental illness as schizophrenia. Sharon Cambell was in and out of hospital for two years—in 1980 and 1981—before, in August 1982, a doctor first suggested schizophrenia, and even then halfheartedly. Paragraph 7.2 of the report shows that.
A similar case is that of John Hinckley who attempted to assassinate President Reagan in 1981. There was a marked reluctance by doctors to diagnose his illness. It is most remarkable that as recently as 1981 the Americans at official level—quite apart from those out in the sticks—appeared to be 458 ignorant about schizophrenia. One would have thought that they may have been a little better than us.
In its recently published briefing papers, Care for a Community, the Royal College of Psychiatrists state that 2 per cent. of the population—that is over 1 million people—will have a spell of psychiatric care during their lifetime. Other sources have stated that one in a hundred of the population has schizophrenia and that approximately 7 per cent. of those may be violent. That may be 40,000 people—almost 100 for every district health authority. Those figures are alarming. In that proportion there will he 84 in the Isle of Wight.
Timely diagnosis can help to ensure that persons who may damage themselves or others do not do so. This morning I talked to Dr. Timms, a psychiatrist at Guy's Hospital who set up a study group to examine those in various hostels, in particular the Salvation Army hostels in which there are approximately 5,000 people.
He said that 30 per cent. of them are schizophrenic. I said, "You quite happily say that they are schizophrenic. How come that doctors don't do this?". He said, "The thing is that doctors are very reluctant with teenagers and people in their early twenties—people like Sharon Campbell—to declare them as being schizophrenic because if they do all kinds of automatic things happen and they are cast in that vein for life". It is a great problem because if doctors do not so diagnose, then this kind of disaster occurs. I believe that doctors and psychiatric helpers of all kinds should be encouraged to have a little more determination to declare people as being schizophrenic if that is their diagnosis.
The second point which the report brings out in several recommendations—though not specifically directed to schizophrenia—is the fact that social workers do not know enough about that illness. They do not know that it is a recurring illness with a chronic course. In 1986 90 per cent. of the 25,000 hospital admissions for schizophrenia were readmissions. I hate to say that social workers' ignorance is all too obvious to many relatives. It has the unfortunate effect of downgrading the confidence which people may have in the social workers.
This evening I spoke to a social worker who has moved from that function to become a I eamleader for the NSPCC. She told me how pleased she was to have made the move but how sad she was about the image which social workers have across the board, not only in this area. There is this case in which, sadly, they come out badly; and there is also the Cleveland case involving a different kind of social worker. However, it is most sad that those people who are trained most carefully do not have the leadership—I believe that that is missing—to give them the confidence to carry out their job in a way which will inspire confidence in others. For what it is worth I throw that out to the country because the Government cannot do much about that. Paragraphs 17.7 and 17.21 particularly relate to the point I have just made.
The third point is that there is too much reluctance to arrange hospital admission. It is alarming to see in 459 Appendix E to the report that the proposed job description for Isabel Schwarz included:To prevent admission of patients/clients from within the communityI believe that that is very remarkable. Of course, that was a proposed job description so I suppose that it never was her job description. Therefore one cannot say that Isabel Schwarz was breaking that rule when she suggested compulsory admission for Sharon Campbell nine months before her death because of her mental and violent state at that time. Three other social workers and a consultant psychiatrist disagreed with that, although none of them knew as much about the patient.
In itself that seems to me strange. We are told that Isabel Schwarz was a highly intelligent university graduate who was very well reported on. Because she was so close to her patients, surely those pompous individuals should have paid more regard to what she said, even if she was a junior social worker.
That is the sort of thing that happened to Hinckley. I thoroughly recommend your Lordships to read about Hinckley. The book is written by his father and mother in alternate chapters. Sadly, I have lent the book to one of my children and I cannot remember its title, but it is a paperback. It is gripping but terrifying about what went on. It seems that the noble Lord, Lord Winstanley, has read the book.
There is also the problem of an unco-operative patient. The worse the schizophrenia the less likely the patient to keep appointments, to take drugs or to visit the GP. To suggest that someone like that should receive social work support only if motivated is effectively to refuse help.
With regard to drugs and improvement though not cure of the condition, the improvement of many schizophrenics depends on drugs. A consultant psychiatrist and a community psychiatric nurse, both with inadequate knowledge of Sharon Campbell, apparently said that she did not need drugs and that her problem was social. It is quite clear from what happened that that was not true.
I am much concerned that the undervaluing of drugs by doctors and social workers is not only most unhelpful but can be dangerous and is all too common. The danger to patients and sometimes to others from excessive reliance on community care is that they cease to take their drugs, again become ill and again risk squalor and even death through lack of care. That leads one to consider the possibility of compulsory treatment orders outside the hospital. However, sadly, that appears impracticable. The people making the report must be congratulated on paragraph 16.12, which makes the difficulty of compulsory treatment all too clear and emphasises the need for an adequate range of after-care services.
That leads on to my sixth point—the housing of someone with whom no one can live. All alternatives to hospital are equally unable to cope if the schizophrenic is too ill. Sharon Campbell was asked to leave her home, a short-term hostel, a special hostel for former psychiatric patients and a bed and breakfast hotel, each time because she caused disturbances, including attacking with a knife. In 460 addition, even less violent schizophrenics can be unacceptable or can find life unacceptable in alternatives to hospital.
Recently on the Isle of Wight—and I believe 1 have already mentioned this in the House but I hope that your Lordships will bear with me if I say it again because it is relevant—a schizophrenic patient who did not get on with the people in this hostel threw a brick through a window in order to go to prison because those in charge would not admit him to hospital and the police were the only people who gave him care, as he explained later to the magistrates. That is disgraceful.
It is most unlikely that municipal or housing association accommodation, as recommended in paragraph 17.28, will be an acceptable substitute. However, I am told that the Department of Health has suggested a hospital hostel—whatever that may be. It would be very helpful if the Minister could tell us more about that and how many it is planned to establish in the community throughout the country. If there are 40,000 people who fall into the category of potentially dangerous schizophrenics, although they might not all have to be in hospital at once, we might require many hospital hostels to fill that undisputed gap with which the other types of accommodation do not deal.
It seems to me that there is a need for a statutory requirement for after-care for all former hospital patients who are or have been suffering from mental disorder. The report touches on that in paragraph 17.23, which, with the other quotation by the noble Lord, Lord Winstanley, was highlighted as a provision that needs to be brought into force as quickly as possible. However, I suspect that we shall need more legislation to provide for all the after-care required. I should hope that the Government will get on with examining that, taking paragraph 17.23 as their starting point.
In conclusion, I should like to suggest that paragraph 17.22, also mentioned by the noble Lord, Lord Winstanley, and paragraphs 17.25, 17.26 and 17.28 should be implemented without delay. I mentioned earlier the most helpful new briefing papers on Care for a Community produced by the Royal College of Psychologists. I believe that goes some way to meeting the requirements of paragraph 17.24. This is a most useful debate and I once again thank the noble Lord, Lord Winstanley, for asking the Question. I hope that the Minister, who I am delighted to see is dealing with this subject, will be able to produce some useful answers to the main questions highlighted by the noble Lord, Lord Winstanley, and to my specific question about hospital hostels.
§ 6.58 p.m.
§ Lord Ennals
My Lords, perhaps I may thank the noble Lord, Lord Winstanley, and the noble Lord, Lord Mottistone, for contributing to this debate and particularly the noble Lord, Lord Winstanley, for raising the matter. I also welcome the fact that the noble Lord, Lord Skelmersdale, is back in his place. I hope that we shall not continue to have these fleeting visits. We should like to see him more and more sitting there to answer our questions.
461 To some extent we are anticipating issues which I know will be raised in the debate on community care which my noble friend Lord Carter will introduce a week from now, and therefore I am glad that he is in his place at this stage.
The story of Sharon Campbell is very complex and the report painstakingly describes the events from 1980 when she was an 18-year-old student from a disturbed and deprived family background. It traces the complicated sequence of events as she passed through the hands of doctors, nurses and social workers over four years up to the climax on 6th July 1984. During that time, as has repeatedly been said, she was admitted to Bexley hospital, sometimes sectioned, sometimes as a voluntary patient and sometimes admitted through the offices of both Lewisham and Bexley social services. She was in and out of residential accommodation of one sort and another. She was under the treatment and care of what seems to have been about 50 professional staff of one sort and another.
I have to say that there are no allegations in this report of ill-treatment or cruelty such as we sometimes hear. It could not at any stage be said that she was the victim of wilful neglect, though certainly she was a victim. The cause has been well served by the inquiry team and the recommendations that have been made. The problems of the professionals involved shine through this report. I do not agree with the noble Lord, Lord Mottistone, on one point, though I agreed with most of what he said. I thought that the social workers did not come out of this inquiry any worse than the doctors. There were problems for all of them in deciding what was best.
Was Sharon Campbell suffering from schizophrenia? The doctors seem very reluctant to reach a firm conclusion. Did she or did she not suffer from that disease? To what extent was she a danger to the community? If she was a danger to the community, why was she discharged into the community? What sort of living situation was best for this troubled girl, who was, after all, struggling for part of this time from childhood into adulthood? As the noble Lord, Lord Mottistone, asked, how does the system best help a patient who does not want to be helped?
The report summarises a number of these issues very well. I quote from paragraph 4.16 on page 13, which deals with the problem of the "revolving door" patient.This is the patient who becomes mentally ill and is admitted to hospital, often as a voluntary patient. In hospital there is good recovery. The patient is discharged into the community and often, following failure to attend medical appointments or take medication, relapses. Readmission to hospital is arranged and the cycle is ready to repeat itself.It is a sad cycle that has affected so many in our society, particularly those suffering from schizophrenia.
Paragraph 16.9 deals with the common problem of lack of co-ordination under this revolving door syndrome. There were times in the course of the care of Sharon Campbell when lack of co-ordination between those people caring for her stood out as a significant feature. It is not that there was wilfulness in the lack of co-ordination but that information that 462 might reach one practitioner might not reach another practitioner in the same or a different discipline. The information was simply not passed on or available to the person who had to take a decision.
The third and only other quotation I wish to make from the report is in the summary on page 78. Paragraph 18.2 states:We were impressed with the time and effort many different professionals put into their care of Sharon Campbell. When she left hospital in 1982, she was well enough to leave only if she had continued psychiatric care and a hostal placement and was provided with some occupation, either in employment or at a day centre.It is easy to understand the deep concern of Isabel's father, Dr. Victor Schwarz. It is clear from what the noble Lord, Lord Winstanley, said that, had it not been for the father and, in fact, the noble Lord himself, this inquiry might never have taken place. It is strange that the department took so long to reach the conclusion that this was the sort of situation which could benefit society by bringing together all the facts, as this report has done.
Isabel was a young and promising social worker, anxious to succeed in her new profession. It was not the first act of violence by Sharon Campbell. Isabel had herself been attacked by Sharon some six weeks before. Sharon had also attacked another patient with a knife. Isabel Schwarz had received threats by 'phone not long before the fatal attack. In the light of all those circumstances, the attack could not have been a surprise to anyone. The report by Mr. Spokes and his two colleagues said that it was entirely predictable that Sharon's condition would deteriorate without treatment and that it was clear that Sharon frequently failed to take her medication—a point made by the noble Lord, Lord Mottistone.
This danger that a patient under treatment would neglect to take the medication necessary to maintain him or her in a reasonably stable condition had already become apparent in Sharon's case. The report states that there had been failures in communication between doctors and social workers in Bexley and Lewisham, thus allowing Sharon to "drop out of sight", to use the words of the report. Therefore, at this stage one's first question is: why was Sharon discharged when so much was known about her violent behaviour and the likelihood that discharge would lead to a deterioration in her condition?
The people responsible for discharging Sharon from hospital must have known about the seriousness of her mental condition. Certainly at this stage one must be aware that, dramatic though the events were, the situation was by no means unique. There have been too many similar cases of violent attacks on social workers and others. Last year Richard Kirkman was stabbed to death at a hostel for homeless people in Stockport, Cheshire. Two more social workers died in the intervening years; Norma Morris was murdered in Haringey, north London, in 1985 while visiting a young man who had attempted suicide; Frances Bettridge was strangled in Birmingham in 1986 by a man who thought that she planned to take away his children. These four deaths, and increasing information about growing numbers 463 of attacks, have prompted local authorities to change their policy in practice in regard to protecting staff.
As both noble Lords have said, the House will inevitably want to know from the Minister what action has been taken, or is intended, by the Department of Health following the 30 recommendations of the inquiry team. Furthermore, what action has been taken to require health authorities to establish a register of discharged patients who are thought to provide some dangers for others such as social workers, other patients or other people? That was one of the specific recommendations also mentioned by both noble Lords.
The report also recommends that a named psychiatric nurse or social worker should provide regular reports, with patients remaining on the register until the consultant psychiatrist is satisfied that they can be removed. How has the department reacted to that proposal?
It was drawn to my attention today that the Parliamentary Panel of Personal Social Services, of which I am a member, has asked questions. The panel wants to see, first, every social worker trained to recognise and record significant information about a mentally ill client. Secondly, it wants adequate systems of recording violent incidents to be set up in all authorities, with information gathered and reviewed regularly so that the lessons are learnt and acted upon. Thirdly, the panel asks for alarms and safer working surroundings for social workers. That has been called for by the British Association of Social Workers in its own report, to which my attention has been drawn. It is that report, Violence to Social Workers, which identifies residential and day-care homes as the most dangerous social service environments in which to work.
Fourthly, the panel asks for counselling to be available to the victims of violence as part of a greatly enhanced system of support for staff under stress. I am encouraged to find that the Parliamentary Panel on Personal Social Services has gone through the report, reached its own conclusions and made representations.
We can see that this a very serious situation and the Minister may he aware that a report from the Labour Party research department revealed some disturbing facts. There are no national or regional figures on the number of attacks on social workers. More than 40 per cent. of those who responded to the Labour Party research had been attacked with a weapon; 83 per cent. had suffered some form of violence; 93 per cent. had been threatened.
Separate from that inquiry a survey carried out last year within Herefordshire and Worcestershire revealed 170 assaults in three months, ranging from bites to broken teeth. A similar exercise carried out in Cleveland from July to December 1987, when the sex abuse controversy was at its height, revealed 173 incidents in which social workers were attacked or harassed, and in 73 cases they were injured.
These facts are very disturbing and must affect the recruitment of social workers. They may also account for the fact that there is a serious lack of social workers in some authorities. Perhaps the Minister 464 can give some information about the recent recruitment of social workers and also say what provision is now available for secure residential places for those patients who are too dangerous to be in an open society. I doubt whether the numbers suggested by the noble Lord, Lord Mottistone, are all likely to require secure accommodation at any one time and I believe that he recognised that. Certainly there are times when security is absolutely essential not only for the patients but for others with whom they come into contact.
Perhaps I may put my last and obvious question. Neither I nor the noble Lord, Lord Winstanley, touch upon these questions without asking "And what about Griffiths?" The matter now goes back to February, when Sir Roy Griffiths produced his report. He did so recognising the urgency of the problems that are faced in providing adequate care in the community, including provision for people exactly like the one we are talking about today.
The Government say that they will report when it is appropriate. It is more than appropriate now. The time has passed when they should have responded to the report. The Government must expect that all of us who are concerned, whether or not we agree with all of the Griffiths report, find it very disturbing that it looks as though there has been no response. It seems like lack of caring when a very important set of recommendations such as these are simply left on the shelf. No doubt at some time the Government will produce a response. It should be done in a debate of this kind, or it may be done next Wednesday. I hope that the Minister will recognise the strong conviction that many of us on this side of the House have that the Government have to come clean and produce a response not only to the recommendations in this report but also to those in the report of Sir Roy Griffiths.
§ 7.12 p.m.
§ The Parliamentary Under-Secretary of State, Department of Social Security (Lord Skelmersdale)
My Lords, as the noble Lord, Lord Winstanley, has said, on 6th July 1984 Miss Sharon Campbell walked in to the office of Miss Isabel Schwarz, a social worker at Bexley Hospital, Kent, produced a knife and stabbed Miss Schwarz to death. Why? The Government set up the inquiry into the care and after-care of Miss Sharon Campbell, to get the facts in spite of the Bexley local authority internal inquiry which had been going on. It is the government inquiry which is the subject of the noble Lord's Unstarred Question tonight. This painstaking inquiry, as the noble Lord, Lord Ennals, described it, was carried out by an independent committee chaired by Mr. John Spokes, QC, who published his report on 26th July. I agree with the noble Lord that it is a painstaking report.
The Government were extremely grateful to Mr. Spokes and his colleagues for their report which examined the care provided to Miss Campbell between 1980 and 1984. It took account of her treatment as a psychiatric in-patient at Bexley Hospital in Kent; her subsequent out-patient treatment; and the care provided by two social 465 services authorities (Bexley and Lewisham) when she was living in Lewisham. It also examined the involvement of Lewisham housing department and the family practitioner services.
I almost said in my opening sentence "out of the blue". Having read the report carefully, it is quite clear that at that time Miss Schwarz was no longer the social worker responsible for Sharon Campbell's case.
The noble Lord, Lord Winstanley, makes the point that Sharon Campbell had a very close relationship with her. I accept that, but there is no reason to believe that this very close relationship continued after the last telephone threat was reported on 8th March; in other words four months before Miss Schwarz's death, even though I accept that we know that the telephone threats were not properly acted upon. It is equally clear to us now that Sharon was a very sick woman. I am not a doctor—still less a psychiatrist—and I cannot say whether she was suffering from schizophrenia or a near-schizophrenic disease. She most certainly had feelings of persecution.
In spite of the remarks of my noble friend Lord Mottistone, the report drew attention to the dedicated care and treatment given to Miss Campbell by many professional staff. The committee considered this an unsurprising, though welcome, finding and 1 am glad that the report gave prominence to it. Psychosis is one of the three major types of mental illness especially schizophrenia and manic depressive psychosis. Symptoms include hallucinations, delusions, apathy and emotional changes. Eight people in every 1,000 will develop schizophrenia at some time in their lives. It accounts for 15 per cent. of all admissions to mental illness hospitals and units. More than half of those who suffer from a first attack of schizophrenia will remain significantly disabled. Manic depressive psychosis accounts for 12 per cent. of all admissions to mental illness hospitals and units.
Although mental illness remains a major cause of admission to hospital, the success of modern methods of treatment, particularly drug therapy, has resulted in shorter lengths of stay and a need for fewer hospital beds. The aim is the provision of a balanced range of easily accessible hospital and community-based services which are responsive to individual needs. Those older mental illness hospitals which cannot form part of the evolving pattern of services are being closed when no longer required. In-patient facilities will continue to be needed to a varying extent. These may take a different form; for example, a psychiatric wing of the district general hospital.
Tranquillisers produce a calming effect and relieve anxiety. The noble Lord, Lord Ennals, and I have had discussions on minor tranquillisers in the past. As we well know, tranquillisers may lead to dependency, and difficulty in withdrawal from them. Major tranquillisers are used in the treatment of psychotic illnesses such as schizophrenia. I am advised that drug dependency does not develop with these major tranquillisers.
Returning to the committee: it identified a number of shortcomings and consequently made 466 recommendations for the better care of mentally disordered people in the community including record-keeping by, and communication between, health and local authorities, professional staff and others. I regard that as a reinforcement of the part of the Griffiths Report referred to, not surprisingly, by all noble Lords. It must be recognised that the Griffiths Report goes far wider than the issues we arc discussing tonight. I am conscious of the feeling of noble Lords and of the public that our response should not be long delayed. I assure the House that the Government have not been idle on this issue. They have had a wide range of responses to the report and they are giving careful consideration to the way forward. I cannot yet say when we will be able to put forward our own proposals.
The committee also considered the circumstances in which Miss Campbell killed Miss Schwarz. It provided helpful advice on the safety, training and supervision of social workers; an area which has rightly been a matter of public concern in recent years and one of keen activity by many interested bodies, including central government. Copies of the report were sent to all health and local authorities in England, to family practitioner committees and to a number of professional bodies. We looked to the health and local authorities directly concerned in the care of Sharon Campbell to consider the report's findings with particular care and act upon them as necessary.
The committee's recommendations will also be of value to all authorities in terms of service planning and good practice and, as with the report of the Department of Health and Social Security advisory committee on violence to staff which I shall mention in a moment, in the development of strategies for responding to violence. Ministers are considering those recommendations which are specifically directed to the Secretary of State and others and which may require some action or consideration at national level. One of the key issues that emerges strongly from the report is the importance of authorities and practitioners maintaining contact with one another. To be effective, services need to be properly co-ordinated and better targeted. In particular, my noble friend Lord Mottistone highlighted the fact that Mr. Spokes recommended that health authorities should maintain a register of mentally ill people regarded as vulnerable in the community; also, that further consideration should be given to forwarding the multi-disciplinary approach to care for patients living in the community. The committee emphasised the importance of accurate record keeping in the interests of effective care.
The Government very much welcome the committee's views on these matters, which are extremely timely, in relation to work that the Department of Health has itself been encouraging in recent years.
As the report noted, recent studies, such as those funded through the department's initiative on coordinated after-care for schizophrenia, have pointed to the value of computer systems in monitoring and follow-up work. Building on these studies, we have been considering what might be done to provide a system of co-ordinated continuing care for people 467 chronically disabled by mental illness living mainly in the community. I attended a working conference in February of this year, organised jointly by the then DHSS and the National Unit for Psychiatric Research and Development, at which a number of service providers discussed the detailed requirements of such a system. The report of that conference was published by the national unit in September and my successor is studying its contents very carefully.
We also made it clear in planning guidance issued to health and local authorities in July that by 1991 each district must have developed a care programme to provide for people chronically disabled by mental illness. More detailed guidance on the components of these programmes is in preparation. We also emphasised that each district should ensure that a consultant psychiatrist has special responsibility for rehabilitation and continuing care.
The committee highlighted the need for authorities to be aware of the precise obligations placed upon them. As recommended, we are looking into the issue of a summary to health and local authorities of their statutory duties in relation to the provision of aftercare, and I think your Lordships will be pleased with that.
In accordance with another of the report's recommendations, which has been mentioned by the noble Lord, Lord Winstanley, the Royal College of Psychiatrists has been invited to publish a document on good practice for discharge and after-care procedures. The royal college has set up a working party (composed of very senior fellows) to draft the document—as well as a response to the report as a whole—and they will seek the views of colleagues in other professions so that a consensus statement on good practice can be issued.
The recent planning guidelines to health and local authorities touched on a number of other issues addressed in Mr Spokes's report. For instance, the guidance stressed the importance of the statutory bodies taking into account the needs of ethnic minorities in their service planning. The committee's comments in this area have also been drawn to the attention of professional bodies, in view particularly of the recommendation that staff treating and caring for mentally disordered people should be trained to respond to the needs of those from differing cultural and ethnic backgrounds.
The planning guidance also emphasised the need for provision of a range of adequate new supportive places for mentally ill people (whether in-patient places; local authority, housing association or voluntary places; sheltered housing; supported lodgings or other similar provision). I am pleased that the Spokes committee praised the efforts of Lewisham's Housing Department in the case of Sharon Campbell; but they rightly stressed the importance of housing provision to satisfactory after-care.
To answer a point made by the noble Lord, Lord Mottistone, satisfactory housing after-care might well consist of hospital hostels, which are normally regarded as mid-way between the hospital itself, with the lesser level of care, but within the precincts of the 468 hospital grounds, before those people who are suitable can be moved into the wider community.
There have been continuing discussions between the Department of the Environment, particularly about provision of special needs housing.
The Government want local housing authorities to expand their role as strategic planners, identifying local housing needs, deciding priorities for investment and working closely with health, social services and other local agencies to secure the provision of housing and support services. They have asked them to concentrate their resources on those in greatest need; clearly many people leaving longer-stay hospitals will be among those needing priority help. Local authorities will retain, in particular, their statutory responsibility to find housing for vulnerable homeless people with priority need.
Where housing authorities identify a need, they are expected to work with voluntary and private agencies to meet it. Government funding is targeted on mentally ill and other vulnerable people through the housing association movement. One of their main priorities is to provide affordable housing for people with special needs, such as those with mental health problems. This approach is well in line with the Spokes committee's recommendation which specifically mentioned the role of housing associations.
Training for staff in the personal social services is another area in which the Government have been taking action. Indeed, the report welcomed our announcement on 4th May this year of the provision of up to £1 million additional funding this year to the Central Council for Education and Training in Social Work, the statutory body responsible for social work training, with further sums to follow for improving practice placements and converting one-year postgraduate courses to two years' study.
Much is therefore already being done in the field of social work training and things have certainly changed since Isabel Schwarz was appointed by Bexley Council in 1982. The Mental Health Act 1983 requries local social services authorities to appoint approved social workers who have the appropriate competence in dealing with persons who are suffering from mental disorder. Those social workers who are to undertake duties under Section 114 of the Act must be approved by the local authority, following the Secretary of State's directions, after undergoing appropriate training (now lasting for 60 days). The training courses for approved social workers are approved by the central council. Local authorities are expected to monitor their approved social worker training to keep it up to date, and also to provide refresher training for approved social workers. The central council is preparing guidance for local authorities about refresher training for approved social workers which is expected to be available early next year.
The central council has also approved a number of post-qualifying courses specialising in mental health and mental disorder for qualified social workers who deal with mentally ill people other than in the specific circumstances defined by the 1983 Act. Most of the courses are in universities. Other post-qualifying 469 courses in advanced social work may include a mental health component. The central council plans to provide some additional curriculum advice next year to qualifying courses on mental health matters.
Any local social services authorities can also provide in-service training for their staff on mental health issues. The Spokes report emphasised the importance of providing proper supervision and training, especially for newly-appointed social workers.
I shall now turn finally, but by no means least, to the question of violence. At the same time as it was decided to have a committee of inquiry into the untimely death of Isabel Schwarz, my right honourable friend the Secretary of State set up a committee to report on the potential for, and measures to counter, violence to staff, and following the general election, I chaired that committee, which became the Advisory Committee on Violence to Staff. It looked at the problem of violence to staff in the health services, social security and social services fields. The issues covered by the report, which was published and widely distributed on 26th July (the same day as the Spokes report), included monitoring incidents, staff training, environmental conditions, staff support and counselling, many of the things the noble Lord, Lord Ennals has been asking for. Following on the report the Department of Health has in production a video for authorities to use in training and in raising general awareness of the subject. As Mr. Spokes acknowledged, the Association of Directors of Social Services issued in 1987 Guidelines and Recommendations to Employers on Violence against Employees which covers similar issues. The British Association of Social Workers has also published this year a further report on this subject entitled Violence to Social Workers.
My committee's report contains much valuable advice for social services authorities. It is now for individual authorities to take whatever further action may be needed to provide a safe working environment for staff. My report pointed out that the Health and Safety at Work Act 1974 placed a legal duty on employers to provide a safe working environment for their staff. I am delighted to see that the Health and Safety Executive has just produced a further report on this subject entitled Preventing Violence to Staff. The report contains nine detailed case studies showing the action different organisations have taken to reduce the risks to their employees. It also suggests a framework that all employers can use to tackle the problem. The case studies include a local authority social work department and community nursing.
§ Lord Ennals
My Lords, may I ask whether this was one of the cases on which the Health and Safety Executive made a report?
§ Lord Skelmersdale
My Lords, the Sharon Campbell case, as far as I know, was not one of the cases. I stand to be corrected and will write to the noble Lord if I am wrong.
As I was saying, the report also suggests a framework to tackle the problem. The case studies 470 include a local authority social work department and community nursing.
I have been asked various questions on which I have not been able to comment. The noble Lord, Lord Winstanley, mentioned the handbook of psychiatry, and quoted from it: he said that it stated that homicide often occurs in schizophrenics who have been ill for over a year. I am advised that it is also true to say that the vast majority of people with untreated schizophrenia for a year or more do not commit homicide. Only a tiny percentage of all homicides arc committed by people with schizophrenia. Some evidence suggests that it is no more than would be expected considering the numbers of people in the population with schizophrenia.
The noble Lord also tried to draw a comparison between this case and another case that he has brought before Your Lordships recently. He suggested that one of the reasons for this unfortunate event was institutionalisation. I am afraid that I must take issue with him here. It was quite clear from the report that in the way that we all use the term "institutionalisation", Sharon Campbell was not institutionalised. She was living in the community, albeit, as I accept, chaotically; she was moving in and out of the community.
That brings me to a point that the noble Lord, Lord Ennals, almost made regarding the so-called community treatment order, a matter that came under much discussion, as he will remember, when the Mental Health Act was going through Parliament. At present the Department of Health holds no formal views on this very sensitive issue. We have not directly been approached to give any. However, the debate continues and departmental officials are watching it with great interest. It seems likely that the Mental Health Act commission and the Royal College of Psychiatrists will present joint proposals for consideration by the department and its ministers in the near future. The department eagerly awaits the report.
My noble friend Lord Mottistone called attention particularly to recommendation 17.22, which was covered very thoroughly in this House in the debates on the mental health legislation. The noble Baroness, Lady Masham, successfully moved an amendment to introduce what is now Section 117 of the Mental Health Act for formerly detained patients. I have already highlighted the fact that proposals for the continuity of care together with the provisions of Section 7 of the Disabled Persons (Services, Consultation and Representation) Act 1986 may minimise the need for any new statutory provision. I shall pass on to my successor the need to keep the matter continually under review.
My noble friend also asked about the number of psychiatric nurses both in the community and in hospitals, which information I regret I do not have with me.
§ Lord Skelmersdale
In which case on this occasion not only shall I not refer to it but I shall not write to the noble Lord either!
The noble Lord, Lord Ennals, asked about secure facilities and progress with the regional secure units. Thirteen of the 14 regional health authorities now have permanent regional secure units in operation. The remaining region, South-West Thames, proposes that such a provision will function in association with several close supervision units already operating in existing hospitals. Therefore, we have cover which is country-wide although not quite so formal as we anticipated when the programme was started some years ago.
472 I have been at pains to show that we have no intention of sweeping this tragic event under the carpet. As Mr Spokes's committee rightly concluded, we must look forward rather than back. I envisage that the action already taken and the action that will be taken not only will reduce the likelihood of such tragic episodes in the future but also should improve the quality of care of mentally ill people living in the community.
House adjourned at twenty-four minutes before eight o'clock.