Mentally Ill and Handicapped

HL Deb 07 December 1988 vol 502 cc624-62

6.22 p.m.

Lord Carter rose to call attention to the level of assistance available to people with mental illness or mental handicap moved from residential care into the community; and to move for Papers.

The noble Lord said: My Lords, the debate which we are about to have concerns one of the most poignant problems in a modern society: the fact that a large number of our fellow citizens—I use the word "citizens" advisedly, because citizens have rights—do not have the same rights and level of comfort and care as the rest of society. I refer to people who are suffering from mental illness or mental handicap moving from hospital into community care—or, as some would argue, community neglect.

As the Griffiths Report on community care published in February of this year pointed out: At the centre, community care has been talked of for 30 years and in few areas can the gap between political rhetoric and reality on the one hand, or between policy and reality in the field on the other hand have been so great".

There is certainly no lack of evidence, reports and proposals for action in the field. The Social Services Committee in another place, reporting in 1985, pointed out that while there is, a general recognition that the days of the largest hospitals are over, there is no consensus about community care".

That report produced no fewer than 101 recommendations for action. The Audit Commission reported in 1986. It recommended a proper division of resources and responsibility between central government, local authorities, the private sector and the voluntary sector.

Finally, as I said, we have the Griffiths report issued in February this year. It produced a range of proposals for the organisation of community care. The response from the Government has been a deafening silence. Meanwhile long-stay hospitals are being run down or closed before proper community services are available. That has resulted in some patients experiencing a worse quality of life than they had in hospital.

There is a confusing and conflicting overlap of responsibilities and provisions involving the hospital service, the health authorities, the voluntary sector, the private sector, the central departments of government and the social service departments of local authorities. In such a situation there is bound to be a misuse of resources.

There appears to be a grave mismatch of resources to need: some 90 per cent. of the expenditure on mental health services is in the hospital services and 10 per cent. on community care. However, the demand is almost exactly the other way round; namely 90 per cent. of those requiring help are in the community, while 10 per cent. are in hospital.

For each of the psychiatric nurses working in the community there are about 25 working in hospitals. In a large mental hospital that I know of in Wiltshire, there is a nurse-patient ratio of almost one to one; there are 350 nurses for 500 patients. In the same area there are 22 psychiatric nurses in the community with a caseload of 30 to 40 patients each.

On the very important question of the closure of hospital beds, there is a deal of confusion over the number of mental health beds which have been closed, and are to be closed, and there are conflicting figures from different sources. The estimates for closures during the last 10 years range from 25,000 to 40,000 beds. I hope that when the Minister responds to the debate he can provide the most up-to-date figures from the Government for the actual number of closures over the last 10 years and for the planned closures in, say, the next five years.

However, whatever the figures for closures are, compared with the closure of the tens of thousands of hospital beds, what is clear is that only some 9,000 of day care places have been provided in the past 10 years. The problem is bedevilled by the not unusual situation of different departments of central government pulling in different directions.

The Department of Health has responsibility for encouraging and promoting the provision of care in the community. At the same time, the Department of the Environment ratecaps the local authorities which increase their expenditure on community care, while the Department of Social Security, through its system of board and lodging payments, tends to guide people towards a form of semi-institutional care in residential homes and yet at the same time administers the new Social Security Act which in some cases has resulted in substantial loss of benefit for former patients.

On the question of board and lodging payments, there is concern about the proposal from the Department of Social Security to transfer the residents who are in the voluntary sector hostels from the system of board and lodging payments on to housing benefit. It has been argued that such a change will undermine the finances of existing schemes and that many of them will be forced to close.

The schemes have been specifically developed by housing associations and voluntary agencies as a part of the Government's initiative in community care. The opportunities for people to move into the community could be seriously reduced and, indeed, it is possible that many would have to stay for an unnecessarily long time in residential institutions at an increased cost to the Exchequer. Although I welcome the recent announcement of Mr. Nicholas Scott, the Minister for Social Security, that he has deferred the proposed change beyond April of next year, there is still considerable concern that the department intends to go ahead with the change much later in the year.

Housing is an area where the problem is most acute. I think that we would all agree that every citizen has the right to a decent roof over his or her head. However, it is clear that substantial numbers of former hospital patients are ending up in unsuitable temporary accommodation, in hostels and in night shelters or are indeed homeless.

The Salvation Army estimates that up to three-quarters of the male inmates of its hostels may be suffering from mental illness. The St. Mungo Housing Association notes that the number of former and long-term psychiatric patients resident in its hostels has increased from 10 per cent. to nearly 50 per cent. Emanuel House in Nottingham, which is a large hostel for the homeless, has seen a substantial increase in the number of former patients from mental health hospitals who are seeking hostel accommodation.

In a recent article in the Guardian there were heartbreaking stories of former hospital patients who were literally starving and who were somehow getting themselves back to hospital, the only haven that they knew. This is just one case of many: Robert cannot think straight, let alone manage to budget on the pitiful £25 a week that he collects from social security benefits. Halfway through the week he has run out of money and is begging for food. The hospital sister has been doling out her own money to desperate outpatients. She says they tell her that they have no money left. It is found that they have not eaten for days.

Only yesterday I had a discussion with a social worker in South London, who described two of the many cases with which he had to deal. One concerns a man of 62, who is leaving hospital after 33 years. He has few skills to enable him to look after himself outside. He is very frightened of the outside world and is desperately insecure. The other case is that of a woman of 40 sufferering from severe brain damage as a result of meningitis. She has an attention span of only half an hour. Her child is in care. She has no idea of how to manage money. She relies on charity to augment her benefits of £40 a week. These are examples of two people who are utterly reliant on a good system of community care.

There is an inner city problem overlaying the other problems that I have described. I referred earlier to the mental hospital near my home in Wiltshire. This has been halved in size over the last 20 years from 1,000 to 500 patients. I discussed the situation with a senior member of the staff in preparation for this debate. He said that there are problems, although possibly fewer than in the cities and conurbations. The hospital serves a rural area which has no town with a population larger than 10,000 to 12,000 people. In that context community care gets a chance to work. The pressures on the patients, hospital and community are much less than in the inner cities.

It is not possible to do more than outline the problem in the time available. I know that other speakers will wish to cover certain aspects in more detail concerning homelessness and employment.

We must remember that this problem will grow. It is estimated that by 2000—only 12 years away—the number of people over the age of 75 will increase by 250,000. If that is so, and in the absence of the finding of a cure, each social service department may have to cope with an extra 600 people with senile dementia.

I am deliberately taking less than the time available to me to give more time to other speakers. There are two under-funded systems dealing with mental health, one in the hospital service and one in the community. The Government must produce their response to Griffiths. Any further delay will be scandalous. That response should include plans to ensure that the rundown or closure of hospitals must not take place without detailed plans for the care of each person to be discharged. New funds must be made available for allocation to community care. The health authorities and local authorities cannot be left to juggle their existing funds to buy community care. There must be some form of transitional bridging finance as hospitals run down and community care builds up. Proper information must be available so that we know what happens to patients when they leave hospital. The Audit Commission, reporting in 1986, pointed out that 37,000 patients had left hospital in the previous 10 years, but nobody knew what had happened to the great majority of those discharged.

In New York it is estimated that 30,000 former psychiatric patients are living on the streets. The Government have a direct responsibility to see that that does not happen here. The first signs that this is happening are already apparent. There is a clear responsibility on Government to provide the leadership and resources that the situation demands and to cut to the heart of the problem and help to solve it. My Lords, I beg to move for Papers.

6.35 p.m.

The Earl of Balfour

My Lords, I am grateful to the noble Lord, Lord Carter, for having initiated the debate. I honestly admit that I did not expect to follow him in the debate. All that I wish to do is to raise one or two of the difficulties involved in looking after those who are of low mental intelligence or mental ability.

One of the troubles in bringing into the community a person who may have been wonderful a few years ago but who is now mentally away with the fairies is that such people cease to think logically. The disastrous effect of their ceasing to think logically is that they distrust nearest and dearest. From that moment on, nearest and dearest have little chance of helping.

Another aspect of bringing such people into the community is that they often have a tremendous fear of being left alone, particularly in the evening when it is dark. In NHS hospitals I have discovered that they are put into wards; they may be screened off so that they cannot see each other but, if one of them falls out of bed, at least the others can ring a bell and say "Old Mrs. So-and-so has fallen out of bed". Although they may be mentally away with the fairies, they all have an inbuilt will to live.

There is also a strong need for regularity of life and care. This care needs to continue in the wee small hours between dinner time and breakfast, almost as much as at any other time of the day. When mentally deficient people are brought into the community, it is almost impossible to give them the regular, institutional type of life of hospital where breakfast, lunch, tea, dinner and bedtime are at set times. Perhaps I may personally say—I have a vested interest: my wife is in a home—thank God for the National Health Service!

There is another unfortunate aspect that affects those people who are mentally cracking up. Although the science of psychiatry has developed tremendously in the past 20 to 30 years in regard to people who are in the process of going round the bend, for want of a better phrase, another problem is that few psychiatrists under the age of 45 really know what questions to ask. I say this without any criticism of their work. It is purely and simply that they have not seen enough of life to know the right questions to ask. If a psychiatrist could be with the patient for, say, two to two and a half hours—in practice, of course, that is far too long a period—he or she would realise that there is something definitely wrong. Many people who are cracking up mentally play the same gramophone record again and again. It is not until they reach the end of that gramophone record and start to play it all over again, that you realise that they are absolutely away.

Equally, with doctors and gynaecologists and such people we are rapidly developing in science. People can be seriously affected by drink or drugs, but if they can receive effective treatment in hospital early enough they often can be put back into society and live as perfectly normal people. Women tend to suffer from this a little earlier than men, but equally a number of men I have known—and no doubt your Lordships have too—have suddenly gone berserk and have wanted young things of 16 or 18 years of age around them when they have reached 50. That is purely and simply because they are going through the change of life. A man can go through a worse change of life than a woman. If only they could see a good doctor, they can have hormone injections which will put them back on the right tracks again.

Lastly, we are concerned for people being in the community. In the proper mental hospitals the doctors may take advantage of the Mental Health Acts if somebody walks out and may slap on a three-day order to bring them back into hospital again. In any other walk of life, including that in ordinary hospitals, any patient has the absolute right to discharge himself. Where people are mentally away this is a danger to them and perhaps to other people.

My last appeal—and I have been speaking for rather a long time—is to the social security services. While they do a wonderful job, I beg of them not to be quite so secretive. When I, as a Member of the House of Lords, or when district or county councillors ask if those services can help they could not be more courteous or more polite, and they say "You just leave it to us. We will deal with it all." They refuse to take advice. I admire the social work dealt with by local authorities, but I ask the DHSS to accept advice from people when it is given from genuine feelings. These are a few thoughts. I have said enough.

6.43 p.m.

Lord Winstanley

My Lords, nobody could overemphasise the importance of this subject, nor could we sufficiently underline the topicality of the debate, and I am most grateful to the noble Lord, Lord Carter, for initiating it. I am also grateful to the noble Lord for sitting through and listening most attentively to a short debate on Thursday last on an Unstarred Question into a specific case, that of Sharon Campbell. It is quite clear that that debate has borne fruit on this side of the House. I await with hope to learn that it has done so on the Government Benches as well.

None of us could deal with the Griffiths report, which is a large document, in a 10-minute speech. I shall not attempt to do so. It is the implementation of Sir Roy's proposals, or of other things in their place, that we are debating. We know that some of his proposals are not all that acceptable. I referred to one the other day. Sir Roy Griffiths believes that community care should be vested in the hands of local government. With the Government's present attitude towards local government it seems to me to be highly unlikely that that prescription will be dispensed. But we must have some other prescription if we are not to have that. Somebody must take responsibility for community care.

The chief medical officer, Sir Donald Acheson, in a magazine called Health Trends in 1985 begged for clarification of the term "community care". He said that it had developed too many meanings and had acquired "an ethos of virtue" without any certainty of what it meant. What does it mean? Can a hospital be part of the community? Does it mean care in or by the community?

I have discovered the DHSS definition written in a document. It is: the provision of alternatives to long-term institutional care". In 1984 the noble Lord, Lord Trefgarne, speaking for the Government on that occasion, put the policy aim more simply as: to move out of hospital those people who do not really need to be there". As a doctor and as a Member of your Lordships' House I fully support that stated aim, but I say without hesitation that it cannot be achieved without satisfying the DHSS definition of community care too. I have just quoted that definition and I repeat it: the provision of alternatives to long term institutional care". the trouble is that in many areas the alternatives are not there. I fear that some of those which are present may soon disappear.

I have been much disturbed by a letter which I received from a body called the Special Needs Housing Forum, which I am sure has been sent to other noble Lords. It says with regard to existing community services: This threat arose when someone in the Department of Social Security decided to *do something' about the 25,000 people who stay in these special needs hostels. Instead of allowing them to go on receiving Board and Lodging payments plus a small personal allowance, they would be switched to Housing Benefit and Income Support.

This would cut their weekly income drastically and mean that hostels couldn't afford to go on providing a service.

It could cut half the available hostel places at a stroke. And even now, demand for such places far outstrips supply".

It is not just hostels or even day care centres which we need, and we need them desperately if the policy is to succeed. We need financial support for those individuals and for their families. We need proper financial support for the families who have to care for mentally handicapped children or for mentally ill adults who are discharged into the community. In addition they require human support—social workers.

I was deeply impressed by a speech in your Lordships' House yesterday by the noble Baroness, Lady Faithfull, about the need for improved training of social workers, particularly when they have to deal with such very complex cases. Handling schizophrenic patients is an extremely complex business. We all remember the old days when there was a change from the so-called generic social workers. The specialised social workers all became generic social workers. In other words they all had to do everything. Yet the length of the social worker's training remained at two years. There is clearly, as the noble Baroness, Lady Faithfull, illustrated admirably yesterday, a need for improved training of social workers. I am certain that that is a prerequisite to any success for the Government's policy of closing some of the large institutions and discharging those patients into the community.

The future of community care as a concept or as a reality does not depend only on the Government—though it depends to a considerable degree on the Government. It depends on us all. It depends on many voluntary bodies which do splendid work and continue to do that work in this field. We are all aware of such bodies and many noble Lords do some of that work themselves. MIND is one such body doing splendid work particularly in relation to the Mental Health Act and the Mental Health (Amendment)Act. MENCAP does admirable work for the mentally handicapped and the Schizophrenia Fellowship focuses on a different area and on patients of a somewhat different kind. The noble Earl, Lord Balfour, in his most enlightened speech was dealing much more with the problem of looking after the mentally handicapped. But the problems of looking after the mentally disturbed or schizophrenic patients are quite different.

Perhaps I may be philosophical for a moment. I think that other noble Lords as well as myself may remember the words of Sir Isaiah Berlin a long time ago when he very perceptively differentiated between two kinds of freedom. He talked about negative freedom (freedom from) and posii:ive freedom (freedom to). I should not dream of criticising any of the voluntary bodies which I have just mentioned but, if I may say so with all possible respect to the workers in MIND, with whom I have worked very closely on the Mental Health (Amendment) Act, I believe they have tended to exert most of their influence on the freedoms from, which are very properly the patients' rights. They are paramount and we must consider them: freedom from incarceration in hospital, freedom from compulsory treatment and similar freedoms. But perhaps the voluntary bodies did not give quite enough thought to freedom to.

In the tragic case that we discussed on Thursday we had an example of a schizophrenic patient being discharged into the community from an institution. She was given freedom to express her distress and hostility in any way she chose and she chose a way which had tragic consequences for a social worker.

We must think about these things on both sides. I know that much thought will be given to the mental handicap side of the issue. I should prefer to move for a moment to the other side about which I know a little more. I hope that this policy of community care succeeds, let me be quite clear on that. However, in order for it to succeed we must think about the other side of the equation as well. By all means include the rights of the patients, they are paramount and must be protected at all times. Nevertheless we cannot ignore the impact on communities or on families of the discharge into the community of mentally disturbed patients and in particular patients suffering from schizophrenia. They have a tendency, as part of their disease, to stop taking the treatment once they feel better, with serious effects. Having been discharged, they stop having their treatment and then their condition deteriorates and they can become a danger to themselves and to other people.

In conclusion I must say that it is a laudable aim to see that patients who do not require to be in hospital should not be in hospital. That is in jeopardy because the steps are not being taken to make absolutely certain that communities are safeguarded and that patients are safeguarded as well. Unless those steps are taken by the Government, by local government or by anybody else soon and effectively, we shall see movements and campaigns in the other direction. There will be movements from the community to suggest that we rebuild some of the large institutions and lock people away again in the manner in which we used to. That would be tragic and would be deeply regretted, but if it happens, the responsibility will lie at the door of the Government, who have failed to implement the recommendations of the Griffiths report.

6.53 p.m.

The Lord Bishop of Southwark

My Lords, last May we debated the needs and problems of the mentally handicapped, the mentally ill and their families. I think it is a measure and a reminder of how urgent and important this matter remains that under the stimulus of the Griffiths report we are debating it again. It was emphasised then by many speakers that moving people from residential care into the community should not be seen as part of an economy drive. It may even cost a little more in financial terms, although the continuing lack of research and monitoring makes this a very difficult matter to assess accurately. That is one of the points which I think we ought to be making on an occasion like this. Again, we need to distinguish between the mentally handicapped and the mentally ill. The mentally handicapped are sometimes described as those who have severe learning difficulties. They will probably require care all their lives in a fairly stable context, sometimes not that dissimilar from the physically handicapped.

On the other hand, the mentally ill may require a lot of care at one stage and little or none at another. Certainly the pattern will vary for many patients. The public often assume that these two groups—the mentally handicapped and the mentally ill—are exactly the same. I think that they need help in understanding that people with mental handicaps are unlikely to behave in the violent and sometimes bizarre way that someone suffering from a severe onslaught of schizophrenia, for instance, might display, particularly if that person lacks suitable medication and help.

Community care at its best offers a more flexible regime than large institutions have been able to offer. However, here again we need to recognise that, as has already been pointed out, the phrase covers quite a large spectrum, from people who are living with their relatives—and this will probably remain a very large proportion—to people who are living in small, family-type houses, right in the streets with others, through to clusters of small houses on one site which may be former hospital grounds. Alongside that sort of permanent residential accommodation in the community, people will also be using and needing day centres for that individual professional help which they require all the time.

I think I can best illustrate some of the points that I want to make this evening from several stories, all of which come from my diocese of Southwark, which is South London and East Surrey. The first story concerns St. Lawrence's Hospital, Caterham, a large and well-known hospital for the mentally handicapped. This hospital, with nearly 1200 patients a few years ago, is due to close in 1994. In the last four years about 550 residents have moved to new homes of one kind or another, some to quite different parts of the country; they have gone back to the places from which they originally came, they are not near Caterham. In the gounds of the hospital itself or nearby, houses and bungalows have been built which provide residential and therefore day care for about 470 non-Croydon people. For the London Borough of Croydon itself, there will be about 160 residential places and 200 day places.

Thanks to dedicated and caring leadership of a very high quality, the whole operation so far seems to have gone smoothly. Progress of ex-residents has been monitored even in other parts of the country, and in one case some were transferred from a home where they were not being looked after properly. There is a long tradition of good cooperation with the local authority. The chaplain is one of the many staff who has been closely involved with the process, visiting ex-residents in their new homes far and near and spending time with local clergy or ministers, for instance, to alert them to the new arrivals and to help them and their congregations adjust to and accept some unfamiliar things. All that has been of a high order, I must say, and of a fairly rare order compared with most others that I know about.

So far then, one might say, so good. But sadly, even here, it looks as though the whole exercise is beginning to slow down and limp because of local authority financial restrictions. Croydon, be it noted, is not a poor borough; it is, shall we say, rate minded. So we are brought face to face even here, where there has been a long and positive tradition of cooperation, with the most intractable problem of all, namely, who is to decide what is an appropriate level of assistance and who then is to be responsible for finding the money, especially if partnership funding is required or regarded as the norm?

Story number two illustrates the same point much more sharply and sadly. In 1984 nine people were transferred into community care with the London Borough of Merton. This was agreed before any long-term strategy had been worked out with the Merton and Sutton health authority. When a strategy was presented, agreement could not be reached on the level of care to be provided or on the division of costs. So I understand that in Merton, a large London borough, the figure remains at nine. There, as at Banstead and other places, it seems clear that health authorities are determined to use some of the moneys saved by the closure of mental hospital wards to undergird existing or new work elsewhere. They, too, have their problems over funding. But with local authorities cutting back and health authorities diverting to urgent needs elsewhere, how can satisfactory levels of financial assistance be made available for the adequate care of women and men trying to cope with the demands of life in the ordinary community?

Wandsworth, another South London borough, badly needs a day centre for the mentally ill. The local health authority has put forward a proposal for joint funding, in line with present practice and with the Griffiths report. But noble Lords will not be surprised to hear that in a borough which is determined to keep its rates low, and especially in preparation for the change to the community charge, insufficient funds are forthcoming. Once again, the mentally ill lose out. I wish to draw the attention of noble Lords to what is, I feel, the false optimism of the Minister's reply in the debate we had in this Chamber on 18th May, when he said: the speed and detail of the development of services in any one area will depend primarily upon the relevant health and local authorities making the best use of resources available to them."—[Office Report, 18/5/88; col. 367.] I am afraid that the situation is that nothing happens because they cannot agree on finding sufficient funds between them because of other, existing pressures. That, of course, brings us to the more tragic side of putting people into so-called community care without sufficient preparation and without adequate and continuing support. As I have already tried to make clear, a good level of assistance for both the mentally ill and the mentally handicapped requires not only accommodation, food and clothing, but also professional support from doctors, nurses and social workers. That is often most easily provided in a good day centre. Good neighbour support is needed from local people, local churches and many others.

One has only to think of the difficult art of filling in the forms for means-tested benefits, for example, or of managing on very small funds when one has not had to do so for years, to realise how impossible that must be for many of the people we are thinking about today. There is an enormous need for the kind of simple practical help—education, if you will—which a good family welfare unit might provide. But there are only very few of them.

I realise that my time is drawing to a close, but I must end by saying that in London mentally handicapped people find their way into a broken-down situation and end up on the streets. I have the recently issued annual report of the North Lambeth Day Centre, which is situated in the crypt of St. John's Church, Waterloo. The report states: We work with an increasing number of people who have a history of mental health problems, some have spent long periods in institutions and have been discharged to the streets or to inappropriate or unsupported accommodation in the 'community'…We, like other agencies are therefore seeing more people who have severe and often acute mental health problems, isolated and without the necessary resources to support themselves, ending up sleeping on the streets. I am the last person to suggest that money is the only ingredient needed for good levels of community care. But there is a minimum, and it must not be pitched too low. We urgently need more evidence to test the validity of the experiences that I now hear about all over south London. Sometimes those experiences are good, but mostly, sadly, they are bad. One chaplain perceptively put the position to me thus: It has been taken for granted that community care will be better, rather than that it can be better. The experience of many workers and patients and relatives is that it can be, but that just as often it fails to be.

7.4 p.m.

The Countess of Mar

My Lords, I am extremely grateful to the noble Lord, Lord Carter, for bringing our attention to the predicament in which the mentally ill and the mentally handicapped who are discharged from long-stay institutions into the so-called "care of the community" find themselves. The Minister is well aware that their problems have been of concern to me for a long time.

A major problem with both groups is that they do not see themselves as being ill. Certification of their inability to work is a prerequisite to enable them to claim additional social security benefits, such as the disability premium. They, and for that matter social security officers, cannot distinguish between a medical statement of their condition and a sick note which certifies that they are suffering from an illness. Those who suffer from learning difficulties—the modern term of mental handicap—will often most vigorously deny their illness. Therefore, they do not see the need for a medical certificate, and as a result they do not receive the financial assistance appropriate to their needs. Their level of assistance is reduced to the income support personal allowance only, and they will not be able to pay their carer for the supervisory nature of the care once they leave an institution.

People with mental illness discharged from hospital frequently regard their GP, community psychiatric nurse, social worker and Department of Social Security office as officialdom, and are therefore hostile to them. They more frequently fail to keep appointments with their GP and social worker and do not receive medical certificates or medication. Many fail to claim any social security benefits at all. They are unable to pay for accommodation and are asked to leave by their landlord or landlady. They drop out of the system, wander the streets by day, sleep rough at night and scrounge what they can from relatives and friends. Sooner or later they will suffer a relapse of their illness and have to be re-admitted to hospital, simply because they cannot cope with the system which is designed to help them to be self-supporting.

We need to bear in mind that this is not a problem confined to those recently discharged from institutions. It is, and will increasingly become, a long-term problem. I will give the House an example which is typical of the sequence of events which arises. Len had been in a mental hospital in Birmingham for 20 years. He suffers from a psychiatric illness, has borderline learning difficulties, is blind and incontinent. About 10 years ago he was selected for discharge into the community. Under the hospital's discharge plan he was moved to another hospital in Malvern where he stayed for two years and was taught some social skills. From there he was discharged into a hospital in Worcester. While there he had various jobs, mainly washing-up in hotels. He formed friendships with people similar to himself, some of whom had severe personality problems.

A year later he was judged ready for his real move into the community. The local social services department found him accommodation in supported lodgings in Bromsgrove, about 12 miles away. He did not work but attended the town day centre. His social worker was unhappy about this arrangement, as his landlady was suspected of exploiting him. The motives of the social worker were not known, but Len developed a sense of anger with and distrust of his landlady. He was encouraged to return to Worcester and to re-establish his old friendships. His new landlady was unable to cope with his incontinence and his inadequate friends. So, on the basis of "the devil you know", he returned to his former landlady in Bromsgrove.

There his social worker reviewed the payments he made to his landlady. It had been noticed that he never had enough money to pay for day centre activities, such as outings. The landlady was accused of being paternalistic and denying him the right to make his own decisions. That provoked a social security crisis which took four months to resolve. Three months after that, Len's landlady's marriage broke down and the matrimonial home was sold. She bought another house which was large enough to accommodate Len as well as herself. She needed the money to which Len was entitled to help pay the mortgage.

The move provoked another DSS review. Benefit officers said the move was a change of circumstances and reduced Len's board and lodging payment to the lower rate, which excluded the extra element he received to pay for his care. The decision went to appeal and five months elapsed before the status quo prior to the move was ordered to be restored by the appeal tribunal. I heard today that the local social security office is still withholding Len's benefit, despite that decision, while it decides whether or not to appeal to the commissioner. That is no way to treat a person who is fit and in possession of all his faculties. It is an abominable way to treat Len with all his handicaps.

The need for a common policy for all the government departments concerned with the discharge of patients and their subsequent care in the community is now extremely urgent. Legislation enacted in October 1986, December 1986, April 1987, July 1987, April 1988, and that to become effective in April 1989, all affects this client group and their accommodation. Social workers, carers and community nurses simply do not know where they are going. Home finders cannot recruit landladies. Social service administrators do not know what effect the April 1989 income support changes will have upon the numbers involved. They do not know which elements of care costs housing benefit and rent officers will deem ineligible for rent purposes. They are unable to prepare realistic budgets for social services support for that client group for the next financial year. As far as they know, central government have made no provision for either direct subsidy or an increase in rate support grant.

Perhaps I may ask the Minister to ask his right honourable friend the Secretary of State for Health, who is I understand responsible for personal social services, to advise social services directors immediately—and I mean immediately—what the position will be after April 1989.

I have tried on many occasions, by being persuasive, to draw to the attention of Ministers in this House the problems being experienced by those responsible for implementing the Government's "care in the community" policy. I shall no longer mince my words. By all means let the National Health Service discharge the mentally ill and the mentally handicapped into the community, but tell them first that they will be extremely lucky if they get suitable long-term accommodation with an understanding landlord or landlady; that they may or may not get a social worker who is capable of solving their problems and who is able to see them regularly; that they will have to learn to cope with the vagaries of the social security system, which is on the whole unsympathetic towards their needs; that their GP or community psychiatric nurse will have problems in keeping up with them if they move—all because the Government will not agree on a proper, humane policy and steadfastly refuse to provide the necessary funds. Let those people have the choice but let it be informed choice.

7.11 p.m.

Lord Rea

My Lords, I think that we should regard this debate, introduced so ably by my noble friend Lord Carter, as a continuation of the debate that we had in May which was introduced by my noble friend Lord Basnett. As the right reverend Prelate the Bishop of Southwark said, the fact that we have had two debates in the same year is an indication of the importance of the topic.

I want to make a few remarks which I hope will be different from those that I made in the previous debate. However, the situation has not changed in the past six months; it may even be a little worse.

Looking at the problem, I should like to make one or two points as seen through the eyes of a practising general practitioner rather than from a national perspective. I have with me a computer print-out with 50 names on it which is the list of schizophrenic patients in our practice. Not all of them present very difficult problems at the moment. Some are in a stable state. As the right reverend Prelate said, mental illness is a fluctuating condition.

We also have many other seriously disabled mentally ill patients who do not come into the category of schizophrenia. For example, our practice provides the visiting medical officers to a hostel for eight severely mentally ill patients who have just been discharged from Friern Hospital. Only two of those eight patients appear on my list of schizophrenics. The others have various other disorders—manic depression, severe personality disturbance, etc. That provides an indication of how as GPs we must always be aware of the problem of mental illness.

I am an admirer of Sir Roy Griffiths, and I think that his report is the best that we have had so far on what the Government should be doing about community care. He mentions the role of the general practitioner in several paragraphs in the document. I am very pleased that he recognises the crucial role of the GP in community care. That applies not only to those discharged into the community from long-stay institutions but also to all those with dependency needs even though they have never been in hospital. It is my experience that the latter are now far more numerous than those who have recently been discharged from hospitals. That is partly because of the policy of community care in which the ethos over the past decade has been not to create new longstay patients. Therefore many who would otherwise become long-stay patients are in the community and many of them are not catered for adequately.

Sir Roy says in paragraph 6.14 of his report: The contract between the family practitioner committee and the general medical practitioner should be amended to specify that the GP, either directly or through his practice staff, should inform the social services authority of possible community care needs of any patients registered with him who seem to have such needs which are not being met and which appear to be unknown to the social services authority. The GP should also be able to satisfy himself that the social services authority has considered the case. The social services authority should therefore confirm that it has received the referral from the GP, and tell him what action it has decided to take". In other words, Sir Roy recognises that the general practitioner and his associated primary health care workers, as the first port of call for people in need, should ferret out the most needy people and monitor whether social services departments are responding appropriately. 1 think that that is a role which good general practitioners are already playing.

As the Royal College of General Practitioners pointed out in its response to the report, more detailed work is needed to establish exactly how general practitioners' new responsibilities are to be defined. Very good relationships between general practitioners and social workers are also required; a state of affairs I am afraid to say which sadly does not exist in many parts of the country. One reason for that is that hard-pressed social services departments often work with under-trained staff—as the right reverend Prelate pointed out and the noble Baroness, Lady Faithfull, said yesterday—and do not have the resources to provide what general practitioners, their patients and patients' families feel is needed.

If social services departments were augmented and funded with earmarked grants as Sir Roy suggests to provide really effective community care, I could foresee a very rapid improvement in general practice social work relationships. That would pave the way for GPs, in association with other primary care workers—district nurses, community psychiatric nurses, health advisers for the elderly—to provide the medical cover which might prevent many vulnerable people from having to be readmitted to hospital when they enter a crisis.

Fully operational and effective community care, if it could be created, would in any case help to prevent those very crises from occurring in the first place. That in turn could well lead to very large savings in hospital costs for acute admissions. That is where the big money is spent in the National Health Service. However, it is only after a substantial initial investment in community care that those savings are likely to accrue. I would suggest that that is a further case, like many others that we have seen recently, where short-termism (if your Lordships will excuse the phrase) is totally inappropriate.

I should like to say one more word about the role of the GP. We should like to be consulted before patients are discharged and be part of a team that plans the community care. Too often an unwise discharge takes place which results in an early readmission. If the general practitioner and the primary care team as a whole were involved at an early stage, in co-operation with other carers, better relationships could be built up and the care for the patient would be better so that readmission might not be needed.

Much discussion on community care centres on housing need. That is of course a basic essential. If it is well planned it will provide a good basis for total community care for the people we are discussing. Yet I feel that housing is not the most difficult part of the operation; though, as my noble friend pointed out, in the inner city situation things are a lot more difficult than they are in less built up areas. That is largely because of the very much higher prices for housing units in London. I understand that £45,000 from various sources is regarded by the DHSS as a suitable sum to provide for a living unit; but in fact my advice is that the cost in London is something like double that figure.

The hostel about which I spoke earlier, where there are eight discharged patients from Friern, has now been in operation for a year and three months. It is one of the good ones. It is a success story. Nevertheless, the total costs for that hostel including buying the house and re-equipping it, were around £240,000, which adds up to £30,000 per inhabitant. Those were costs incurred some years ago; now costs are very much greater.

Apart from housing, I consider that the most important aspect is to make mentally ill people feel welcome and part of the community into which they are sent out to live. Too often their housing is segregated as are their day centres. Their difference from mentally average people stands out even more in the community than it does in the safe and often nurturing, though frequently sordid, hospital environment. There is a great need to set up and equip more units where some semblance of a work environment is created; one in which mentally ill and mentally handicapped people can be made to feel useful and be allowed to earn a little money which, it is hoped, will not be immediately deducted from their social security payments.

As Sir Roy points out, there are successful examples of community care to be found scattered throughout the country. It is important that the reasons for their success are identified so that they can be repeated and high quality community care can become a reality as much (or more) for those already in the community who are too often drifting as for those who are about to be discharged from hospital. However, that cannot be done without substantial extra funding, as MIND has pointed out. Some £500 million is a suitable sum. It would be a very wise investment. I hope that the noble Earl will be able to tell the House a little more about the Government's response to Sir Roy's report, and perhaps give us some welcome news that there may be some more money on the way.

7.23 p.m.

Lady Kinloss

My Lords, the noble Lord, Lord Carter, has given us the opportunity today to discuss some aspects of care in the community for people with mental illness or mental handicap who are leaving care.

When I read of Miss Sharon Campbell's case, my husband remarked that the fate of the social worker had happened to him—almost happened to him—some 40 years earlier during the war, but as he was seated at a trestle table, he was able to shove the table top into his attacker's stomach. Perhaps very serious attention needs to be given to the conditions in which interviews by social workers take place, having regard to the fact that they may need to protect themselves. That is not to say that I do not feel the greatest sympathy with those who suffer from mental handicap or mental illness. However, due thought must be given to the protection of social workers who, in their charity, provide support for the needs of their suffering clients.

Anyone who has been in hospital, even for a short time, knows that there is a certain shock when coming out and that it takes a little time to adjust. There are about 30,000 people with mental handicaps who are still in hospital and homeless in the real sense. I mean that they have a roof over their heads but they do not have a home of their own. Moreover, there is another class of person who are living with elderly parents and are in danger of becoming homeless in an actual sense when the elderly pay, as they must, the debt of nature. There are also those with mental handicap or mental illness who sleep rough and are in temporary hostels or even, for one reason or another, find themselves in prison. However, we are committed to community care, but—and this is not in any sense a politically divisive question—how are we to cope with it in an ageing community?

There are large numbers of people who have been in hospital for many years. When they are sent out into the world at large, unless they are given very carefully considered support we shall see some of them ending up in cardboard boxes under the arches. Perhaps in some cases they have been sent out into the community rather too quickly. Some organisations are worried that the pace of hospital run-down and closure is outstripping the development of community services.

Anyone who is sent out into the community after a period in a psychiatric hospital requires proper preparation and help. The Royal College of Nursing is very concerned about some of these cases. They need to be shown how to shop, board a bus, and even perhaps how to cook for themselves. They really need sheltered accommodation or a hostel. In many cases board and lodging facilities are unsatisfactory, as they receive very little help.

The National Schizophrenic Fellowship is concerned about those suffering from schizophrenia moving into the community without sufficient support to look after themselves. A pilot study of 750 schizophrenics who had recently been discharged from three hospitals notes 36 per cent. with two or more discharges in three years. These people really do need hostel accommodation, group homes or some other form of sheltered home. The most important thing is for them to continue with their medication. If they are on their own they frequently forget to take it and so they return once more to hospital.

Another important issue is registration with a GP and, even more important, supervision and care from community psychiatric nurses and community mental health nurses, where they are available, who work full-time in the community and who will understand their needs. They will supervise their medication and see that they receive their benefits.

The Government have repeatedly said that extra money is going into the health service. That is very welcome indeed. But I understand that it does not go to health authorities; it goes into family practitioner committees. I am not saying that that is wrong, but investment in training and community work is essential if community care is to succeed. MIND and the Royal College of Nursing agree that manpower planning and effective training are essential to the success of community care. Community services require staff to work independently and take decisions without supervision. Perhaps I may ask the noble Earl who is to reply whether the Government are considering ways of giving extra and effective training to those who work with the mentally ill or mentally handicapped in the community and especially those who suffer from schizophrenia. As the noble Lord, Lord Winstanley, has already said, special training is needed for helping schizophrenics.

I have mentioned before in your Lordships' House that I am very concerned for the 16 to 21 year-olds who are in board and lodging and the effect that changes in board and lodging payments will have after April 1989. After the age of 19 a young person with a personality disorder who is discharged from local authority care into supported lodgings finds that the social services are no longer allowed to provide financial support. The young person has to rely on social security benefits, which are not sufficient for board and lodging, care and personal needs.

One case which has been brought to my notice is that of someone whom I shall call Joan, who is severely mentally handicapped. She was with foster parents from a young age but they were unaware of the way in which to claim social security benefits once she was over 19 years old. Therefore because they did not claim and are not considered as acting on a business basis, Joan only receives the personal allowance paid to 18 to 24 year-olds. She receives £39 a week instead of the £150 that she should receive. Her foster parents feel morally unable to evict her although they receive no financial recompense. I feel that she is very lucky to have such caring foster parents; otherwise she might end up, as others have done, under the arches.

I hope that the Government will look at the whole range of problems that are posed by care in the community and the supporting services for the mentally ill and mentally handicapped in our midst.

7.30 p.m.

Lord Mottistone

My Lords, I too should like to thank the noble Lord, Lord Carter, for introducing this Motion because it is necessary to make everyone continually aware of the problem both for themselves and for the carers for the mentally ill and mentally handicapped. Noble Lords will be aware that my particular interest is in the problems of schizophrenia and that I am advised in these matters by the National Schizophrenia Fellowship.

On 1st December we had an Unstarred Question on a schizophrenia matter which was raised by the noble Lord, Lord Winstanley. I shall endeavour not to duplicate the points mentioned then but there are some features of the report on the Sharon Campbell case which relate to this debate and are worth repeating.

To get the problem of the level of assistance available in the community into perspective, I should like to remind noble Lords that the idea of emptying the mental hospitals is not new. It was reflected in the 1959 Mental Health Act and is backed in principle by sensible people as well as do-gooders. Labour as well as Conservative governments have been working towards reducing beds in mental hospitals over the past 30 years. What seems to have gone wrong is that in the period leading up to the 1982 Mental Health (Amendment) Bill all the thinking in the DHSS—which led in due course to the 1983 Act—seemed to become over-biased towards keeping a check on psychiatrists, with a demand for repeated tribunal hearings for patients. The numbers of those appeal tribunals have in consequence increased enormously, and psychiatrists are strongly discouraged from sending people to hospital even when they should go there.

The case of Sharon Campbell, the subject of last week's debate, is a sad example of this. Subsequently it seems that the Government have been over-persuaded that the solution lay in care in the community and that this would be no more expensive than hospital care. Indeed, I remember hearing it said in this House that it would be cheaper. This attitude was adopted without any pilot schemes to find out how care in the community would work. We just went trundling into it. I am afraid we have made mistakes. The net result has been that from 1981 to 1988 the emphasis of government policy has been on shutting down hospital beds for mentally ill people. This has been carried out more quickly than it has been possible—or as we now know from practical experience even suitable—to create care in the community to match.

I refer briefly to my speech last Thursday. How do we cope with the person with whom nobody can live? All alternatives to hospital cannot cope if the schizophrenic is too ill. Sharon Campbell was asked to leave her home, her short-term hostel, her special hostel for former psychiatric patients and a bed and breakfast hotel because each time she caused disturbances, including attacking with a knife. Even less violent schizophrenics than Sharon Campbell can also be unacceptable in any little community, or may find the presently available alternatives to hospital unacceptable.

In our debate on 1st December I asked the Minister to tell us more about hospital hostels which it seemed might provide a form of care which could better cope with the person with whom nobody can live. My noble friend Lord Skelmersdale explained at cols. 967 and 968 what hospital hostels were, but he did not give any indication of how many there might be. I have heard of one at the Maudsley Hospital which has been going for 10 years. It has admitted 33 people and discharged 11 without readmission so far. That does not leave much space for new arrivals. Of the 11 people moved out, seven were put into an attached shared house with strong support from the hostel staff. It therefore does not seem that they moved far away from the conditions in which they had been living.

Reporting on their work in the hostel the Maudsley staff said that no locally available hostel or other residential facility was thought capable of adequately supporting these extremely vulnerable individuals. There is therefore a problem; and there is a problem of numbers. It will be most helpful if my noble friend Lord Arran can give some idea about how soon we might see more of these hospital hostels, and how many their might be by, shall we say, 1990. They may well fill an important gap in the community care for the mentally ill and, if so, we shall certainly want several of them.

Another suggestion I made on which ministerial comment might have been more helpful was that Recommendation 17.22 of the Sharon Campbell report should be implemented without delay. The recommendation was that health and local authorities in co-operation with relevant voluntary organisations should have a duty jointly to provide suitable after-care for former informal hospital patients who are or have been suffering from mental disorder until it was agreed by those people that it should no longer be necessary. The noble Lord, Lord Winstanley, nods his head because he made the same recommendation. It seems from Chapter sixteen of the report that the legislation in this area is not sufficiently comprehensive to have covered Sharon Campbell, and, by that token, many other mentally ill cases. I should perhaps remind noble Lords, who may not have read the report, that the problem with Sharon Campbell is that she murdered her social worker. It is therefore not a lightly handled business. It would be most helpful to have an undertaking from the Minister that Recommendation 17.22 is being considered as a matter of urgency.

It is clear from all speeches that a great deal more needs to be done to ensure adequate help in the community for people who have suffered, or are suffering, from mental illness. I believe that we should not shut down the beds in the hospitals so quickly. Many of these people require what used to be called asylum, in the nice sense of the word. They need to be protected from themselves and from the outside world. In some cases they need to be looked after so that they do not threaten other people. However, if we are not going to do that, we must have better facilities in the community where people with whom nobody else can live can be suitably handled.

I should like to be more confident than, sadly, I am that my noble friends in the Government are grappling seriously with this problem. I very much wish that this debate will stir them to do so more actively than they are at present.

7.39 p.m.

Lord Thurlow

My Lords, I am very glad to be able to follow the noble Lord, Lord Mottistone, because I heartily endorse every single proposition that he put forward. I should also like to confine my remarks to the subject of schizophrenics. This is a field with which I am personally familiar from sombre experience, and I regard it as the most serious and difficult part of the interlocking problems.

It is curious that tonight there has been an echo of yesterday afternoon's debate when the noble Lord, Lord Mishcon, summed up by making three pleas. There was a plea for the acceleration of action, a plea for the provision of more resources and a plea to increase and improve training. Those pleas applied to the Children Bill, but they also apply to this debate.

Noble Lords have already said that the 1959 Act laid down admirable principles which generally have been endorsed ever since. However, there has not been the opportunity to apply the principles correctly. We are now in a sombre situation of increasing gravity, as all noble Lords have pointed out this evening. We are not even holding the position; it is becoming worse.

In regard to resources local authorities continue to be in the lead position for providing aftercare, for better or for worse. No doubt they receive great support from the health service but they must provide the main means of aftercare. There is no basis of a coherent policy because there is a gap between the provision of resources and the way in which they must be spent. No doubt there are good examples. This evening I am perhaps the first noble Lord to mention a good example of aftercare; it is the splendid experiment at Torbay. I hope that many local authorities will repeat and follow it, but it is still an experiment.

All noble Lords who have spoken tonight agree that, in general, local authorities throughout the country are not measuring up to their responsibilities. There are perfectly understandable reasons for that, one being that they are squeezed for funds. They are not in a position to spend what they want and, with great respect to many of them, they do not understand the priority of this need.

Thirdly, there is the plea for more training. The noble Lady, Lady Kinloss, has already referred to that and I shall not duplicate her words. It is common ground that there are not nearly enough qualified psychiatric community nurses. Somehow or another the void must be filled.

I should like to turn to a particular matter which has not been covered tonight and which I know is highly controversial. During the debate on the Sharon Campbell case reference was made to the difficult problem of compulsory treatment orders and to the question of how to give power to the elbow of doctors and social workers who are unable to induce schizophrenics to take the medication and go to the day centres as they have been advised. The Spokes Committee recited some of the considerations but made no recommendations. Perhaps that is not surprising in view of the formidable practical difficulties and problems.

I have lived with a schizophrenic who refused to take his medicine, which resulted in the inevitable deterioration of his condition. There is no alternative: patients with acute schizophrenia who will not take their medication will become worse and every kind of serious sympton—for example, violence and nuisance—will follow. As the noble Lord, Lord Mottistone, has said, it becomes impossible to look after them. We are dealing with people who cannot be looked after by families in ordinary living conditions. There are more such people circulating as a direct result of the policies of closure and often they are violent. Last Thursday we heard of the sad case of Sharon Campbell, and there are a good many more. However, for each homicide there are hundreds, perhaps thousands, of cases of violence by untreated schizophrenics and there are many suicides.

I can see no way of avoiding, or at least mitigating, the growing dangers to both the community and the patients without recourse to compulsory treatment orders combined with much improved monitoring, registration and computer records. Most people who have considered the matter regard the difficulties as being too great. With respect, I doubt whether they personally have had to endure attacks from violent schizophrenics. Even if means can be found, how will nurses proceed in the face of resistance to bring the patients to a treatment centre? The Spokes Committee concluded that the only effective sanction would be to admit to hospital as a compulsory patient anyone who consistently refused to take the prescribed treatment. Difficulties would follow. There would have to be second opinions and appeal procedures. However, against all the difficulties and resource problems must be weighed the continuing dangers which exist and which are increasing. We cannot continue to duck those awkward decisons.

If sanctions were imposed it would probably be unnecessary to resort to them in many cases. However, the professions would have some power at their elbow to help them to induce their patients to do what they should. Every day parents, relatives, hostel staff and members of the public are having to face violence and all forms of antisocial conduct, or live under the shadow of fear of violence. Those evils must not be ignored under the banner of respect for human rights. As the noble Lord, Lord Mottistone, said, that was the fashionable cry in 1983 and 1985. In our debates everything tended to be subordinated to the rights of the patient. The dangers and interest of the patient tended to be lost sight of. It is very much to be hoped that the Royal College of Psychiatrists in its forthcoming report on aftercare will grasp the nettle.

7.50 p.m.

Lord McCluskey

My Lords, in welcoming the initiative of the noble Lord, Lord Carter, in having a short debate on this matter, I should like to declare my interest. I am Chairman of the Scottish Association for Mental Health, which is a voluntary body substantially supported by government funds. It pursues a policy of promoting care in the community and is a body which provides both sheltered residential accommodation and supported employment training for a total of more than 500 people in Scotland. Indeed, we are the largest provider of such employment training for people with disabilities and I believe that that gives me a right to speak. Both the carers and those for whom we care have given us a good deal of feedback on what are the problems.

Your Lordships will not be surprised to learn that we as a body are highly critical of the chasm—and that is the only word for it—that exists between the rhetoric of successive governments and the reality, the reality in Scotland of wholly inadequate community care, facilities, funding and resources.

I should like to begin by emphasising the distinction made by the right reverend Prelate the Bishop of Southwark between mental illness and mental handicap. Most of the recovering mentally ill need relatively short-term support, shelter, training and finance within the community. I only draw attention to one other difference which is possibly the most striking of all; perhaps one person in four of the population will at some time in their lives be afflicted by some degree of mental illness which requires treatment. Therefore, in relation to mental illness we are not talking about managing a small identifiable group whose dependency is permanent but we are talking about any one of us who may be struck down seemingly at random by mental illness and who may thereafter require outside help to return to normal life.

If I have time, and I understand that the debate is running ahead of time, I shall address myself to the problems under three headings: poverty, homelessness and neglect. I recognise that many people who experience mental illness are cared for by loving families or friends. I do not wish to suggest that mental illness necessarily condemns the victim to a life of deprivation, idleness and neglect; obviously it does not. However for some—and this is the prospect which is opened up unless they are helped—that is exactly what may happen. It is they who are most in need of organised community care. It is they who we fail if the levels of assistance are inadequate. It is they who have nowhere else to go and no one else to whom they can turn.

Perhaps I may first refer briefly to poverty. Most of those who are discharged from residential care and cannot return home will either find their way to some form of hostel or will have to seek private board and lodgings with a private landlord. Those in managed hostels receive £9.55 per week to spend on bus fares, hair cuts, cigarettes, shoe repairs, newspapers and all recreational and social facilities. That is a miserably inadequate pittance. Those who have to go to private landlords, and they are the majority, receive housing benefit and income support and they are, in terms of personal spending power, no better and perhaps worse off. In a few months' time in Scotland and a little later in England they will become liable to pay the community charge. Even if they qualify for the full rebate, they may still have to find in my area some £60 to £80 annually out of their meagre pocket money. People as poor as that—and their chances of employment are minimal—may be physically in, but are hardly part of, any community I know.

Some of those boarding in the private sector face another problem—of prescriptions. As your Lordships know, a prescription costs £2²60 per item. The mentally ill are often prescribed drugs in small frequent doses because doctors fear that there is a danger that they may take an overdose. They sometimes require other drugs to counteract the effects of the primary drugs which they are taking. However, mental illness is not included in the list of chronic medical conditions qualifying for free prescriptions. Therefore, unless the patient is exempt by reason of poverty he tends to do without the prescribed medicine. The problem of persuading non-residential patients to continue their medication is already severe and if they also have to pay prescription charges it becomes nigh insuperable.

The poverty that clings to those who move from residential care into unemployment and poor quality lodgings eats away at their self-esteem and prevents them from developing any structured lifestyle in which they can achieve and consolidate true mental health. I have given the Minister notice of these questions and I should like him to tell us specifically if those persons who have been discharged from residential care after treatment for acute mental illness and who have gone to live in private boarding accommodation have any prospect of being exempted from the community charge. I also ask him whether or not the Government have any plans to assist those afflicted by mental illness but not resident in managed accommodation to meet the potentially crippling costs of their prescriptions.

I should like to say a few words on homelessness. There is a vicious circle here. Homelessness tends to precipitate stress and mental illness but the very symptoms of mental illness by alienating family, friends, neighbours and workmates tends to precipitate homelessness. Therefore, many of those who leave hospital after treatment for mental illness end up in private boarding houses, sharing rooms with strangers often in very poor conditions in the worst areas of the town or city. As I have said, their chances of employment are almost zero. They can easily be driven into neglect of their medication, idle hopelessness and alcohol abuse or other forms of behaviour which are deemed to be antisocial or even criminal. Therefore, they can easily be trapped into the spiral of becoming down and out and of drifting hopelessly and aimlessly into homelessness.

It is not clear to me that the Government understand the desperate situation of such people. The noble Lord, Lord Winstanley, reminded us that perhaps half of the existing hostel places may be lost overnight very shortly. Such hostels are often the only refuge for those with mental health problems. Are more of those people to be driven onto the streets?

The kind of thinking that could lead to this sudden loss of perhaps hundreds or thousands of places is an example of the phenomenon experienced by all who work in the voluntary sector and concern themselves with mental health and community care. That phenomenon is the lack of coherence and consistency in central government, whatever its political colour. Too often the left hand does not seem to know what the right hand is undoing. Therefore, the voluntary agencies are constantly having to duck and weave to avoid being bludgeoned by the frequent changes of direction, pace and purpose of government departments and agencies. They alone have the funds to sponsor accommodation projects, training, counselling and the like. That is very frustrating and bewildering.

Only 5 per cent. of those who experience mental illness become hospital in-patients—a well known statistic. However, especially in Scotland, the overwhelming bulk of the funds and resources provided for mental health go into hospital care. Therefore, resources for community care are inevitably, as the noble Lord, Lord Thurlow, said, inadequate. There is little reason for optimism. At present the tragedy is that in the United Kingdom, in which vast sums of public and private money are spent on meritricious projects and pastimes, so many of the non-hospitalised mentally ill have become neglected because government and various other statutory bodies will not find the money to spend on the unglamorous field of community mental health.

In Scotland we do not have vast numbers of people impoverished on the streets. Instead of turning large numbers onto the streets, we keep in psychiatric hospitals many people who, with the necessary support, could return to the community to rebuild their lives and rediscover their independence and personalities. For in Scotland there are twice as many hospital places per head of the population as there are in England and Wales. The Scottish Office, whose education department has responsibility in this field, sent out a circular on 1st June 1988 in an attempt to avoid the scandal of patients being discharged from psychiatric hospitals when no adequate community facilities exist. Three times in the circular the Scottish Office refers to what we all know to be the limiting factor—the inadequacy of existing or available resources. That same unacceptable justification is put forward for the failure to bring into force Section 7 of the Disabled Persons (Services, Consultaton and Representation) Act 1986. When will those resources be found? I ask the Minister to tell us when the Government plan to implement Section 7 of that modest little Act.

I should like to mention one last matter. There is a deep reluctance among professional therapists to leave the environment of the psychiatric hospital and go into the community and offer their skills there. I believe that there is a need for health boards and health authorities to offer and to provide redeployment training for their staffs and training about the nature and principles of community care for people with mental health problems. Unless the professionals join other carers in the community and see at first hand both the opportunities and the massive shortfall in what is needed we shall never make a reality of community care.

The noble Earl is tonight in a position to offer us some comfort and hope. We trust that he will not simply add to the verbal mountain that casts a shadow over all our endeavours.

8.1 p.m.

Lord Taylor of Gryfe

My Lords, one of the advantages of a mistake in the Whips' Office is that I am following the noble and learned Lord, Lord McCluskey. He spoke of his Scottish experience in this field and I know that all of us in Scotland are indebted to him for the authority which he carries in Scottish affairs and his constant reminders of our obligations in this particular field. I hope that the noble and learned Lord will be encouraged to come to the House more frequently and deal with these matters which represent a deeply held concern in all parts of the House.

I hope that at the end of this debate the Minister will be aware of the depth of that concern and that he will respond in a positive way to some of the questions that have been raised this evening. We would particularly like to know when the Government are going to respond to the Griffiths report. I gather that the date of the Griffiths report was about last February. Surely it is time that we had some indication of the Government's attitude on the important issues raised in that report.

I express a personal interest in this matter. I am the chairman of Scottish Action on Dementia. Dementia is regarded in the Secretary of State for Scotland's report on the health service in Scotland as being the priority consideration. This is in response to the Sharpen report which he commissioned earlier. With an ageing population, inevitably dementia will have increasing importance.

In addition to the subject of care that is required in this area I have noted that the Scottish Association for Mental Health has prepared an interesting report on the position of dementia cases under the law. I am sure that the noble and learned Lord, Lord McCluskey, has much to contribute in that area for simplifying the legal position of guardianship and advice for people who suffer from mental illness, particularly dementia. That report states that guardianship under the Mental Health Act was designed as a method of caring for people in the community. Instead, it is being used as a method of removing sufferers from home to community care. This is an important matter.

The noble Lord, Lord Mottistone, asked about the relative costs of community care and residential care. My information is that residential care costs £230 per week as against £160 per week for care in the community. That suggests that the latter is not only desirable socially, but desirable economically.

In relation to costs I quote one other interesting statistic which has been provided by the Scottish Association for Mental Health, with which the noble and learned Lord, Lord McCluskey, is associated. At least twice as much is spent on building and improving hospitals than is spent on funding community care, yet 95 per cent. of the people with mental health problems live in the community. It costs twice as much in the maintenance of hospitals yet only 5 per cent. of the people with mental illnesses are in hospitals or residential care.

Like the noble and learned Lord, Lord McCluskey, I read these reports from government departments. I have in my hand a particularly glossy report on the priorities in the Scottish service. This identifies services for old people with dementia in hospitals and in the community as their first priority. But we are becoming a little tired of glossy documents saying "This is our concern" or "This is government policy" but with little action to support these confessions of interest. Therefore, I hope that the Minister will give us a positive response.

I am interested not only in the Government services but also deeply concerned about state support for the voluntary organisations in this field. For some years I have been involved with an organisation called Link, the Glasgow Association for Mental health. It receives some government funding but could do with more. It recognises that there is little aftercare service for people who emerge from hospital with mental health problems. Link has set up a number of clubs in which people can meet and discuss their problems in a social environment. It encourages them and helps them to feel restored to the community.

The organisation is also deeply concerned with providing employment opportunities for people with mental health problems who have come from hospitals. People who emerge from a mental institution do not readily find employment. There must be organisations which monitor that situation and which encourage employers to take on people with such difficulties. Therefore, aftercare clubs, pressure on employment opportunities are undertaken by Link.

The problem for people with mental illness is the inevitable revolving door principle. They go into mental hospital for a period and then leave for a short period but are then back in again. Therefore, we have to make them feel a part of the community and on the way to recovery rather than simply engaged all the time in this meaningless and hopeless practice.

I remind the Minister of the responsibilities which the Government have in relation to the Disabled Persons (Services, Consultation and Representation) Act 1986. This states: All parties who have been in mental illness or mental health hospitals for more than six months should, if and when they are moving into the community, have a full assessment of their needs". That requirement has not been implemented. Another paragraph states: They also should have an authorised representative to speak for them and obtain appropriate services in the community". That has not been implemented.

We debated these matters in the House. We passed the Bill. We assumed that the Government would have responsibility to carry out the legislation which we passed. I would welcome a comment from the Minister as to how and when those obligations are to be implemented.

8.10 p.m.

Lord Renton

My Lords, we have a few minutes in hand and I shall be grateful if noble Lords will bear with me while I make one point that is relevant to the debate. I apologise for my late arrival which was due to my involvement with a charity of which I am a patron. It was important that I should be there.

The point I wish to make is this. I became chairman of MENCAP in 1978. I immediately started to agitate, along with others, for getting mentally handicapped people of various ages out of long-stay hospitals where many of them had lingered for years. In 1980 the Government agreed with this, announced the policy and gave us some help. I call it pump-priming help because it was largely help with administration. It was in order to get our Homes Foundation scheme going, making it possible for mentally handicapped people to live in small groups in small places all over the country.

I was a little surprised to hear what my noble friend Lord Mottistone said as regards the policy having been a mistake. I must make it clear that in our experience of the mentally handicapped it has not been a mistake. The policy has mostly succeeded, with a few exceptional cases. We continue to welcome it and we shall continue to try and make it work.

Lord Mottistone

My Lords, before my noble friend sits down, I did not say that the policy was a mistake as regards the mentally handicapped. I was speaking entirely about the mentally ill. I believe that it has been a mistake to go so fast in their case.

8.11 p.m.

Lord Ennals

My Lords, this has been a very powerful debate. It was opened by my noble friend Lord Carter, to whom we are all grateful for his lucid case. We have also had some very moving speeches in the course of this quite short debate particularly from the right reverend Prelate the Bishop of Southwark, the noble Countess, Lady Mar, the noble and learned Lord, Lord McCluskey, and others. All the others were very thoughtful and informed speakers. One matter that was common to all was the great concern about the situation existing now in our society. I hope that when the Minister comes to reply he has something positive to say which matches up to the concern that has been expressed right across the Chamber.

As noble Lords probably know, I am deeply involved with the work of MIND and the services carried out by its local associations up and down the country. Earlier today I was at a meeting of the trust which tries to cope with the rising tide of homelessness and the growing army of people sleeping on park benches, under bridges, over hotel heating vents, in church porches, station concourses, empty houses, cardboard boxes and sleeping under and above newspapers in all kinds of places where they can find a position from which they are not moved.

There are two pictures of Britain today. One is yuppie and prosperous and the theme is spend, spend, spend; the other is very downtrodden, neglected, cold, forgotten and probably involves the mentally ill. Many of them are in prison and probably wrongly so. It has emerged from almost everyone who has spoken today that there is a new crisis. It is new because of the dimensions of that crisis. I hope that when the noble Earl comes to wind up this debate the Government show a similar sense of urgency.

I was very distressed when I heard a speech given by the noble Earl's friend Mrs. Currie when opening a MIND national conference last week. She was speaking about community care and she said: during this year and next, we will be looking closely at what we have on the ground, particularly from the point of view of the patient. I need to know more about what services we offer, and what actually faces a depressed young mother, or an alcoholic, or a disturbed offender, or a disorientated old lady, or the family of a schizophrenic when they ask for help in each region of the country. At present, I don't have a full enough picture, and sometimes suspect that not all parts of the local services do either". She continued: Ministers will consider whether there are any steps it would be right and practical to take to improve the care of the mentally ill people". I despair when I hear words like that coming from a Minister who is paid to know what the situation is in our country and in our hospitals and communities where people have been passed into them, and probably wrongly discharged, without a plan having been worked out for them and also without families to care for them. They are also without the community support that can make life tolerable, liveable and also enjoyable. For them there are none of the joys of life.

I wonder whether the Government feel a sense of responsibility about these matters. Perhaps there are some people in this House who are well qualified—the noble and learned Lord, Lord McCluskey, is one and there are plenty of others—and who feel that they know something about the local community and the challenges that have to be met. We find the Minister saying that the Government need to know a little more and then they will consider whether there is something that they can do.

Some of us know something of the situation in the old Victorian psychiatric hospitals. Over the weekend I quickly read through some of the recent health advisory service reports on our psychiatric hospitals. They make very grim reading and that is not just the reports made 10 years ago but this year, last year and the year before. They refer to gross overcrowding, dirty, shabby, badly repaired, smell of urine, unsuitable, drab, depressing, unsuitable, depressing and so the list continues. They are dilapidated and institutional life means that there is no place to live in dignity.

As regards treatment, there are some very fine nurses doing the job as best they can. The services were found to be deplorable, entrenched, defensive, custodial, misguided, degrading, de-personalising, negative, backward and so on. That is not a situation that we want to preserve in our society. The Government are right and it has been the policy of successive governments over the years, as the noble Lord, Lord Renton, said, that we should plan a combined operation. This would be over the years because it could not be done at once. The policy was to close not only the hospitals for the mentally handicapped but for the mentally ill as well. This would be done in parallel so that services matched. As people came out they went into a new type of service provided for them in the community.

This has been a policy that does not split us party politically and I am not certain that it does so when we look at the present situation. It is not as if the hospital closure programme has yet gone all that far. There has been a very substantial decrease in the number of beds. There have been approximately 200,000 admissions to and discharges from psychiatric hospitals each year. Fewer than 64,000 people are now resident in psychiatric hospitals. Long-stay hospital provision is being reduced at a significant rate with a drop in mental illness hospital beds of 25,000 in a decade.

When we consider the mental hospitals only two have been closed. I understand that 28 more are likely to close by 1995 with health authorities selling off the land. I hope that they will be turning the money back into the mental health services. I understand that that is not happening at present. I hope the Minister will say whether we can be absolutely certain that what is saved by the health authorities and the hospital building programme is put instantly and immediately into the services without delay. I shall later argue that the sums should be put into the community services in advance. Without the resources we cannot provide what is needed. One can look through all kinds of information that is given. One is beginning to see a decline in the provision available in the community. The expectation is that it will decline still further.

I expect that some noble Lords will have seen a brief that I received, and no doubt others will, from the Parliamentary Panel on Personal Social Services. It is a well-informed body under its all-party officers. The panel points out that the, Response to demand for community care i.e. new Day Centres, Group Homes etc. must be set against Government plans for gross capital expenditure by Local Authorities to fall by 5.9 per cent. in 1988–89 and by 14.7 per cent. by 1990–91". That is a terrible situation. I am told that if I want further information I can get in touch with a Conservative Member who is chairman of the panel. He is a fine man and is probably better informed about the subject than anyone else in the other place.

I look at the type of services that should be provided. Reference was made by the noble Lord, Lord Taylor, and by my noble friend Lord Carter to dementia. Each district health authority will have to provide for an additional 300 dementia sufferers as the population grows older. Reference was made to the Disabled Persons (Services, Consultation and Representation) Act 1986, which provided a legal framework for advocacy, assessment of need and the provision of services. However, many sections of the Act—perhaps the most important ones—have not come into operation. Crisis intervention services are particularly necessary when there are schizophrenics in our society who have a recurrence of their condition. They need instant help and it is important that someone else as well as they themselves knows that they need instant help. Yet only four walk-in hospitals are available throughout England and Wales. This is a more important provision than the idea of a stop to the hospital closure programme.

We have talked about housing and the Government must do something about it. It is an essential component for community care. Yet since 1979 the housing investment programme has been cut by 60 per cent. in real terms. Housing subsidy has been eroded and council house starts are at an all time low. Housing Corporation allocations to housing associations have been reduced in real terms and are overstretched. The private rented sector has continued to decline. In these circumstances the availability of housing is at a minimum. As someone said earlier, psychiatric patients are at a great disadvantage in terms of housing. Many people with mental illness are caught in a Catch-22 situation. In hospital, they are not considered to be suitable for ordinary housing. Out of hospital, they are not considered to he vulnerable. Their needs are not being met.

Someone said that we have been talking too much about the rights of people who have been in psychiatric hospitals. I react against that very sharply. I want to fight for the rights of people who have had the misfortune of being incarcerated in mental illness or mental handicap hospitals. They are entitled to all the rights to which we are entitled. To think that somehow or other we can degrade them, demote them or put them into a category of people who do not deserve rights is appalling, especially when it is suggested in your Lordships' House, which over the years has been a bastion of protection of human rights. I know that it will go on being so.

The right reverend Prelate the Bishop of Southwark said that money is not available. This is the essence of the problem. MIND made a valuable proposal which was referred to by a previous speaker. It recognised that there would be a saving to the health service. It said that there was a great need for more money, especially at a time when the rate support grant is being decreased and rate capping is being imposed on local authorities. It proposed that there should be an immediate bridging grant of £500 million. It said that not only was more money per year needed but that there had to be a major injection of funds so that local authorities would be able to provide the services which the noble Lord, Lord Mottistone, and other noble Lords have recognised are necessary.

The noble Lord thought that the time had come to stop or to slow down the hospital closure programme. I am sure that that is the wrong answer and I was glad that the noble Lord, Lord Renton, intervened to say that. I recognise that the problems of schizophrenics and those with mental handicap are totally different. I recognise that the noble Lord, Lord Mottistone, made his proposal in regard to schizophrenia. I fear that if after all these years of bringing forward the policy of movement from the hospitals into the community we were now to slow down or stop it, it would take another decade or more before we would be able to get it moving again. Many of the hopes of people and their families that there would be something to enable them to live in the community would be shattered. It would be wrong for us to allow that to happen.

We have had many debates on this subject. Thank heavens your Lordships are wise in their choice of subjects. The Minister must say something about the Griffiths report and the vital recommendations contained in it. It is appalling that after so many months local authorities and health authorities do not know what will happen. Of course there are criticisms about the adequacy of community care when the authorities do not know where the responsibility lies. He must say something about resources. It will be no good just to turn out ancient figures showing that there are now more psychiatric nurses in the community. If one starts at a low enough level one can always produce figures to show growth. We must have from the Minister a statement to give us some confidence that the Government, unlike Mrs. Currie, understand the position, know where we are going and will lead the health authorities and the social services into providing a service which respects the human rights of the people who are now in hospital or in the community without those rights. The Government must take a lead on this crucial issue.

8.26 p.m.

The Earl of Arran

My Lords, we are truly grateful to the noble Lord, Lord Carter, for raising this important subject. It is important and will always remain so. Those are not vacuous and idle words. The title of the debate is significant because it calls attention to the level of assistance available to people with mental illness or mental handicap moved from residential care—I assume that the noble Lord, Lord Carter, is referring to hospitals—into the community. The debate, as I had suspected, has been wide-ranging and there are many important points to cover. I shall do my best to deal with as many as is possible, but perhaps at speed now and then.

The burdens imposed by both mental illness and mental handicap are heavy. They weigh on the sufferers, on their families and also on the services which provide treatment and support. But as your Lordships know, and as has been mentioned in the House on previous occasions, dramatic improvements have been taking place over a number of years. In the treatment of mental illness, for example, the development of a wider range of services outside hospitals altogether, with the advent of new treatment such as the major tranquillisers and the anti-depressive drugs, has led to a marked fall in the number of patients resident in hospital. The policy of providing services better suited to meeting the individual needs of mentally handicapped people has meant that the number of those destined to spend their lives in large mental handicap institutions has also fallen, and a much wider range of provision is now available for those who cannot live at home or who need, with their families, to do so.

The Government's primary aim is better provision for mentally ill and mentally handicapped people and their families. We want to see health authorities and local authorities co-operating together to develop a locally-based range of co-ordinated services. A comprehensive mental health service is the result of many partnerships between specialist psychiatric services, other medical and general practice, clinical psychology, local authority social services, housing authorities, voluntary organisations and self-help groups. But equally important is the involvement of the families and friends of people with mental disabilities and, by no means least, those people themselves suffering from mental illness or a mental handicap. As health districts develop their plans for new mental health services it will be essential for them to consider not only the span of services that they need to provide but also the extensive resources available from this range of interested bodies and individuals who can contribute to the development of a successful service.

The noble Lord, Lord Carter, asked for details of the reduction in mental illness and mental handicap staffed and available hospital beds over the past 10 years. The figures are 24,800 and 16,400 respectively for the period between 1976–86. Those figures are for England. We do not have forecasts for future closures. We expect health authorities to assess the number of beds needed based on the development of local services which can of course provide in-patient care in different forms.

I can assure noble Lords that we fully appreciate the anxieties expressed by many relatives and friends of both mentally ill and mentally handicapped people when faced with a change in the pattern of the way care has been provided over many years. However, there are benefits to be gained from having available a greater range of care provision so that those are more closely suited to the varying needs of mentally ill and mentally handicapped people.

Because the needs and problems of mentally ill and mentally handicapped people in the community are so different, I should now like to consider them in more detail. As regards mental illness, the Government's longstanding policy is that people with mental illness should have access to all the services they need as locally as possible. Our aim is to have a full range of local services, such as in-patient and day hospital facilities, day centres, residential homes, hostels, sheltered accommodation, supported lodging or special fostering schemes, group homes, drop-in centres, sheltered workshops, social clubs and self-help groups, as well as education training and employment services.

Some people will be able to live in ordinary housing with the support of visiting professionals. All this calls for considerable co-ordination and collaboration between the providing agencies, and also improved communication between the caring professionals, the sufferers and their families.

Collaboration still needs improvement. There are geographical, administrative and financial reasons why some health authorities and local authorities still find it difficult to plan together to provide integrated services. It can be done, as some districts have already demonstrated. I am very glad to accept the views of my noble friend Lord Balfour concerning the fact that early treatment is highly desirable. Of course the Government are anxious to promote preventive and early intervention measures.

I would now like to turn to some areas of special concern. Although an increasing proportion of mentally ill people have been discharged from hospital, it is still sadly true that some do not recover fully and may be left with severe disabilities, for which they need special help. The new style of service will be judged by how well those with special difficulties are helped. In the past too much of the care for this group was only provided in large distant hospitals. The development of locally based services does not imply any less commitment on the part of Ministers to provide proper care for this most vulnerable group of patients. Every local service must plan how best to provide that care without further adding the burden of institutionalism to the disabilities of illness.

It is also necessary to look carefully at available resources. In considering the possibility of hospital closure or run-down, we must bear in mind that at the end of 1986 there were some 10,000 beds empty in the mental illness service as well as some 8,000 vacant day hospital places. It therefore makes sense to ensure that resources are used in ways most appropriate to the patients needs.

The provision of effective continuing care for those discharged from hospital treatment is of central importance. Ministers have repeatedly emphasised the importance of professional teams' planning and agreeing individual care programmes with each patient and, where appropriate, with their families, before discharge. Once the patient is discharged, there must be proper monitoring and co-ordination of these programmes especially for those who are chronically ill or regarded as most vulnerable, to help clinical teams identify any problems as they develop and to act accordingly.

In response to the remarks made by the noble Lord, Lord Rea, we agree that the family doctor has a central role in the treatment and management of mentally ill people in the community. We are glad to read reports of much closer collaboration between general practitioners and psychiatrists, with some 20 per cent. of psychiatrists now spending some of their time working in primary care setting.

We are particularly concerned that the patient or his relatives do not lose touch with services and do not have to seek out for themselves what help is available. A measure of our concern is that planning guidance, issued to health and local authorities in July, requires that by 1991 each district should have developed a care programme to provide a system of co-ordinated continuing care for people chronically disabled by mental illness. We also emphasised that each district should ensure that a consultant psychiatrist has special responsibility for rehabilitation and continuing care.

As my noble friend Lord Skelmersdale reminded noble Lords in the House last week, he attended a working conference in February of this year, organised jointly by the DHSS (as it then was) and the National Unit for Psychiatric Research and Development at which people from the health and social services discussed the detailed requirements of a continuing care system. This conference built on research funded by the department in Salford, Southampton and Hackney to investigate the use of computers to assist in ensuring both that patients are less likely to "fall out of care" and that patients and carers received the information they need to ensure quality care.

A report of that conference was published by the national unit in September and the department is studying its contents very carefully as it prepares detailed guidance on the components of these care programmes. We are also, as my noble friend made clear in the House last week, taking account of relevant recommendations in the Spokes Report on the care and after-care of Miss Sharon Campbell, a concern that was underlined by the noble Lord, Lord Winstanley. As noble Lords who spoke on that occasion recognised, that report has made a very helpful contribution to thinking in this area.

The noble Lord, Lord Thurlow, raised the question of compulsory treatment in the community. That is the subject of discussions which have been taking place with such organisations as the Mental Health Act Commission, the Royal College of Psychiatrists and MIND. It is a complex area where there are strongly held views on all sides. No changes will be considered without a full consultation with all those concerned with mental health.

The noble Lord, Lord McCluskey, mentioned Section 7 of the Disabled Persons (Services, Consultation and Representation) Act 1986. As part of the discussions on implementation of the Act, officials of the department met local authority representatives on 17th November. The timetable for implementation will depend on the outcome of discussions with local authority and health authority representatives.

Although many people can cope, with professional support, in normal housing and sheltered bedsits, we accept that asylum in the sense of refuge should remain a necessary part of any comprehensive psychiatric service. The essence of the new service, even for the most severely disabled, is that it should be locally-based and hence more accessible for patients and their families.

I agree entirely with my noble friend Lord Mottistone on the importance of hospital hostels. I cannot, however, tell him the number presently provided by health authorities since they are not returned on statistics separately from other in-patient beds.

The Department of Health has been actively involved in research and development into ways of providing services to those who need long-term care in a health service setting. Research on high dependency hospital hostels has been completed in Manchester, London and Southampton, and in the course of the last year, the department has sponsored and contributed to five seminars presenting the clinical and economic evaluations of these projects. These seminars have been very well attended by practitioners and planners, and it is hoped that a publication summarising the findings will soon be available.

The noble Lord, Lord Winstanley, referred to the need for improved training of social workers. The Government have made extra funding available to the Central Council for Education and Training in Social Work to improve the practice content in social work training. Approved social work training of those who have statutory duties under the Mental Health Act now lasts for at least 60 days and has heightened social workers' understanding of mental illness.

The right reverend Prelate the Bishop of Southwark referred to lack of research into closure of hospitals. Research is being conducted by the Medical Research Council into the process and consequences of the run down and closure of Friern Hospital and Claybury Hospital in north-east London. The Department of Health is glad to have contributed to the funding of that research and is studying the reports of the research team with close attention.

I turn now to the provisions for mentally handicapped people and the help that they need. I am aware that many families and others involved in providing services are concerned that the community may not provide the right environment for some mentally handicapped people to give the care and protection that they require. That is why we have encouraged health and local authorities to co-operate and work together to ensure that the particular care needs of each mentally handicapped person are met through community based services that are appropriate and cost-effective, but with genuine choices for clients and the families. This also involves a need for the statutory service providers at local level, and with respective housing departments, local councillors, community groups, schools, youth groups and of course the voluntary sector, to ensure the development of good will and support of potential neighbours when selecting sites for accommodation. We appreciate that there are difficulties, but with good will they can usually be overcome.

Jointly planned development of mental handicap services has not yet been as widespread as we would like to see. But despite problems of organisational and geographical boundaries there are, as with mental illness services, some good examples where co-operation between all concerned really does produce the co-ordinated mental handicap service we want to see. Much depends on individual determination and good will to get together to make the machinery work effectively.

The movement to community care has made it even more essential that we recognise the importance of training and staff developments at all levels. This point was mentioned by the noble Lady, Lady Kinloss. With this in mind, we have taken steps to emphasise both the scale and urgency of the training development required to keep pace with the development of services. Bodies with statutory training responsibilities have recognised that shift in service patterns over a number of years and the effect that this must have both on professional practice and attitudes and the skills of a wide range of staff and management. Officials have been working closely with these and other bodies concerned in staff training. We want to improve training and in particular to encourage the shared training of NHS and local authority staff for work in the community, and central funding has helped in this progress.

How services can develop in any one area will primarily depend on the relevant health and local authorities making the best use of resources available to them. However, there are ways in which central government can make a direct contribution to the development of community care projects. I have already mentioned our training grants and, as many noble Lords will know, we have made a substantial financial contribution to moving mentally handicapped children out of hospital into more suitable forms of care.

Some people with a mental handicap also show very severely disturbed behaviour, or they may be mentally ill or need care in conditions of some degree of security. These people with special needs require special solutions, and officials have been studying how different authorities are meeting these needs. A guidance document for planners is being prepared which the Department of Health hopes to issue next year.

I am now some way through my speech and have highlighted a large number of central government initiatives to boost community care, all of which are currently under way. Some noble Lords—not least the noble Lords, Lord Carter, Lord Rea and Lord Taylor of Gryfe—have suggested that the Government are dragging their heels on community care, especially in relation to Sir Roy Griffiths' report. I would argue on the contrary that what I have described is a constant record of commitment, activity and progress. Of course we look to the future, and Sir Roy's report will assist Ministers in planning further action. Ministers are studying the report and the many and varied responses to it with great attention. It has moved the ongoing debate about community care forward significantly and stimulated thinking among all organisations and professions concerned with the delivery of care. I can reaffirm our commitment to bring forward our own proposals following this period of scrutiny. The views put forward in the debate will be taken into account in framing those proposals.

Lord Ennals

My Lords, can the Minister give some idea of when we are likely to have a reply?

The Earl of Arran

My Lords, I think that that would be unwise because I cannot say with absolute assurance.

I know that this response will disappoint many noble Lords who may have hoped for our intentions to be revealed tonight. The Government are aware of concern, not least in your Lordships' House, that action should not be unduly delayed. Equally, however, in such a complex and challenging area concerned with the welfare of some of the most vulnerable and needy people in society it is right that we take sufficient time to find the right answers before embarking on a major programme of action. For that we make no apologies. Precipitate action not backed up by careful thought and scrutiny would not be in anybody's interests, least of all that of the individual clients or patient, but let me emphasise again that government proposals for further improvements in community care will be forthcoming in due course.

I have spoken of the action that central government already have in hand. It is equally important for health and local authorities to continue to build on the progress made so far at the operational level. We remain firmly of the view that there is scope for progress within existing arrangements, as the many successful and imaginative projects developed locally in the past few years illustrate. Local authority resources devoted to community care increased by over 26 per cent. in real terms between 1978–79 and 1986–87 to help fuel those developments.

We acknowledge that progress has not been uniformly good and that there is a major challenge for all concerned with these services to ensure that the resources devoted to them are managed in the most efficient and effective way, but there is certainly no reason to despair of making progress within existing structures. Health and local authorities can work within them to make significant improvements in services locally and suggestions of planning blight do a disservice to all those currently involved in developing such schemes.

What else can central government do to help? There is no magic wand that we can wave, but we can encourage. The regional review system enables the NHS management board and Ministers to discuss with regional health authorities points of concern on planning or the provision of services and to set objectives for action. Good collaboration is one of the points for which we look out, and we tackle regions in the review process if there seem to be problems.

Before I conclude, noble Lords are of course aware that financial assistance is available through the income support and housing benefit schemes and community care grants under the social fund and the independent living fund. These schemes are means-tested, but all recognise the extra needs of sick and disabled people.

The noble Countess, Lady Mar, spoke of the difficulties that patients have in claiming social security. Patients will usually be receiving benefit while in hospital. This will normally be increased on discharge. We appreciate that some individuals may find it difficult to claim that benefit, but the new system of benefits introduced last April was intended to be easier to understand and administer.

The noble and learned Lord, Lord McCluskey, asked whether there are likely to be exemptions from payment of the community charge for persons suffering mental illness. I understand that there will be exemptions for people in residential care homes and nursing homes. Exemption for vulnerable groups in other types of accommodation is a matter receiving attention. I am unable to give further details on this occasion.

Baroness Seear

My Lords, does the Minister include in the list of exemptions people who are being looked after with great difficulty by their families in their own homes? If the Government do not give more assistance soon and if, on top of everything else, such people have to find the poll tax to pay for those whom they are looking after, they will break, and it could well be the last straw.

Lord McCluskey

My Lords, will the Minister consider the fact that the relevant government legislation is the 1988 Act, which excludes these very people? Are the Government giving consideration to amending that Act on this point?

The Earl of Arran

My Lords, I understand the noble Baroness's point. I am not certain whether the specific category of people she mentions is included in the exemptions. I undertake to find out and let her know in writing.

In conclusion, I am bound to say that the Government remain committed to the development of locally based services and are constantly reviewing how development can best be achieved. Having heard what I have said about all the ways in which we are actively improving services, care programmes for example, I hope that the noble Lord, Lord Ennals, will accept that needing to know more about regional services is not a smokescreen for inactivity. But there can never be room for complacency. The task of managing the resources devoted to the mental health service is a major challenge for management and professionals at all levels and we must ensure that the right services reach those who need them most.

Lord McCluskey

My Lords, the noble Earl has sat down without using up all his time. Will he respond to the third question of which I gave him written notice, about prescription costs?

The Earl of Arran

My Lords, the noble and learned Lord, Lord McCluskey, will realise that we are very short of time. I shall respond to his point but I am equally anxious that the noble Lord, Lord Carter, should also be able to speak.

Lord Carter

My Lords, I am extremely grateful to all noble Lords who have taken part in this wide-ranging debate; it has certainly revealed the size of the problem. I am grateful to the Minister for the comprehensive way in which he replied, but he will understand my disappointment with his use of such phrases as "in due course", "to move forward" and "an on-going debate". They are not much help when we had hoped to have the assurance of the Government that they were responding to the Griffiths report.

My Lords, with that in mind, I beg leave to withdraw the Motion.

Motion for Papers, by leave, withdrawn.