The Mentally III and Handicapped

HL Deb 18 May 1988 vol 497 cc328-71

3.10 p.m.

Lord Basnett rose to call attention to the needs and problems of people who are mentally ill and mentally handicapped and their families; and to move for Papers.

The noble Lord said: My Lords, it is with a sense of humility that I move the Motion standing in my name on the Order Paper. It is with humility because I know that some of your Lordships speaking after me, because of close associations with organisations concerned with mental health and handicaps, will speak with more authority than I. I speak with humility because my experience has made me more intimate with the questions than the answers.

However, I believe that there are three questions which clearly deserve an answer. First, are we sufficiently aware of the size of the community of people with mental illness and disability and the scale of their needs and their families' needs and problems? Without knowing that, we do not have a sufficient political priority to provide the resources. Secondly, are we aware of our failure sufficiently to meet their needs and the consequences for them of that failure? Lastly, as an inevitable consequence of the second question, if we are becoming aware of those matters, why has this failure occurred and what do we need to do about it?

The scale of the problem is fairly well documented. The 1975 White Paper stated that each year some 5 million people consult their general practitioner about a general health problem, with 600,000 of them being referred to a specialist service. More recently, MIND has said that over a lifetime one in four people will experience psychiatric symptoms. Of those, more than one in five will seek help from a general practitioner while over one in 10 will be treated with drugs. Out of every 1,000, 17 will be referred to outpatients. According to MENCAP the figure for mental disability shows that there are 1.2 million people with that handicap; over 2 per cent. of our population.

That large and, with the growth of dementia, growing population has led one author, taking an international view, to describe this as, a pandemic of mental disorder, the scale of which has not entered the public's awareness, not drawn the attention it deserves from the media and not gained the political priority and resources it deserves.

A doctor friend of mine has explained that last point by suggesting that there are no votes in mental health. That is no doubt unjustified and perhaps as unjustified as drawing your Lordships' attention to the fact that when the National Health Service was debated on 28th March, of the 30 speakers in that debate not one mentioned the issue of mental health. While MIND and MENCAP are doing sterling work in arousing public awareness, this is a task which needs government resources. A government funded educational campaign would increase public awareness and understanding.

As we become more aware of the failure properly to implement current policies, the consequences of that failure become more and more obvious. Care and support by the professionals has been too little available, with a consequent and sometimes unbearable pressure upon the family. In the absence of family support, in too many cases the mentally ill or mentally disabled face unsuitable temporary accommodation, institutional hostels, prison or the company of vagrants. There is no doubt that that has occurred.

The Audit Commission Report of 1986 stated: It must be a matter for grave concern that although there are 37,000 fewer mentally ill and mentally handicapped patients today than there were 10 years ago, no-one knows what has happened to many of those who have been discharged". Despite the 1986 Audit Commission report, the DHSS has not funded a full-scale enquiry to discover what has happened.

However, there is some anecdotal evidence. The Esther Rantzen programme "That's Life" has on three Sundays dealt with community care and mental health; two were concerned with what happened to people discharged from mental hospitals and one with families which care for them. On our screens was a picture of distress, chaos and disorder. After the programme they received far more letters than usual, which divided into five categories: from parents about the distress of parents trying to cope with a mentally ill relative; from relatives and hospital staff about the fate of those discharged without parents who because they have no parents cannot cope; from relatives, patients and staff about the fear of relatives and patients at the prospect of hospital closures; and from relatives and prison staffs about the plight of the mentally ill who commit offences; and lastly, from the general public, outraged at the state of mental health care.

The Minister of State has asked for a selection of those letters. Perhaps I may quote a passage from one of them. It is from a family who has a mentally ill daughter and who has had to put the other children in boarding school in order to take care of her. It describes the circumstances at home, and says: I get a higher rate of attendance allowance and invalid care allowance. It comes to about £50 altogether and those few pounds absolve the State from any further responsibility". There is no doubt of the misery, chaos and disorder of some of the mentally ill and their families in our society.

The causes arise from a combination of the failure to provide or ensure the provision of resources and a reduction of essential support from housing and social security, together with a failure to co-ordinate our services. On available financial resources, the hospital and community health service spending has increased by only 1 per cent. per year in real terms since 1980–81. The Government have agreed that 2 per cent. growth per year is necessary to meet demographic changes and advances in medical technology. On this basis hospital and community health services have been substantially underfunded since 1980. In addition to that, local authority expenditure has not risen to provide the services needed to take account of the fact that in the past 10 years hospital in-patients have decreased by 16,800. In order to meet the needs of those people the Audit Commission has said that local authorities needed to have spent £240 million more in the past decade. In fact they spent £20 million more.

More generally, because of Government policy the low level of local authority response to the needs of community care is depressing. Less than one local authority in five spends as much as £2 per head of population per year on mental health services; three out of five have not increased their expenditure to keep pace. A further nine have actually cut their expenditure in real terms. And all that undermines the community care programme.

Housing is of course an essential component of community care and yet the housing investment programme has been cut by 60 per cent. in real terms since 1979. Housing subsidy has been eroded and council house starts are at an all time low. All of that again undermines the community care programme as do the problems of personal financial support. Debt and budgeting problems play a significant part in reducing a person's ability to continue living independently in the community and can cause an otherwise unnecessary return to hospital.

The impact of the Social Security Act 1986 can only mean fewer basic rights, more means testing and reduced financial support for many. In particular the introduction of a cash limited and discretionary social fund will worsen the plight of rather than assist the people with mental health problems who are trying to re-establish themselves in the community.

The familiar pattern of personal poverty, growing financial debt, poor housing and deteriorating physical and mental health is being reinforced. And that occurs within a structure of a mental health service which is confused and where responsibility and accountability are fragmented between different tiers of the National Health Service and local government. That must affect the way in which public funds are used to support community care policy. That makes the absence of recommendations from the Griffiths Report concerned with the coordination of health, social services, housing and the voluntary and private sector puzzling.

No doubt others will comment more fully on the Griffiths Report. I shall content myself with observing that there are welcome and unwelcome recommendations. For instance the recommendation that a Minister of State should oversee community care is seen by most as a good idea as is the recommendation that social service authorities should be supported by general and specific targeted grants providing a significant proportion of the total cost of the programme.

But while the emphasis on individual needs is welcome there is no mention of the service user's right to challenge the decisions. The clear implication that families or informal carers should provide the necessary care—only if this is impossible should public funds be spent—must be unacceptable to many while the question of means-testing which runs right through the Griffiths Report would make many people a good deal poorer.

One statement however within the body of the report reflects what I believe is a consensus as to how community care should be introduced. It is that: no person should be discharged without a clear package of care devised and without being the responsibility of a named care worker.".

I wish to conclude by suggesting five essential developments to bring about that situation. The first must be to ensure the availability of more financial resources to make a reality of community care. MIND has estimated that £500 million in five years is needed to finance the transition from hospitals to community care and that in addition a national care fund is needed.

Secondly, I think that consideration of personal income problems must have priority. A comprehensive disability income would begin to relieve these problems but would have to be linked to the provision of other forms of help, support and treatment. Perhaps as important is improving the availability of employment. The Government really should try to be more helpful in this area than they were, for instance, in insisting on the removal of your Lordships' amendments to the Local Government Act.

The third important consideration is the help for carers. Those relatives or friends who care informally for people with mental illness need help in cash and in kind. A proper carer's benefit would assist those who wish to care for a disabled relative, and effective support from health and social services would ensure that carers were able to continue caring for longer than they can at present.

Fourthly, there is the key problem which was not addressed by the Griffiths Report—that is, the coordination of health, social services, housing, the voluntary sector and the private sector. A good quality community mental health service will provide psychiatry, psychology, community nursing, occupational therapy and support to general practice linked to the provision of social services through field social work and home helps, together with housing management and peripatetic support to clients. Effective means of co-ordination of these are essential.

A mental health service development group which would have delegated budgets and would draw representatives from each of the agencies mentioned above is one suggestion for achieving that. A joint consultative committee could perhaps do that work. The Government in their review of the National Health Service will, I hope, give a higher priority to the question of mental health than we have seen in resource terms recently. Fifthly there is the key component of community care which is good quality housing and appropriate support. Most patients need support, help and attention at least from time to time; but they also need decent housing, either as individuals or in small groups, where they can obtain the support they need and where they can rebuild valued lives and go out into the community to make friends and build relationships.

If the Government are inactive on those issues, care will not be there in the community for those who need it. What will be there will be a growing demand to slow down releases from hospitals and institutions. None of us wants that. However, it is a situation which is a consequence of a series of policies, from the availability of resources through social security support to housing, all of which converge to the further disadvantage of the most disadvantaged group on our society—the mentally ill and the mentally disabled. The Government need to act now to repair the damage which has been done and to establish community care on a more caring basis. I beg to move for Papers.

3.30 p.m.

Lord Skelmersdale

My Lords, it is not often in this House that a junior Minister is asked to explain the Government's policy on an issue for which he has some executive responsibility. Mental illness and mental handicap are two such issues, and so I am grateful to the noble Lord for raising this important subject.

As we all know, nothing very fast or very dramatic happens in this area. But down in the jungle of statutory and voluntary provision something has been stirring in recent years. In the mental illness field, modern treatments such as the major tranquillisers and the anti-depressive drugs have led to enormous changes in the need for hospital provision brought about by a marked fall in the number of patients resident in hospital by half, to just over 60,000 in the last 20 years. Over the same period the policy of providing services better suited to the individual needs of mentally handicapped people has meant that the number of people destined to spend their lives in large mental handicap institutions has also fallen by about half to around 31,000.

That has resulted in a two edged approach to provision of care both inside and outside hospital. Care in the community has become the buzz word. This means moving towards a modern, locally-based mental health service involving very much more than the redistribution among health authorities of the resources presently contained in the large multi-district hospitals. Delivering a comprehensive range of services involves or should involve health authorities, local authorities (especially social services, housing, education and leisure services), the voluntary sector, the private sector, the families and friends of people with mental disabilities and last but by no means least, those suffering from mental illness or a mental handicap themselves. 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 words of the Motion are interesting because they call attention to the needs and problems of mentally ill and mentally handicapped people and their families. Although I shall deal with those separately, I know I am about to shock many of your Lordships by asking, are they so very different? Indeed, almost the first question I asked when I took up my present portfolio was, what is the difference between mentally ill and mentally handicapped people? I got a very quick reply: the ill are potentially curable. Of course there are fundamental differences in the forms of care or treatment required by each group. However, going round the country as I do I am struck by the many similarities in services needed for those who are severely mentally handicapped or who are chronically mentally ill. In my view it is right that this should be so because the definition of care in the community covers both groups.

What we need in this country is an acceptance of the basic philosophy that people should not need to live in large hospitals unless there is no alternative. Government policy is that people should be encouraged to live at home for as long as it is practical and desirable for them to do so. That sounds obvious, but let us examine it. We know that almost all mentally handicapped people and most long-term mentally ill people can now live better lives in the community. Their position must be made secure by providing alternative accommodation, properly planned, to take account of the alternative facilities available; the capabilities of the caring and treating authorities, whether statutory or voluntary, public or private; and most importantly the views of parents and, whenever possible, those of the people themselves. In other words, the ideal is a personalised care plan.

However, before we can get to that we need, as my noble friend Lord Jenkin said in Care in Action in 1981, to set three tasks for the mental illness services. We have stuck firmly to those priorities and they remain at the centre of our current policy aims.

The first of these tasks was to create as quickly as possible a local service in those districts which still had little local provision. That involved reducing the catchment areas of mental illness hospitals to their own local health districts. The second was to provide in every district enough suitable accommodation for the care of elderly mentally ill people, taking account of the likely increase in numbers. The third task was to make arrangements satisfactory to patients and staff locally for the closure over the next 10 years or so of those mental illness hospitals which were not well placed to provide a service reaching out into the community and which were already near the end of their useful life.

It is by no means a matter of chance that in listing these three policy objectives I spoke of development of local services before I mentioned hospital closures. There is a good reason for that. Closure of mental illness hospitals is not a primary objective of mental illness policy. Any closures occur as a consequence and a consequence only of the development of local services and of the continuing fall in numbers of resident patients. I am most concerned to emphasise that no hospital should close until there has been a re-provision of a full range of replacement services. It is not our intention that all the large mental illness hospitals should close and, indeed, the majority of existing hospitals are likely to be incorporated within the future district-based services.

Our aim is to have a full range of local services, including day centres, residential homes, hostels, sheltered accommodation, supported lodging schemes, ordinary housing, group homes, social clubs, drop-in centres, sheltered workshops and self-help groups, as well as education, training and employment services. Achieving this calls for a considerable degree of co-ordination and collaboration among the providing agencies as well as improvements in communication between the caring professionals and their patients and families.

As in other areas of health and personal social services, it does not matter who provides the facilities so long as they are provided. I know that much still remains to be done to improve collaboration. There are many reasons—geographical, administrative and financial—why some health authorities and local authorities are still finding it difficult to get together to plan and provide integrated services. I do not shy away from the question of resources. There are always calls for more spending but innovation and good practice can be achieved in spite of all the difficulties. Health and local authorities in areas ranging from inner London boroughs such as Hackney on the one hand to West Dorset on the other have shown how things can be done to the great benefit of the users of the service.

I was surprised to hear the noble Lord, Lord Basnett, describe that as depressing. I hope that no speaker in the debate will blame rate capping. Noble Lords will remember that Hackney is one of the rate-capped boroughs. If Hackney can show the way forward, so too should those London boroughs which have not benefited from that financial reprimand.

I have mentioned the need for more resources. But it is equally, if not more, important to consider the management of those resources and to look at whether improvements are possible to secure the right services at the right time for those in the most need. It was for this reason that we asked Sir Roy Griffiths to undertake his overview of community care policy. Sir Roy has produced a very interesting report which we are studying closely. The issues it raises are important, too important to be buried, as Sir Roy said the other day, and demand the most careful scrutiny from all concerned with the future of care services. There are no easy answers to many of the points raised—to quote Sir Roy again no Rubik Cube which will be easily solved"— and it is therefore right that we take the time necessary to analyse his recommendations thoroughly before deciding on the way ahead. We need, for example, to set the recommendations in the wider context by looking at the conclusions of other relevant work such as Lady Wagner's report on residential care. We also need to ensure that the outcome of this exercise is complementary to the results of our review of the health service.

I note what the noble Lord has said about a Minister of State with responsibility for care in the community, for example. There are other points in the report with which the noble Lord agreed but equally some with which he did not agree. That emphasises how difficult it is to come to a conclusion.

I should like to emphasise one point. We have said that we will bring forward our own proposals in due course. I can firmly repeat that commitment this afternoon. Weare listening carefully to all the views put to us as we frame those proposals and will particularly note your Lordships' comments this afternoon and take account of them in deciding on action.

I should 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 sadly true that many people do not make a full recovery and are left with disabilities, at times severe, which leave them with special needs. How well those patients are cared for and how well the needs are met must be one of the standards by which the new pattern of service is judged. In the past far too much of the care for that group was available only in the large distant hospitals. The development of locally based services does not imply any lower degree of commitment on the part of Government to provision of adequate care for this most vulnerable group of patients. The problem that each local service must solve is how to provide that care without adding the burden of institutionalism to the disabilities of illness and handicap.

The provision of effective continuing care for those discharged from in-patient treatment is of central importance. Ministers have repeatedly emphasised in this House, in another place and elsewhere the importance of professional teams agreeing individual care plans with each patient, and where appropriate with their families, at the time of discharge. Clearly such a plan is likely to be in the interests of the patient once he or she is back in the community. With proper monitoring and co-ordination, especially in the case of those who are chronically ill or regarded as most vulnerable, it will help clinical teams to identify any problems as they develop and to act accordingly.

I have been speaking of those coming from long-term care. But we need to look critically at the needs of those who have come through an acute stage of their mental illness. The House will be aware that consideration has been given to the feasibility of some form of compulsory treatment in the community to prevent relapse in the case of certain chronically mentally ill people who do not see the need to continue medication voluntarily. This is a complex matter and there are conflicting views on the principle and practicality of such an approach. Several groups are party to the continuing deliberations, including the relevant professional groups, the Mental Health Act Commission and the patients' rights lobby. No specific proposals have yet been put to Ministers.

I believe the time is nigh when the interested parties must come to a decision one way or the other, otherwise we shall continue to drift from pillar to post. It is the patients who have had short-term admissions for treatment who will suffer.

I am particularly concerned that staff in the range of facilities within the community pattern of care—for example, day hospitals, day centres, outpatient clinics—work closely together so that the patient or his relatives do not lose touch with services and do not face the problems of having to find out for themselves what help is available.

A measure of our concern is that we are currently considering what might be done to provide a system of co-ordinated continuing care for people chronically disabled by mental illness. I attended a working conference in February of this year, organised jointly by the department and the National Unit for Psychiatric Research and Development, at which a number of people from the health and social services discussed the detailed requirements of such a system. I also intend to be present at the national unit's annual conference in September when that work will be carried forward. A report of the February conference will be published by the national unit and I shall be studying its contents very carefully.

The Government recognise of course the immense contribution made by informal carers, and I should like to pay tribute to their dedication and humanity in the face of the daunting but worthwhile tasks they face. It is clear that those carers need advice and information about how to cope both with emotional and with practical problems, as well as the back-up of effective services which will enable them to lead as normal a life as possible. The department has instigated a number of measures aimed at improving matters in this direction.

First, we are funding a programme of research being undertaken by the University of York to investigate the financial circumstances of a sample of adult carers of working age, to investigate the nature and impact of caring responsibilities of spouses and to evaluate support services for carers. This will supplement the information derived about carers from the Government's general household survey and the national survey of disabled people, and will enable planning for community care to take account of the needs of all carers.

We are supporting a number of national voluntary organisations directly or indirectly interested in carers through our general scheme of Section 64 grants. These organisations include MIND—with which the noble Lord, Lord Ennals, has a long but sometimes interrupted connection—the Association of Carers and their Elderly Dependants and the Alzheimer's Disease Society. We are also providing funding through our Helping the Community to Care initiative for a number of projects specifically aimed at the needs of carers.

In 1986 the entitlement to claim the invalid care allowance was extended to married women, and as the overwhelming majority of carers are understood to be married women, this should offer some compensation for many people who have to give up work to look after a disabled relative.

I am aware of the concerns of many families and others involved in the provision of services that the community at large may not provide a welcoming environment for mentally handicapped people. In this context we have continually stressed the importance of consultation with the local authorities and winning the good will and support of potential neighbours. Authorities have been advised that possible initial resistance from neighbours should be considered when selecting sites for accommodation and that special steps such as liaison with local councillors, community groups, schools and youth groups are likely to mitigate those difficulties.

In the care of mental handicap in the community much depends on individual determination and good will to get together to make the machinery work. When we talk about joint planning for mental handicap services we naturally, as I have already said, first look to health authorities and social service departments to take the lead. However, other agencies are much involved.

I cannot overemphasise the fact that, like everyone in the community, mentally-handicapped people have a wide variety of needs. Some they share with the rest of us but others are special requirements depending on their disabilities. Consequently the range of general and specialised services necessary to meet all their needs will be provided not just by statutory bodies, whether local authority or health departments, but also by the voluntary and private sectors which have made and will continue to make an essential contribution. The Government do not passively welcome that contribution: we actively encourage it.

I should like to conclude by returning to what I said in my introduction. One of the central themes of our years in office has been the development of community care services. The Government remain committed to that and are constantly reviewing how it can best be achieved. We have a good record in providing more resources for service development. At 1985–86 prices gross expenditure in hospital and community health service spending on mental illness grew by 16 per cent. in real terms between 1978–79 and 1985–86 to £1,077 million. This year hospital and community health services expenditure will increase by about 10 per cent. in cash terms and personal social services expenditure by about 8 per cent., compared with forecast general inflation of 4.5 per cent. in the last year. This has benefited community care developments enormously and helped to extend the range of services provided throughout the country.

However, I agree finally with the noble Lord, Lord Basnett, that there is no room for complacency. The task of managing the resources devoted to community care is a major challenge for management and professionals at all levels. We must ensure that the result is the right services for those who need them most.

3.50 p.m.

Lord Winstanley

My Lords, the noble Lord, Lord Basnett, is to be congratulated on bringing forward for debate a subject of such immense importance.

It is a field in which he had a very distinguished record in his public life before he came to this House. As we know, he has done a great deal for the people with whom this Motion is concerned. In your Lordships' House there are many other people who have been concerned with this matter for very many years. This House has a proud record in this field. In 1983 the Mental Health Bill was debated night after night and a whole number of amendments were made to it. It was improved enormously before it was finally enacted. The noble Earl, Lord Longford, initiated two or three debates on this subject in the House and set up a committee of inquiry serviced by the Richmond Fellowship—a splendid body, which does such good work in this field. It presented a most detailed report, after lengthy inquiries, to Her Majesty's Government—to which we have not yet received a response. The noble Lord, Lord Allen of Abbeydale, who is to speak to us later, has always taken a very close interest in this subject, as indeed have many other noble Lords.

The noble Lord who introduced this debate was absolutely right in putting the figures with regard to the size of this problem quite starkly before your Lordships' House. It cannot be disguised. I do not want to guess the ratio but there can hardly be a family in Britain now in which there is not some member who at some time will require psychiatric treatment. Indeed in many families there will be several members who will need residential treatment, sometimes compulsory treatment within a mental health institution of one kind or another. This is a large problem that cannot be hidden or forgotten. As the noble Lord said, it is a growing problem.

The Motion draws attention to the needs and problems of people who are mentally ill and mentally handicapped and their families. We must never forget that the needs of those two groups—the people who are mentally ill or mentally handicapped and their families—are not always identical. Indeed sometimes they are in fairly sharp conflict. That is a matter about which we have to think constantly when making effective provision for the care of the mentally ill. We also have to think about the families and the impact on local communities and on other members of the family who are not mentally handicapped or mentally ill.

We are fortunate, as the noble Lord, Lord Skelmersdale, has told us in responding to the debate, that the reply will be given by the Minister who has departmental responsibility for this subject. We also have a noble Lord who has a deep personal commitment to it and parts of his speech today sounded to me as if they were his own words, not just those of his private office. I believe that his heart is in the right place—whether he is free to do with it what he wishes we do not know. However, it is reassuring to know that we have a Minister with some departmental responsibility for the subject and who takes a great interest in it.

By curious coincidence—something of which I am quite sure the noble Lord, Lord Basnett, was unaware—shortly this afternoon the All-Party Mental Health Group of both Houses of Parliament (of which I have the honour to be vice-chairman) will be meeting to hear an address by Professor Robin Priest, Professor of Psychiatry at St. Mary's Hospital, Paddington, and Registrar of the Royal College of Psychiatrists, entitled, What is Parliament Doing to Psychiatric Patients? I should have liked to hear that address before speaking to your Lordships. However, I have managed to extract one or two notes from it and perhaps it would not be altogether inappropriate for me to mention them—though it would not be entirely proper for me to make Professor Priest's speech before he makes it himself in about an hour's time upstairs.

To noble Lords and to Members of another place, he will say: Mental health care has improved beyond recognition since the founding of the National Health Service". That is absolutely true. Further, he will say: Psychiatry has been taken into the main body of medicine". That is something which has taken a very long time. For many years it was regarded as totally separate. It was hidden away in separate institutions and not regarded as part of the ordinary body of medicine. He will also say: The standards of mental hospitals have been raised towards the levels expected in general hospitals. Almost all health districts have some psychiatric beds for their population". That is encouraging, but how has that improvement been effected?

It has not been done by this Government, the last government or any previous government, but in the main by a gradual change in public attitude and an increasing understanding of the nature of mental illness and mental handicap. Without that increased public understanding, almost nothing could have been done. The fear and misunderstanding of mental illness and the stigma attached to it did so much to delay and obstruct developments of many kinds.

In his response the noble Lord, Lord Skelmersdale, said many things of great interest—I wish I had the text of his speech before me. There is so much of it that I should like to look at later. He said that we want to see modern, locally based mental health services everywhere. I should like to see that too but I should also like to know by whom it will be controlled. I will come to that point in a moment. Later in his speech he went on to say that no hospital should close until there had been a re-positioning of the services previously provided by the hospital.

We have been saying that for years. We are all in favour of community care. We are aware that community care is not a cheap option. But in very many cases it is the better option for the patients and their families. This is not a party matter; members of all parties and of none have said that we should not start closing down the large mental institutions and hospitals until we are quite sure that we have in place in the community the organisations and the services to provide community care. If we do the one before the other, two things will result. We shall put the patients and their families in jeopardy and dislocate the local communities. This will cause a great deal of trouble and in the end do something to change the mental attitudes, which, as I have said, have improved so much in recent years. If one once causes that kind of trouble in local communities by not providing properly for the people who are mentally ill, it will be no time at all before the prejudices start to return and we find the old biases returning—and once you have those you have a battle indeed.

The noble Lord said that it does not matter who provides the various services as long as they are provided. I say that too. I am most interested in the Griffiths Report, which he will remember was released in almost total silence the day after the Budget. Fortunately it has since received a great deal of publicity. He will remember when we recently debated the report of Sir Donald Acheson on the public health function, and the noble Lord said, absolutely rightly, that those two reports would have to be looked at closely together. I agree with that. They will have to be looked at in conjuction. But they will have to be considered very soon.

It is not a subject that can be left. Something must be done urgently. We have seen so many committees of inquiry that have produced reports which moulder in pigeon-holes. The Griffiths Report must not do so. I am not saying that the Government must accept all the recommendations, but they must do something about the issue to which the report is addressed.

Who is to be responsible in the community for community care? Sir Roy Griffiths clearly says that it should be the local authority social services departments. In some ways that is putting the clock back. I do not think that that is too bad a thing. I said in the earlier debate concerning Sir Donald Acheson that if we did that, and if local authority services departments suddenly found themselves responsible for community care and other such services, there may be a case for reinstituting the old, very powerful and influential office of medical officer of health. One would then have a known, responsible official. Everyone knew who he was and where he was. The two reports must be considered in conjunction and very soon.

Looking again at the brief notes of the speech that Professor Priest intends to make at any moment, he refers to the local authorities' responsibilities. He may not state this in his speech but I can say it: Social workers are employed by local authorities—even those that work in hospitals. Some years ago the hospitals agreed to hand over the responsibility for providing Social Workers"— we no longer have lady almoners in hospitals— to local authorities and the money for their salaries". He goes on to say: Now the local authorities are unilaterally withdrawing the Social Workers from the hospitals and pocketing the change I am not at all sure that that is right, but if it is going to be suggested at an important meeting of Members of both Houses later today, I should like to know what the Minister has to say.

Social workers in hospitals do a very important job indeed. They take most of the pressure off the ward sister. They answer questions. They deal with immensely complicated forms concerning this, that or the other benefit and the information that has to be sent to the department if an individual's circumstances change. Those workers are immensely important. They are employees of the local authority social services department. Is it true that the local authorities are withdrawing them? If they are, what is being done about it? I should like to hear an answer to that question.

I should also like to hear the preliminary reactions of the Government to the suggestion of Sir Roy Griffiths about giving specific responsibility for community care to local authority social services departments. I am not taking sides on this for a moment, but I should like to know the answer. I hope that somebody will be put in charge and that we shall know who is in charge and who is responsible if things are going wrong.

I said in an earlier debate that I have had personal experience of this in many ways. I have had many years in general practice and working in hospitals. I did my medical training long before the National Health Service started in 1948. Such knowledge as I gleaned about mental health—and teaching was very rudimentary in psychiatry—was in the huge mental institutions which were the most dreadfully impersonal places. I am delighted to see the improvement that has been achieved in recent years, brought about very much by a change in public attitudes rather than by government. That change has been of immense value. But I should be terrified if I thought that we were going to return to the old days.

However, let us look at some of the problems of introducing the concept of community care. I again quote two examples. One can have disasters of both kinds. In many cases it is better for the patient and the patient's family if he or she can be cared for adequately in the community. Of course one must have the back-up services; one has to have the social workers. One has to have the occasional respite for holidays with residential centres and day care centres to give everyone a proper rest. However, if these matters are not dealt with properly on both sides there can be disasters.

I had experience of two such disasters. One concerned a young man in a hospital who was almost institutionalised, having been there for many years. He was about to be discharged. The local authority had found him a flat which he had been taken to see. There was a social worker attached to him who was going to look after him. He had been in hospital for so long that he had no idea how he would manage in the community. We made a television programme, which included an interview with this young man, explaining the concept of community care. Before that programme was transmitted, so frightened was this man of being discharged that he committed suicide in the hospital. That is one case on one side.

The other case concerns a consultant pathologist in the Manchester area whose daughter was a social worker in a hospital in the South-East. She had a patient in hospital who was mentally disturbed and who was discharged for community care and put into a hostel which he did not like very much. He rather blamed the social worker for the conditions in the hostel. One day he marched into the hospital and stabbed her to death. I do not wish to say anything about the lack of security arrangements in the hospital; the fact that the panic button did not work; or that a patient could walk into a private office in a hospital without being stopped. I say nothing about that. However, the dangers of pursuing community care without immense sensitivity and without providing all the necessary resources are very serious indeed and should be borne in mind.

I hope therefore that when the noble Lord speaks to us again, as I know he will with leave, he will tell us that the Government will not pursue this question of closing down the institutions without first making sure, as he said he feels we ought, that the services are already in place in the community. We should halt the one until the others are in place. Perhaps we should also look at other legislation that is going through the other place and your Lordships' House which also affects the mentally ill and the mentally handicapped. The social security legislation, as I pointed out in another debate initiated by the noble Lord, Lord Banks, recently, makes the position immensely complicated. I have explained to noble Lords that the form of application for one benefit is now 17 pages long. It took me all day to help a person to fill it in. I cannot conceive that a mentally ill or mentally handicapped patient will ever be able to fill it in. They will need help.

We shall shortly have the community charge. We have many carers who are doing a great deal of work looking after mentally ill or mentally handicapped people. They are extremely concerned about what will be their situation under the new law, if and when it is finally enacted.

I am quite sure that I have said enough. If I sit down soon I may be able to hear the speech of Professor Priest from which I have quoted so often. It will be made in a committee room upstairs. I say once again that it is a very important subject, as your Lordships' House has shown many times. We have in our House the first chairman of the Mental Health Act Commission. The commission has done very interesting work. We have a new mental health Act, which has done a great deal to increase the rights of detained patients. However, psychiatrists point out to me that as a result of that Act, and very properly, much of their time is taken up in adversarial situations, pleading one or other side of an argument about the release or further detention of a patient, rather than in looking after patients.

The situation in this field is not wholly satisfactory, although I acknowledge, as do others, that it has improved vastly in recent years. But there is room for much more improvement. I hope that we shall hear soon a firm and definitive statement about what Her Majesty's Government intend to do about the recommendations of Sir Roy Griffiths.

4.8 p.m.

The Lord Bishop of Southwark

My Lords, I too should like to thank the noble Lord, Lord Basnett, very much for enabling us to talk and think about this subject today. I realise that I shall cover some of the same ground that has already been covered in all three speeches. It is almost impossible to avoid this with such a wide topic, but perhaps I can discuss it from a slightly different angle. I found the speech of both the Minister and the noble Lord, Lord Winstanley, very interesting and helpful.

There is a fascinating comment in paragraph 7 of the introduction of the report by Sir Roy Griffiths where he says: To talk of policy in matters of care except in the context of available resources and timescales for action owes more to theology than to the purposeful delivery of a caring service". The implication of that sentence, I fear, is that theology offers little help to those who have to get on with the job. Not so. Whatever the constraints—and we all recognise that they are considerable—those on the ground need to know in which direction they are trying to move and why. Otherwise there are real dangers in any walk of life, but notably in this field, that administration can become an end in itself and bureaucracy will ride triumphant over the weightier matters of justice and mercy and hope. Theologians are well aware of the constraints imposed by human limitation and human sinfulness, but that does not render their insights valueless.

I shall illustrate that. I believe that it is very important to preface any consideration of the proper care of mentally ill or mentally handicapped people with a consideration of why we are doing it and what we hope to achieve. Like the Minister I was a bit surprised to find that we are discussing both mental illness and mental handicap at one time, because they are still so often confused in the public's mind, whereas it is true that mentally ill people usually recover or at least achieve significant improvement with the help of modern drugs. So their needs are usually rather different, if only in timescale or physical mobility.

The General Synod of the Church of England debated the role of the local church in relation to the needs of mentally handicapped people in 1984. In the course of that debate many speakers stressed the importance of changing public attitudes towards those who are mentally ill or handicapped. There is still so much to do in helping each other to recognise our common humanity and none of us is as sane or as stable as we sometimes like to think. That is something to which the L'Arche communities bear conspicuous and moving witness. I can commend them to your Lordships as places which are really very moving and very encouraging. They are one way of helping the mentally handicapped.

In our discussion we recognised how difficult it can be to change attitudes at first, because of the many fears and prejudices that exist. Belief in the goodness and care of God for all his people helps us to sustain and develop that conviction about our common humanity and that we are in a deep sense all of equal worth, no matter how damaged a person's brain may be.

I have recently been in touch with the chaplains of several large mental hospitals which lie in my diocese. As one of them put it, what mentally ill or mentally handicapped people need to know above all else is, that they are accepted, they are loved, they are listened to, they are cared for". So the question is, as we have already heard, how best, with the help of all our modern medicine and economic wealth, can this be done?

That takes us to the debate about the relative merits and costs of care in the community or care in hospital. Within those two broad distinctions there are others. It is important to underline what has already been said: community care may mean—in fact it usually does mean—care at home by relatives, who are still the main providers. It may mean care in the small residential hostels, which may be purpose built and very good for that. It may mean living on one's own in a house or flat. Hospital can mean a huge Victorian mental hospital, albeit modernised in parts, and much has been achieved, as the noble Lord, Lord Winstanley, particularly emphasised. It may mean a psychiatric ward or wing in a ultra-modern district hospital, or—and this is important—it may mean a geriatric ward, not so marvellous, or a prison cell, and Brixton is a good example on my own doorstep.

Ever since the early 1960s there has been this strong pressure to empty the large mental hospitals and return people to the community, but what is now being recognised is that community care is a very broad term which can mean almost anything. It is far from proven yet that some forms of community care now on offer are an improvement on what patients had before in a more structured environment. Ethical questions arise about the quality of life which exists for the mentally ill or mentally handicapped and whether, for example, the supposed freedom which they now enjoy outside the institution is real freedom at all. What kind of freedom is it to sleep rough because there is nowhere else to go or, because someone is so confused and has fallen out of what little provision there was when he or she first came out, deliberately to break a window in order to get back into the relative warmth and security of a prison cell?

It is ironic that the number of mental hospitals we are closing at present is matched almost exactly by the number of prisons we are building. The savings may not be quite so great as we imagine. Security and a measure of control even in a large hospital can also mean—I do not say it always does and it certainly often did not in the past—a measure of affection, friendship and support which is not always available and certainly not automatically so in the wider community. We need to keep that in mind.

So the question of the quality of community care and the volume and use of resources to make it good is crucial to the whole debate, as the Minister pointed out very strongly. Cutting costs cannot be an end in itself. That is a profoundly ethical point. I should like to end by illustrating what I have been trying to say in a rather more general way and perhaps, as was also said in the earlier speeches in the same general way, by drawing on the experience of a relative of mine who died 18 months ago in her fifties. For many years Jean—I shall call her that—was a schizophrenic and she had spent many years in hospital. It was for the most part a rather poor, restricted life that she led there and she was not happy. Then, with the help of modern drugs, somewhere at the end of the 1960s or in the 1970s (I cannot remember exactly when) she went home once again to live with her elderly mother. The strain on both of them was very great. Her mother had to cope as best she could. Sometimes her daughter refused to take her drugs and became violent.

Apart from the little help that the general practitioner could offer—for the most part only on demand in a crisis—there was no trained support for either of them and some apprehension existed among the neighbours. Eventually that arrangement came to an end and it shows us clearly why drugs and discharge by themselves are not enough. Jean went to live in a part of the country where the health authority was one of the relatively few which were experimenting with a much wider range of support in the community. Jean had a place of her own in which to live. She had a patient and sympathetic GP who knew what to expect and did not mind the occasional bursts of rather irrational behaviour or demand. A community psychiatric nurse called regularly and a day centre was there, to which she went every week. There was also the availability of residential care for a week or two whenever she had a bad patch and needed some stabilisation.

For ten years she lived much more happily in that place, befriended by many neighbours and members of her local church. That is a picture of what good community care is all about. But it does require at least all those basic ingredients; without them it does not work. The Griffiths Report, if it is implemented in broad terms, will certainly help to target attention more effectively. I hope that that will happen, but unless the actual resources of trained nurses—and I do not think that has been much mentioned but it is extraordinarily important—and community psychiatric nurses, support for carers, the day centres and so on are also in place, and of course appropriate housing accommodation, we are doing mentally ill or mentally handicapped people no kindness by simply placing them in the community. In this, as in so many other things, there are no short cuts or cheap solutions. I am talking not just about money but even more about human care and, I would want to say, prayer.

4.21 p.m.

Lord Ennals

My Lords, it is a long time since we had a debate which concentrated purely on mental illness and mental handicap. I suspect there has not been one since the debates to which the noble Lord, Lord Winstanley, referred in connection with the 1983 Act. As a Member of the other place at the time, I was extremely grateful to your Lordships' House for making some improvements to that legislation. I wish the House equally well in dealing with other legislation still before us.

The debate takes place on the initiative of my noble friend Lord Basnett. I congratulate him on a very well-informed—in spite of his modest introduction—and sensitive speech which has produced most interesting contributions from the Minister, who introduced several additional issues, from the noble Lord, Lord Winstanley, and from the right reverend Prelate whose every sentence showed the tremendous human sympathy and understanding required in the debate.

We have now a very disturbing situation. On the one hand, there are public statements suggesting that mental illness and mental handicap are priority services and have been so for years and years. On the other, we have a situation of appalling human neglect, of which this House really must take urgent notice. The noble Lord the Minister gave some figures of expenditure including some increases. I suspect the increases—he was talking about community care—are mainly due to the increasing age of our population and the increasing incidence of senile dementia as well as the greater life expectancy of the mentally handicapped and the greater improvement rate of the mentally ill.

I became involved in this issue 20 years ago when, as a Minister, I had to deal with the report of the Ely Hospital in South Wales. That was the first of the "horror" reports on conditions in psychiatric hospitals for the mentally ill and the mentally handicapped. It was the first of many, awakening the government of the day—and the then Opposition too, because it was not a party matter—to a sense of urgency in dealing with the problem. All parties resolved that it had to be an issue of priority.

A start was made with new resources for improving old hospitals and building psychiatric wards in district general hospitals. My friend and boss at the time, Richard Crossman, played a very important role. Those involved then started to contemplate the planned reduction and eventual closure of old hospitals and the development of care in the community. I must say that I was a little disturbed to hear the Minister suggest today that it may be necessary to go slow on the plans for hospital closure. If he did not mean that, I will give way now to him. I do not want to misunderstand what he said.

Lord Skelmersdale

My Lords, may I intervene briefly to correct an obviously wrong impression. I did not in the least intend to suggest that we should go slow. I was suggesting that the policy should be strictly and rigidly adhered to. My own responsibilities include this matter. Where there is local argument over whether mental illness or mental handicap hospitals should close, this is something I look at most particularly.

Lord Ennals

My Lords, I am grateful to the Minister. I shall say what I was going to say in case he should come under pressure. It has taken a long time to initiate the movement towards hospital closure and the improvement of community services. It took a long time before the first hospital was closed in Banstead. If we turn our back on this, as I know some people are suggesting, it would be a terrible tragedy and we might not get the impetus again. I believe the emphasis must be on additional resources for community care.

Certainly, there is a severe problem of resources and of keeping a balance between the community services and hospital closures. Mental illness inpatient days have fallen by 20 per cent. since 1977 while expenditure on hospitals has increased by 7 per cent. in real terms since that time. This is partly because of increased unit costs as the number of patients has gone down. But as my noble friend said, the figures for local authority expenditure on community health services are moving nothing like so fast as the offsetting hospital rundown. To give one or two examples, day hospital and day centre places have risen by only 9 per cent. over five or six years and by only 9,000 in that period. In 1985, 24 local authorities still had no day care services at all for people with mental illness. The number of psychiatric nurses has risen, but only modestly. And that applies also to occupational therapists, of whom there is a gross inadequacy in the community. There is also the fact that housing provision has been greatly reduced as a result of the 60 per cent. cut in the housing investment programme.

A severe situation faces those who are discharged from hospital. An interesting question has been raised by the National Schizophrenia Fellowship. The director said: We badly need your help in asking Ministers what is actually happening and going to happen to people with a severe mental illness like schizophrenia. In 1986 25,000 people were admitted to hospital with schizophrenia, and of these 90 per cent. were re-admissions. Where were they between admissions—in the community of course—but where were they living and what care did they get?". We know too of the very severe problem, touched upon by the right reverend Prelate, of the increasing number of people who are discharged from psychiatric hospitals and become homeless. In 1983 over 170,000 households applied to local councils because they had nowhere to live; only half were provided with accommodation. Many more of course did not trouble to apply because they did not believe they had a chance. Many mentally ill people living in large hospitals are there only because they have nowhere else to go. Often when they are discharged into the community there is not the careful planning there is supposed to be. Many of them end up sleeping rough on park benches, in grossly unsatisfactory temporary shelters, or in old institutions with emergency bed and breakfast services. Some—I am afraid an increasing number—simply take their own lives. That is a terrible tragedy which should not be allowed to occur.

Several years ago it became clear that the mental health services were heading for a crisis. People were daily discharged from hospital into a community which was not adequately prepared to look after them. The consequences have been very serious. I have been looking at the evidence given to the Social Services Select Committee of another place. I should like to pick out at random some of the quotes in the introduction to the report. MIND told the inquiry: A number of inappropriate discharges from hospitals are taking place when no real support exists in the community to care for that person.". The Psychiatric Rehabilitation Association said: Many patients are being discharged to the community unable to cope with day to day living.". The National Schizophrenia Association wrote that most chronic schizophrenics: are returned to their 'families', if any. The rest are on park benches, in prisons, doss houses or seedy and rapacious lodgings". The Society of Clinical Psychiatrists wrote of: turning the mentally ill and unrecovered onto the streets, boarding houses, lodging houses, gutters and prisons.". So it goes on. The report was published during 1984–85.

Shortly after that the right honourable Norman Fowler decided to ask Sir Roy Griffiths to recommend a course of action. In December 1986 the Audit Commission published a report which made a reality of community care and documented the grim situation. That was taken almost as a basis of evidence for Sir Roy Griffiths' report.

Clearly this is not the occasion for a detailed debate on the Griffiths Report. However, some of the comments that have been made today cause me a great deal of concern as regards the timing. The Minister implied that the Government would not reach conclusions until after they had decided on the outcome of the NHS review. That is a very long delay. It is not merely a matter of what the Government recommend but of what Parliament will accept. Surely the Minister will not say that, for example, by the end of this year the shape of the National Health Service will be absolutely clear. I plead with the Minister and the Secretary of State because if they are saying that they will not respond to Sir Roy Griffiths' report until the future of the National Health Service is decided I believe that to be a grave and serious error. We cannot wait that long.

Sir Roy Griffiths pointed to local authorities as having the main responsibility. How can they plan if they do not know whether the Government accept that basic recommendation or will reject it? A debate in the near future is urgent and decisions should be taken before the summer if local authorities are effectively to take the action that is required. I have chronicled the year after year delay—the Audit Commission, the Select Committee and now Sir Roy Griffiths' report—but meanwhile no decisions are being taken. That imposes terrible problems not only on patients and authorities but on families and voluntary organisations.

I should like rapidly to pay tribute to the voluntary organisations: MENCAP; MIND; the Richmond Fellowship; the Mental Aftercare Association; the Mental Health Foundation, which has a major role in research and grant making; the various local and housing associations set up for this purpose and working closely with social service departments. I believe that the voluntary organisations co-operate well together. For example, MIND and the Richmond Fellowship are members of a joint working party on the quality of care, a subject which has already been touched upon by the right reverend Prelate. It is very much the actions and the success of the voluntay organisations that have brought about a change in attitudes which all noble Lords warmly welcome.

We must deal rapidly with the main recommendations of the report from Sir Roy Griffiths. I shall not now enter into the details but only touch on important aspects. I believe that funding will be the central issue. I suspected that in his comments the Minister was a little complacent about the funding situation. I believe that if responsibility goes to the local authorities there must be a major injection of funds to enable them to develop community care facilities. I am talking not merely of institutional and residential care but of the support that must be given to families to enable them properly to look after the mentally ill or mentally handicapped person living within the family. Such people impose an almost intolerable strain upon the family unless support facilities are available.

It is important to note that the need is not only for additional revenue funds. I have argued MIND's proposal many times. There needs to be a bridging fund to provide additional resources allocated specifically for local authority use during the move-over period before the National Health Service can spare any of the savings for local authorities. The Minister has not commented on that proposal but I hope he will do so in his final speech.

Other proposals have been put forward by MIND and other organisations but I shall not now take time to enter into them. I plead with the Minister for an opportunity to debate the matter in this House in order to look at a whole series of proposals not only from Sir Roy Griffiths but from responsible organisations. I also plead with the Minister to deal with the issue that was rightly raised by the noble Lord, Lord Mottistone, on 4th May. It was the problem of families and relatives not being informed when patients were discharged and therefore creating extreme difficulties. The Minister accepted the difficulties but did not suggest any way in which the situation could be resolved. How can local authorities and families of patients being discharged from hospital make proper provisions unless they know that they will be discharged? We sought to achieve that in the Disabled Persons (Services, Consultation and Representation) Act 1986.

Today we are calling for a greater realisation of the effects on the happiness and mental health of so many people in society. They are suffering because they are in inadequate or inappropriate accommodation either in the health service or local authorities. I hope that action can be taken quickly by the DHSS and Ministers concerned and that there will not be delays. We need a properly funded major initiative in order to establish care in the community for those who do not need a regime of hospital-based treatment. That cannot wait for another year or so. It is required immediately if we are to fulfil the responsibilities which we have as a community for the growing number of people, including those with senile dementia, at present under the care of either the health service or local authorities.

4.38 p.m.

Lord Campbell of Croy

My Lords, I should like to join other noble Lords in congratulating the noble Lord, Lord Basnett, on raising this important subject today. He has drawn our attention to the needs and problems of the mentally ill and mentally handicapped. He has rightly separated them because they are in different categories.

I shall concentrate on mental illness, which can afflict anyone who has previously been normal and mentally well. Although the illness can last for long periods there is a prospect of improvement or cure. However, mental handicap is normally the result of a defect in or damage to the brain. While a great deal can be done for the person, complete transformation to normality cannot be expected.

Both serious mental illness and mental handicap cause disability. When we refer to disabled people we must include those who are physically entirely sound but are unable to function effectively or rationally with their minds. During 1981, the International Year for Disabled People, some of us made special efforts to promote public awareness of mental illness and handicap. As some noble Lords will know, I was chairman of that year for Scotland. Unless the population are informed and ready to encounter mental illness in public places, they may well react unkindly to what they see simply as eccentricity, blankness or aggressive attitude in a stranger whom they meet or observe.

Thirty years ago and more, people suffering from serious mental illness were put inside institutions, out of sight. Here I emphasise that a complete change in treatment has taken place. This requires more public knowledge and understanding. Advances in medicine and treatment in recent years have made it possible for many mentally ill persons to live nearly normal lives outside institutions. They usually continue to need supervision and may be on a regime of tablets, medicines or injections. Some also need access to a refuge, even to hospital, if there is a relapse. They cannot be thrown into the outside world and left to fend for themselves entirely. Of course, what I have been describing does not apply to those who are dangerous to others or to themselves. Those are a small proportion, I am glad to say, but they must still be kept under restraint.

The fact that more of these people can live and circulate in the community is to be welcomed. It is better for them, unless they are suffering acute distress; and it relieves the burden on the resources of mental nurses, who are specially trained and need a high degree of dedication. They, too, of course are also needed in community care. At the same time, arrangements must be made for care to be available in the community for those who have come out of institutions.

Reference is sometimes made to the Italian experience. This is not the occasion to go into it. I shall briefly record that, by national policy, the hospitals and institutions dealing with mental patients in Italy were closed over a short period, and in some areas of Italy virtually nothing was done to cater for the patients so dispersed. That has been an object lesson to other countries which observed what then happened.

Besides the necessary community care, there should be widespread awareness of what is entailed. That would be our aim. I believe that a valuable service was performed in a series of articles by Marjorie Wallace in The Times newspaper about a year ago. The subject of her articles was the illness which is responsible for about one-half of the serious mental disorders in this country, that is, schizophrenia. I understand that the cause of that illness is still not known for certain, or understood, and that there is as yet no cure for it. Progress has been made in successful treatment to reduce its unfortunate effects. In the public mind, it is unfortunately still regarded as a kind of Jekyll and Hyde phenomenon instead of what it in fact is; namely, a severe and distressing mental illness. I suggest, as I have on other occasions, that parliamentarians would make a contribution to better understanding by carefully refraining from using the terms "schizophrenia" and "schizophrenic" in other, usually derogatory, contexts. My only minor criticism of the series of articles is of its title. It was called "The Forgotten Illness". In my view the illness was never recognised or known by most people outside the medical profession so it had made no impression for the public to forget. For me, it is "the misunderstood illness."

Descriptions have already been given by earlier speakers of the mentally ill living in desperately inadequate conditions, in no state to look after themselves, so there is no need for me to add to those descriptions. The Motion of the noble Lord, Lord Basnett, includes reference to the needs and problems of … families". That is highly relevant. There are far more problems for families with mentally disabled members than for those with physically disabled members. There are paradoxes, of which the public may not be aware. For example, schizophrenia does not normally strike and appear until the ages of about 14 to 16, and then it persists for life or for many years. The medical profession normally warns parents that the teenager concerned is likely to sever links with the parents as part of the illness and that that must be accepted by the parents. The advice given to them is that their presence, let alone any pressure, can make the condition worse. The result is that worried and willing parents are restricted in what they can do to help, and often cannot provide a home for the sufferer on doctor's orders. That is indeed a paradox that makes even more difficult the treatment of sufferers with that mental illness in the community.

I suggest that much more should be done to inform and brief officials and others whose work involves dealing with the public. This was illustrated by a case that the noble Lord, Lord Harris of Greenwich, raised in a debate on 4th March. It can be looked up in Hansard. Unfortunately, the case had a tragic ending—the suicide of a young man in custody. The behaviour of that young man while he was in custody exhibited the classic, easily recognisable symptoms of schizophrenia to anybody with any knowledge or experience of mental illness. It should be possible in future for such a case to be identified quickly as requiring medical, psychiatric attention.

I turn briefly to mental handicap. I wish to make one point. I believe that it is a mistake to generalise. Degrees of mental ability vary widely within the handicapped fraternity. I take as an example Down's syndrome. There are some who have great potential to enable them to live almost a normal life. It is wrong to assume, however, that they are all capable of reaching the same standards of attainment.

In making arrangements for Down's syndrome children, it must be recognised that some parents will have difficulties arising from complete inability to communicate by speech and from the problems of constant violence. In other cases the Down's syndrome child will be almost normal. One Down's syndrome family can have enormous problems requiring virtually 24-hour close supervision, while another can enable the child to live a near normal life. In both cases the parents will be devoted and caring, but the demands are of a quite different order.

A great deal remains to be done in spreading information and guidance about the mentally disabled. I urge the Government to play their part in full.

4.48 p.m.

Lord Thurlow

My Lords, we are privileged to have at the Dispatch Box the Minister whose special brief is specifically related to community care. We welcome this and wish him well.

Community care, as the noble Lord, Lord Ennals, told us, is very much under-rated in its requirements. I have had personal experience as a parent. I know the dangers, the risks and the embarrassments. I think that it is almost impossible to over-rate the problems that may ensue from any further escalation of the numbers of those who are coming out of the big institutions.

Looking back over 10 years we can acknowledge, as the noble Lord, Lord Winstanley, said, significant progress in public understanding. There has been a remarkable change. We are very grateful, as the noble Lord, Lord Ennals, said, to the voluntary organisations which are largely responsible for this. In particular, I should like to mention the National Schizophrenia Fellowship which does wonderful work in bringing us up to date. I am afraid the picture I still have is that, in spite of all the improvements and the increase in understanding, the amount of human suffering continues to grow. I believe that the numbers of patients are, if anything, increasing and likely to continue to increase. I am referring to the mentally ill and not to the mentally handicapped with whom I have had no particular personal association.

The Griffiths Report can be a milestone. We have had many excellent reports, as has been pointed out. But, in many ways, this report is different from its predecessors: it pinpoints a whole range of practical possibilities for action and does so in a very concise and forthright way. If many of the recommendations made in the report were implemented fairly quickly, this could create a revolution for many of the mentally ill. Sir Roy Griffiths has emphasised the fundamental need to have someone in a position to apply priorities and to see that those in need receive due care. There are so many overlapping authorities that it is necessary to have someone at the centre whose ministerial responsibility it is to keep track and to pull everything together, to encourage local authorities that are backward and to keep things moving generally.

In the other place on 31st March the Parliamentary Under-Secretary said that, we share the view that not enough resources have followed the patient out of hospital into the community". She continued: The 31 planned closures of large hospitals will help to put that right".—[Official Report, Commons, 31/3/88; cols. 1313–1314.] I do not follow that argument. Further "planned closures" imply a further great aggravation of the demand for community care which costs a great deal more per head if it is properly carried out with the right facilities and properly trained staff. It costs a great deal more per head than care in the big institutions. There still seem to be very great dangers ahead.

One of the main concerns is the number of separate services that all cater for different aspects of the problems of patients. For instance, the Griffiths Report proposes that the community care element of the social fund should be withdrawn from the social security system and the funds earmarked transferred to the social service authorities. We know that no department likes to lose part of its empire and one can see a ready-made scenario for the "Yes, Prime Minister" programmes. The Prime Minister calls in the Cabinet Secretary and says, "We have to stop this wrangle that goes on and on between the DHSS and the Department of the Environment", or whatever department is concerned; I do not point the finger at any particular one. Sir Humphrey Appleby draws himself up in his inimitable way and says, "Prime Minister, what a bizarre and what an amusing suggestion! As long as the departments disagree no clear-cut budget demands can be brought forward. The health vote is the main millstone around our necks. We do not want to do anything to make it easier to show that more money is needed. Oh no, Prime Minister, do nothing. That is the golden rule of bureaucracy. Let the departments argue forever".

That, of course, is an absurd caricature. I paint the picture simply to illustrate the strength of my view that there is—I am sure your Lordships will agree—a tremendous difficulty of continuing delay in a field in which the difficulties are so great. I can only express my earnest good wishes to the Minister in his work to try to knock heads together and get on with co-ordinated action.

There is an urgent need for more key workers to whom patients and relatives may turn. As we have been told, there are now 2,600 community psychiatric nurses. According to the estimate we need 10 times as many; that is, 26,000. That sounds a great deal and of course it is a very big increase. However, we have 60,000 staff working in the big institutions. One can consider the parallel of the military services and what must be done to remedy urgent requirements for specialised manpower. There are blitz programmes for training. If the need is accepted people will be forthcoming and training could be given.

I doubt whether public opinion, though it is much more alive to the problems than it used to be, has yet faced up to the unpalatable fact of the extent to which the costs of care in the community are greater than the costs incurred under the old system. For their part I hope that the Government acknowledge this change. In principle, are they prepared to make the extra resources available to local authorities to keep pace with discharges? If not, in spite of what the noble Lord, Lord Ennals, said, I hope that the programme of closures will be slowed down.

We now have an effective and quite-easy-to-understand blueprint. I hope that the Government will take hold of this and bring before us shortly a programme for new action.

5 p.m.

Lord Rea

My Lords, the fact that all is not well in community care for the mentally disabled has been made clear in the speeches we have heard. Even the Minister admitted this when he said that the Government were not complacent, which may be a way of saying that they are actually quite worried.

This disquiet is reflected in a recent crop of reports on the subject. The most recent is the Griffiths Report. There is also the Wagner Report on residential care in the community. It is a long report. The book and the lyrics are very good, although they may not be to everyone's taste. Those are perhaps suitable Wagnerian characteristics. At the end of last year there was the widely praised Audit Commission report.

To me the document that best summed up the problem and made the most sensible recommendations was the report of the Select Committee on Social Services of another place on Community Care for the Mentally Ill. The evidence was taken in 1984 and the report was published in 1985. It should be remembered that the committee had a Conservative majority and that at the time of its inquiry into community care one of its members was Mrs. Edwina Currie.

Perhaps I may give a few quotations from the report. On costs, paragraph 21 said: A decent community based service … cannot be provided at the same overall cost as present services … We are at present providing a mental disability service which is underfinanced and understaffed, both in its health and social aspects". The Minister of Health at the time—I cannot remember who it was as different ones have moved past our eyes very quickly; it could have been one of two but I am not sure which—was quoted as saying that, "If the functions of a hospital facility which has been greatly underfunded in the past are transferred to community care the cost will go up". In the light of those statements the request by MIND for £500 million of additional money over five years as part of its response to the Griffiths Report seems entirely reasonable.

As a practising general practitioner in inner London I find that the policy of community care has provided us with more experience of dealing with the continuing care of seriously mentally disabled people. We have found it more difficult to get acutely mentally ill patients admitted, but if they are admitted they bounce back again quicker. It is not so much long-stay patients being discharged into the community who provide the problems—in many cases, at least in Camden, they have so far been reasonably well cared for—but those who should have been in the long-stay category but never stayed in hospital long enough to qualify.

The population of mental hospitals has gone down from 131,000 to 60,000 in the past 20 years, but much of that reduction has been due to natural wastage. I do not mean that those tall chimneys emitting black smoke are used to dispose of the elderly inmates of those institutions. I refer to death from natural causes. At the same time there has been a limitation in "starting off" new patients as long-stay cases. It is the short-stay but possibly severely ill cases who give rise to most anxiety and for whom provision is least good.

Paragraph 24 of the Social Services Committee report states: The almost obsessive concentration in public policy on the mechanisms of 'getting people out of hospital' has sometimes obscured the basic fact that most mentally ill or handicapped people already live in the community … A common claim is that 90 per cent. of care is provided by hospitals while 90 per cent. of the patients are in the community". It may have changed a little since 1985 but I doubt whether it has changed by more than 1 per cent. or so.

It is worth looking at the term "community", which suggests that there is a caring body of people ready and able to take on the role of nurturing mentally disabled people when they are cast into their midst. In the case of patients being in their own families, this has always been so. As other noble Lords have mentioned, families still provide most of the care available in the community, but it is often a severe burden for them.

Providing care for people who are not related to you is a very different matter. Such people are not welcomed. In fact, resistance to small residential units is often manifest, as the Minister pointed out. Community care can be a euphemism. At worst it can mean dumping mentally ill patients on to an unconcerned or even hostile population, or requiring families to provide 24-hour care to their sometimes difficult and unpredictable relatives. A somewhat cynical view of a psychiatrist friend is that community care is a form of "newspeak." (It is perhaps interesting that the social services report which I mentioned was compiled in 1984.) I do not want to be unduly pessimistic. The concept of community care is a good one. It is just that, to be effective, it needs adequate resources not only in terms of bricks and mortar but also in adequately trained staff. If skilfully handled, many community organisations can and do make a significant contribution. I am able to report a success story, in that my own practice has assumed responsibility for the care of eight residents in a hostel recently opened in Camden through combined funding. It is for patients discharged from Friern. It works well, though some of the residents still have to return all the way to Friern for daytime occupational therapy. It is also a pleasure to record how productive team work with community psychiatric nurses has proved to be, especially with some of our most disturbed patients.

Many of the "free living" mentally ill patients are in need of much more in the way of day care facilities. Some of these were mentioned by the Minister. It sounded an impressive list but they are by no means evenly distributed through the country. We need many more of them. The community psychiatric nursing service is crucial to the success of the community care policy. In this respect I echo the noble Lord, Lord Thurlow, and should like to ask the Minister for information about how this branch of the nursing profession will grow in the future.

I am aware that some nurses who are transferred from the psychiatric hospitals can be retrained to work in the community but in fact the community psychiatric nurse, working outside a hospital, is a new and rather special type of nurse; such people are invaluable in this whole move into the community. We are told that there is something in the region of 2,000 to 2,500 at present. A desirable ratio, as a minimum, would be one per 10,000 of the population, which would mean 5,000 or 6,000 throughout the country. Indeed, the noble Lord, Lord Thurlow, actually mentioned 26,000 as being an even more appropriate figure. I would be most interested to hear what the noble Lord has to say about the matter.

While on the subject of nursing staff, I should like to voice the disquiet felt by both the psychiatric and the mental-handicap nurses in the Royal College of Nursing. They feel that the Griffiths Report has not given sufficient weight to the part which psychiatric nurses should play in the planning and the operation of community care. I must say that I think they are right, especially as social workers since the—to coin a nasty word—"genericisation", or the reorganisation, which followed the Seebohm Report have lost some of their mental health expertise. Of course I hope that with the increased length of training for social workers, which has not been agreed, some of that expertise will be recovered.

There is also much anxiety among the nursing staff of the psychiatric hospitals about their future redeployment, especially with regard to their pension rights and security. I think the Government should fully meet those concerns.

I have not talked about the mentally handicapped because on the whole their health care needs are less than those of the mentally ill, if—and it is a big "if"—they are in a stable and caring environment. In fact, as a doctor, I find most mentally handicapped people easier to deal with than some patients who are supposed to be psychiatrically normal. Nevertheless, their physical care is of the utmost importance as they are a most vulnerable group.

As we all know the mental health service is often called a "Cinderella" service. We should not forget that Cinderella left a slipper behind at the ball, which eventually led her to riches and happiness. I do not think that we can ever expect a "happily ever after" solution to mental health problems. However, some robust footwear may be in the hands of the noble Lord and in my view that could at least alleviate much of the current distress.

5.14 p.m.

Lord Mottistone

My Lords, notwithstanding the encouraging remarks that we have just heard from the noble Lord, Lord Rea, I do not believe that I am exaggerating when I say that there is a crisis in our midst in some parts of the country, especially with regard to the mentally ill. Although more will always need to be done for those people, society at large seems to have become aware of the needs of the mentally handicapped. Thus I propose to concentrate my remarks on the mentally ill in general, especially those suffering from schizophrenia.

As Marjorie Wallace said in her illuminating articles which have appeared in The Times over the past two years, Schizophrenia is the forgotten illness", although my noble friend Lord Campbell of Croy might prefer the phrase "the misunderstood illness".

Two and a half years ago I initiated a debate on just this subject and I am therefore deeply indebted to the noble Lord, Lord Basnett, for bringing the matter once again to your Lordships' attention. The debate will help to ensure that the illness is not forgotten or misunderstood. In the previous debate practically all the speakers, including myself, sought to bring home to the Government that the policy of closing mental health beds faster than care in the community was developing was placing an intolerable burden on the sufferers from schizophrenia and on their families. However, the situation is now worse in some parts of the country and it is a tragedy that the Government have not done more during the past two and a half years. I am sure that they have done some things, and I am sure that they have done their best to allocate some of the money, but it has not been enough. The problem stems from the fact that care in the community is provided to a large extent by local authorities and not by the health authorities.

The noble Lord, Lord Ennals, in a most powerful and impressive speech gave examples which emphasised the need to speed up care in the community. The information he gave us has assisted me in that I do not need to waste so much of your Lordships' time. However, while I entirely agree with what he said, I did not find it consistent with his almost equal emphasis on not slowing down the closing of beds. I agree that it would have been better if care in the community had progressed faster, but it has not done so. Therefore it is a terrible mistake to close the beds down at one rate and have the provision of care in the community progressing at a totally different rate. So the noble Lord's insistence on not slowing down on bed closures is inconsistent with his general approach, which I applaud.

Lord Ennals

My Lords, what I was really saying was that the priority should be to do what we have to do as regards community care and not to take the easy course, which is to slow down the whole procedure.

Lord Mottistone

My Lords, I shall not pursue the argument. I have made my point and I think the noble Lord has probably made his.

During the period between 1975 and 1985 the shortfall in replacement for closed beds by places in the community both in day care and residential came to a total of about 32,000. Indeed, I think my noble friend the Minister mentioned that fact; he implied that that was all that was necessary. However, I am advised that the number of cases of schizophrenia has not decreased by anything like that amount. Some of those people may now be more capable of living in the community than they were before 1975, but that does not mean to say that the total problem has gone away. The figure of 32,000 is a measure of the addition to the problem for families and sufferers, which was already intolerable for many of them before 1975. Therefore, it is not at all satisfactory at this stage to allow health authorities to grind away at shutting down beds in hospitals when they have not made absolutely certain that there was suitable provision in the community.

However, those country-wide figures cover a wide variation of family burdens. Some parts of the country are faring better than others. I am lucky that the Isle of Wight—although of course more could be done by both the health authority and the county council—seems to be meeting the need better than most. That is partly due to the fact that the two authorities deal with exactly the same area—to wit, the island. That is where we are lucky.

I hope that when the Government come forward with their expected overall new proposals for the NHS—I make this strong recommendation to my noble friend—they will include the rearrangement of health service geographical boundaries to coincide with those of the counties and districts. It would make a tremendous difference. I know from experience that it will make for much better coordination of effort. My noble friend mentioned that point and I say that this is the way to do it. It is possible that he and his colleagues have not thought much about the matter. I strongly urge him to do so. It will also help to achieve greater understanding with a third party whose unseen efforts to assist in coping with the mentally ill do not receive the recognition they deserve—namely, the police—whose own boundaries generally accord with those of counties.

When a schizophrenic is discharged from hospital, refuses to take his or her drugs and rejects family help, an all too common experience, he or she often breaks the law in desperation to obtain some sort of care. By chance, last weekend I read in the Isle of Wight County Press of a case which illustrated that point. A 39 year-old chronic schizophrenic threw a brick through the window of an elderly person's flat. The magistrates were told that he had been discharged from the local mental hospital a year or so previously to share a home in the community with five other former patients. He did not settle down in that environment, because the brick throwing was one of several similar cases during the previous year. The object, so the newspaper reported, was to get back to Whitecroft Hospital, our local hospital, or into prison where he could be cared for.

The newspaper article concluded happily by saying that he now felt comfortable in a new home with other former patients. Let us hope for his sake, and that of the police, that that position will continue.

That example shows that community care does not always provide asylum, even when the accommodation has been reduced to five former patients. Our director of social services was telling me the other day that they had one home built to take about 30 former patients. They found that the schizophrenic patients would not stay there because there were too many of them. They now have about 20 carefully selected landladies who take in not more than five schizophrenic former patients. They try to handle those patients in that way.

It is an experiment which shows that the earlier provision did not work. That is another reason why we must be flexible and why having the two community care sources, health and local government, together can achieve that solution much better than when they cross boundaries. That example also shows that the police often have to treat as criminal cases those for whom medical care has been withdrawn and to provide the care for a mental patient which should be met by health or social service workers.

To conclude, I return to the families. The families founded the National Schizophrenia Fellowship some 16 years ago so as to share their problems. It has made great advances, especially in the past five years, establishing a network of branches all over the country. It is doing its best to raise funds with minimal resources. I have joined with others to found a parallel fund-raising campaign entitled SANE (Schizophrenia, A National Emergency). That organisation seeks to make people aware of the seriousness of the problem and to gain a basic sympathy for schizophrenics as a way of raising vast sums for research and for carers.

Thirty years ago people dared not speak of cancer and sought to ignore, for example, the mentally handicapped. The community now has a much healthier and more sympathetic view of both types of sufferers. Last year, for example, the Isle of Wight hosted the special Olympics, which provide international competition for the mentally handicapped. Her Royal Highness the Duchess of Gloucester most graciously came to those games and it was a joy to see how loving she and others were to the friendly advances of mentally handicapped people.

A similar ready acceptance of the mentally ill is not so forthcoming from the community as a whole. I can understand that because in some cases the mentally ill can be frightening. We need to achieve that acceptance; but in the meantime the pressure on patients and families, as I described earlier, remains and the NSF in particular desperately needs more of a share of funds from government sources to enable it to develop its resources now while charitable interest slowly develops. It responds to over 6,000 calls for help a year nationally, plus many more locally.

Out of the £1.2 million DHSS budget for voluntary mental illness organisations, the NSF receives only £83,000. Other new organisations, such as the Manic Depression Fellowship, which also deserves to be funded scarcely get a look in or receive very small grants. However, among the numerous small and very small grants given by the DHSS for mental illness the grant for MIND stands out. It is £415,000, which takes over a third of the entire budget. MIND receives three times as much as the next organisation—the Alzheimer's Disease Society—which receives £120,000, after being given special priority by my noble friend. That seems to be an inequitable sharing of resources. I hope that my noble friend will be able to rectify that position in future years.

As well as contributing more fairly to the burdens of those fledgling charities in their early years from whatever sum can be made available, I emphasise to my noble friend that a substantial increase in the overall budget to get those worthy charities for a hitherto unpopular problem in society off the ground could be a worthwhile investment for the future.

5.26 p.m.

Lord Allen of Abbeydale

My Lords, this is a debate on an important topic. We are much indebted to the noble Lord, Lord Basnett, for arranging it, even if it seems to have attracted an attendance a little less than we had about 24 hours ago. I propose to limit my remarks in the main to the mentally handicapped. Perhaps I may be permitted to start on a personal note. I recently succeeded the noble Lord, Lord Renton, as president of MENCAP, having followed him previously as chairman of MENCAP. I should like to take the opportunity to pay tribute to the work that he has done over the years on behalf of the mentally handicapped, not least in reminding your Lordships from time to time of their needs and problems.

I find it a little sad that not all the members of the noble Lord's party have listened to him. Like many of us, I looked at what was said in the Conservative Party Manifesto about poll tax. I read that it was to be a fixed charge for local services paid by those over 18, except the mentally ill and elderly people living in homes and hospitals. I am afraid that it stands out a mile that the author did not have the slightest idea that the phrase "mentally ill" did not cover the mentally handicapped.

It is interesting to recall that when we were discussing the Bill dealing with the Scottish poll tax the Government agreed to an amendment exempting the severely mentally handicapped. Incidentally, there was no hint of protest from anyone that the House was exceeding its proper functions. When subsequently the English Bill was introduced, it contained a comparable provision about the severely mentally handicapped; but, hardly surprisingly, not a word differentiating the mental illness of the manifesto from other forms of illness.

That lack of knowledge of what is a simple, basic issue is the more disappointing in that in 1981 the Conservative Policy Group on Mental Health produced a rather good report. It enunciated two underlying beliefs. The first was that life was not nearly as good for the mentally handicapped as it could and should be. The second was that there were ways in which the lot of that substantial section of the community could be improved. In the seven years since, has life for the mentally handicapped become as good as it could and should be?

There have been changes. As has been explained, there has been a greater public awareness, but I am afraid that it is still not possible to answer that question with a resounding affirmative. It is not that the Government have done nothing. No one who heard the noble Lord, Lord Skelmersdale, could possibly maintain that. He can properly point to a number of legislative and other changes for which the Government can rightly claim credit. One is still bound to ask whether enough has been done or is in prospect. The uncomfortable fact remains that there is a widespread belief among the mentally handicapped and their families that their problems are still not understood and that there is an inadequate appreciation of the need to foster their independence and their right to a life as nearly normal as possible with the freedom of choice which is open to more fortunate citizens.

In the next few minutes I shall try to explain some of the reasons that uneasiness and discontent are so widely felt despite the various steps which have been taken. Perhaps I may start with the subject of education. First, as the noble Lord, Lord Basnett, reminded us, in Britain there are something like 1.2 million people with some kind of mental handicap. Of these, perhaps 160,000 are severely mentally handicapped and some 60,000 of those are children. Of the severely mentally handicapped, about one in three has a sensory or motor disability in addition to permanently impaired mental ability. It is a small wonder that there was a very warm welcome for the Education Act 1981 following the Warnock Report and heralding, so it seemed, a new dawn for those with special educational needs. However, the working of that Act has so far proved to be very patchy. For example, one local education authority in the course of a year issued statements for 1,200 children, whereas another managed a miserable 25. Waiting periods for well over a year for the completion of statements are not uncommon. The Government are well aware of these imperfections but the noble Baroness, Lady Hooper, at col. 1125 on 11th May, could offer no more than a review of the Act later this year.

This happens to be one of the few days on which we are not talking about the Education Reform Bill and I do not propose to do so. However, against that background it is not surprising that the discussions on the Bill have caused a good deal of anxiety lest children with learning difficulties will be put at even greater risk than hitherto of finding themselves outside the main stream, and anxiety about the effects of opting out on those children. It has also been noted that although the Government have made a number of proposals affecting these children, some of the more important ones were not in the Bill as originally introduced.

I next turn briefly to the history of the Disabled Persons (Services, Consultation and Representation) Act 1986. That Act received Royal Assent in July 1986 and some of its most important provisions, including the assessment of those coming from long stay hospitals, have still not been implemented. I am in no doubt that the noble Lord, Lord Skelmersdale, will be ready to remind us yet again that the Government have always said that implementation must wait until resources are available. However, many people are increasingly asking why, when we are nearly two years on and the Government say that they are serious about care for the disabled, there is still a failure to provide the comparatively modest resources which will be needed.

I turn now to the Local Government Finance Bill. Again I have no intention of embarking on any detailed discussion of that Bill today—not even the definition of "severe mental handicap". However, I must make the point, echoing something said by the noble Lord, Lord Ennals, that the prospects are viewed with alarm by many parents in the community who have grown up children living at home who do not qualify as "severely mentally handicapped". There is also anxiety on the part of individuals who find the prospect of the tax something of a deterrent to any plans for independent living—a policy which they thought was looked on with approval by the Government.

Looking at the noble Lord, Lord Carter, I must return for a moment to yesterday's Question about the Independent Living Fund. I believe it is conceptually wrong to take the payment of benefit outside the statutory system but, apart from that, there are still many unanswered questions about this fund: how long is it to last and so on? Apart from anything else, it was not ready when the statutory changes were made last month.

I do not want to add anything to what has been said about care in the community, particularly on the very day when a report on this topic has been published by the Public Accounts Committee in another place. It is a somewhat critical report and to me made rather uncomfortable lunch-time reading. However, as it seems to be the fashion in this debate to quote Sir Roy Griffiths perhaps I could have my pennyworth and refer to the passage in which he states that although community care has been talked of for 30 years, in few areas could the gap between political rhetoric and policy on the one hand, or between policy and reality in the field on the other hand, have been so great. I recognise that the recommendations of the Griffiths Report are not free from controversy and are likely to give rise to a good deal of argument. However, I go along with the hope that something will soon be decided, and I noted the commitment into which the Minister entered when he spoke earlier this afternoon. It has been observed that the report was not received by the Government with any great fanfare of publicity.

I could go on, but I shall content myself with one more addition to my cumulative list and that is the instruction to those operating the social fund to consider whether charities may meet an applicant's needs with the implication that charities may now be looked to in order to finance public policies. I know that this is not a new point but it is still causing anxiety among some of those who believe that they pay tax and national insurance contributions in order to ensure that statutory help will be available to those in need.

I have tried to highlight a few areas where there is disquiet and apprehension among a sizeable but inarticulate section of the community. I appreciate that others beside the Government have responsibilities, including local and health authorities. I also believe that the commitment and personal attention which the Minister has given to these matters has been widely appreciated.

I believe that the Government have compassion for the less fortunate members of society and wish them to share in the nation's rising prosperity. I believe that they have a social conscience. The trouble is that they do not always show very much imagination in seeing how their policies will work out for some, and they continue to look as though concessions are being forced out of them when they run across difficulties raised by other people which one would have thought they might have foreseen for themselves. There is certainly an impression that they are not over-generous with resources for the kind of problems that we have been discussing.

In the time at my disposal I shall not attempt a measured assessment of the Government's performance, diagnostic, formative or summative. But perhaps a more old-fashioned end-of-term report might have read something like this—"in the end has the right approach and tries hard but is not very imaginative and finds it difficult to keep up; could do better".

5.40 p.m.

Lord Prys-Davies

My Lords, we are very grateful to my noble friend Lord Basnett for giving us this opportunity of discussing this important subject. We thank him for his comprehensive review of the problems of the mentally handicapped and the mentally-ill patients and the problems of their families and for presenting that review in an outstanding speech.

I think that one of the crucial messages which emerges from the debate is as follows. The sensitive and difficult process of change from hospital care to community care, which we welcome, is running into problems in many parts of the country. That is because the development of community facilities is not keeping pace with the run down of large mental hospitals or their closure.

The noble Lord, Lord Mottistone, speaking from the opposite side of the House, produced very telling figures to show that as the result of the run down and closure of large hospitals there is by now a huge shortfall of places in day hospitals and local authority day centres. In the result, a substantial part of the burden of looking after patients who were formerly accommodated in hospitals, or who would have been formerly so accommodated, is now too often shouldered by parents and families without adequate facilities in support.

Again, we have been told this afternoon by many speakers that some patients are very lonely in the community at large when they find themselves in substandard hostels or bed-and-breakfast hotels without adequate support. We have been told that a small number end up on the streets or railway stations or even prisons.

When we write as we do from time to time to Ministers questioning the imbalance between hospital care and community care we are repeatedly told that the Government's policy: is not the running down and closure of hospitals, but better provision for individuals according to their assessed needs". That is the stock answer which I have received over the past two years. But to many parents, families and to some voluntary organisations the reverse appears to be the case. It appears that there is a gap between the stated policy and the reality as it exists.

The National Schizophrenia Fellowship is not aware of any evidence to back up the Government's claim that there is no imbalance between hospital care and community care. According to the Royal College of Nursing it is evident: in many parts of the country that community care facilities are not operational when the long-stay institutions have been closed". This conclusion is consistent with a number of authoritative reports published since 1985 including the report of the Public Accounts Committee published today.

But while the Government now seem to accept that community care is not a cheap option, they have yet to accept the need for additional resources on the scale required during this difficult crossover period when both the hospital and the community services have to run in parallel.

When I wrote to the noble Lord, Lord Skelmersdale, last year about the problems of a particular hospital for the mentally handicapped, he gave me this answer in his letter of 13th July: The original plan would have taken a number of years to achieve the transition to community care, [it] would have presented difficulties for maintaining services and would have been financially wasteful in keeping parallel provision in both the hospital and the community. That was a frank answer, as one would expect from the noble Lord, Lord Skelmersdale, whose contribution in this field is appreciated by all Members of the House. But one has to keep the hospital facilities and the community facilities for some time to come both available for mentally-ill patients and mentally-handicapped patients.

If the bridging costs, although they may appear to be financially wasteful, are not made available, one finds oneself in the position that on the one hand one cannot allow expenditure on essential improvements to a hospital for those patients who require high dependency because the hospital has no future and therefore its condition worsens. But on the other hand, one cannot spend as one would wish on building up the community facilities because one has to maintain the hospital facilities. So at the end of the day this particular problem is essentially a problem of shortage of money. This is a problem which only the Government can solve. But it can be solved given the will.

I strongly endorse the powerful plea made by my noble friend Lord Ennals that significant bridging funds should be made available during this difficult crossover period in order to build up the services which are required. I trust that the Minister will be able to comment on my noble friend's plea when he comes to reply to the debate.

In view of the great difficulty of hospitals running down their services before provisions are available in the community, I would urge the department to make it mandatory on health authorities to satisfy themselves that sufficient care facilities are available locally before they discharge more patients from their hospitals to the community.

Lord Winstanley

My Lords, I am interested in the noble Lord's argument all of which I support. I am also interested in the question that he has just put to the Minister. But I hope that in elaborating his argument the noble Lord will bear in mind that the difficulty is that the catchment area of some of the large institutions which are to be closed is so wide that one does not know to which community discharged patients will actually go. They do not all go to one community or to the immediate locality of the hospital. If they did, things would be much simpler. But what one does find is that as a hospital closes so some of the long-term patients go to far flung parts of the country in very different areas altogether.

Lord Prys-Davies

My Lords, that is a fair point. Whether the patient is to be returned to a local community or a distant community, the health authority ought to satisfy itself that the facilities are available.

I anticipate that the Minister may answer by telling us that the department has already made it known in either the 1985 circular or the 1986 document that patients should not be discharged before facilities are available in the community. He may plead either the circular or the document. To that answer, we reply that all too often the circular and the document are overlooked. We ask the department to consider taking the further step of making it mandatory for health authorities to satisfy themselves that the facilities are available. It is essential that the imbalance should be corrected. Otherwise, with 28 hospitals for the mentally handicapped scheduled to close between now and 1990 and about 35 large mental hospitals scheduled to close between now and 1995, the imbalance could undermine public confidence in the policy of community care, not only as a practical proposition but also as a philosophy.

Turning to an allied matter which has been touched on by a number of speakers, where the facilities which are required are not available either in hospital or in the community, a heavy and unfair burden is put on families who care at home for the mentally ill or mentally handicapped. There are distressed parents and families who undertake such tasks 24 hours a day for 365 days a year with inadequate support. In far too many districts there is a dearth of short-term respite facilities for families. Will the department press the regional authorities to consider how they can best ensure the provision of respite facilities for those hard-pressed families, and encourage the setting up of such facilities in districts within their regions? I hope that that item can be placed on the agenda.

Another worrying matter is that parents who are now in their 50s, 60s and 70s may be worried about what will happen to a son or daughter when the surviving parent dies if there are no care facilities available. Mr. Jackson, the chairman of Rescare, writes: The disturbing question that hangs over all caring parents is, 'What will happen when I die and am no longer here to care?' And the disturbing fear is that the son or daughter will ultimately be left to wander the streets unkept, unwanted, abused and exploited". I am not sure how best to answer Mr. Jackson's difficult question in the short-term and in the absence of residential services for such a son or daugher. It has been suggested to me that the department and its lawyers, possibly with the help of the Charity Commission, should consider setting up a national trust or encouraging others to set up such a trust. Although it would be difficult, the trust should be charitable. Parents could bequeath to it their estate or the proceeds of sale from a home to be applied for the benefit of a son or daughter during his or her lifetime in addition to statutory support. Thereafter, proceeds could be applied for the benefit of the orphaned mentally ill or mentally handicapped.

Lord Mottistone

My Lords, perhaps the noble Lord might like to suggest that such proceeds should be sent to the new charity which I mentioned, SANE.

Lord Prys-Davies

My Lords, I am grateful for that suggestion. I shall consider the matter and possibly offer advice on the basis of that intervention.

We are all conscious that there are a number of important gaps in the services which do not make headline news. Services for some small goups of patients are sadly lacking in many parts of the country. One such group is the 80,000 autistic persons who have many unmet needs. I understand that in many parts of the country, early diagnosis of the condition is inept and treatment is lacking or inappropriate. The National Autistic Society, which has a well-proven track record in the field, and its local societies, such as the South Wales Autistic Society, which I support, have during the last 20 years provided 16 schools and 19 adult centres. Their education programmes are yielding rewarding results. Yet those schools and centres care for no more than about 1 per cent. of autistic people. More research to establish the cause of the illness is urgently needed. More residential schools and centres are also urgently needed. I urge the department, possibly in conjunction with the DES, to consider what assistance it can give in that direction.

In the course of our debate there have been many references to voluntary bodies which are working with other such bodies and with the statutory bodies and local authorities to improve services for the mentally ill and the mentally handicapped. They do a tremendous job. They bring support, understanding and hope to thousands of people. However, the voluntary organisations are handicapped—some more than others. They are handicapped by a shortage of funds. Will the department fund those organisations more generously in order to help them in their work for the mentally ill and mentally handicapped? That is my last plea to the department, at least for today.

5.58 p.m.

Lord Skelmersdale

My Lords, this has been an invaluable debate, as I envisaged in my previous remarks. I am very grateful to the noble Lord, Lord Basnett, for initiating the debate and to all noble Lords who have spoken in it. However, it oocurs to me, as I stand to wind up for the Government, that, as the noble Lord, Lord Winstanley, predicted might happen, we have had many equations today but remarkably few solutions. If I had hoped for guidance from the debate on how to conduct my responsibilities in the area, I would be to a great extent a rather disappointed man.

Indeed, anyone coming new to the subject would believe that the problems of long-term patients coming out of hospital are the same as those of patients who come from normal family homes and who go for short stays in hospitals for treatment before coming out again. The media constantly make that mistake. Reference has been made this afternoon, for example, to the recent Esther Rantzen programmes on this subject. One of the first television programmes in which I took part when I took up this particular responsibility was one of Roger Cook's. In both those sets of programmes these mistakes were made.

In my travels around the country—on average one day a week during the time when Parliament is sitting and, I am glad to say, three days a week when it is not—I have discovered that the problems are quite different. In the past, I admit, there have been difficulties with the discharge policy proceeding too fast. I do not believe that that has been the case over the past two years.

Restricted community care—which is not supposed to be a new catch phrase but I hope explains what I mean—is in good shape in most health authority areas. However, the problems occur where there are ex-short stay patients or those whose stability in the restricted sector (as I have called it) has become such that they have decided to move into other accommodation. If it is properly conducted that is the ultimate in community care; people move from the ultra care situation into more and more limited requirements for personal care. It is there that the problems really arise.

As I implied earlier, 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. I was interested in and I take the point of my noble friend behind me concerning what is termed in the jargon "coterminosity"—in other words the same geographical areas of local authorities and health authorities. I admit that there is a lot to recommend it. However, it is not necessarily a logical decision but a highly political decision as to whether coterminosity should apply in those parts of the country where it does not occur. Although applied for the best of reasons, it upsets a great many people. Indeed I seem to remember that a previous Conservative Government is believed to have lost a General Election because they were so brave as to muck around with county boundaries. I should not like that to happen.

However, there are ways in which central government can make a direct contribution to the development of community care projects. For instance, under our mentally handicapped children initiative we have made available to health authorities and the voluntary sector a total of £11½ million to help finance projects aimed at moving mentally handicapped children out of hospital into more suitable forms of care. Some 340 children have been helped directly through that initiative. Equally important, our initiative has played an important role in helping to demonstrate to authorities what can be done. The number of children in large mental handicap hospitals has fallen from 2,400 in 1980 to below 400 at the end of 1986. Most authorities have plans to make alternative provision in the near future for those remaining.

What else can central government do to help? There is, as we all know, no magic wand that we can wave. But we can and we do encourage health authorities. The regional review system enables the National Health Service 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 we look out for, or rather the absence of it. In the review process we tackle regions if there seem to be problems.

The noble Lord, Lord Basnett, asked the crunch question at the beginning of the debate: how many mentally ill and mentally handicapped people are we talking about? I regret to have to tell him that that is not known in any definitive sense. Hospital admissions and discharges are known but I assume that the noble Lord was referring mainly to those in the community. It is estimated that there are 50,000 to 100,000 people in the community who are chronically disabled by mental illness, and that schizophrenia affects about 1 per cent. of the population. We shall have a guide certainly to the numbers of mentally handicapped and I hope to an extent to the mentally ill when we receive the reports of the Office of Population Censuses and Surveys, the first of which is expected later this year.

Not surprisingly most speakers in the debate have referred to the Griffiths Report. I should like to say particularly to the noble Lord, Lord Ennals, that I understand his impatience. But I think that it is much more important to get it right than to get it fast. Anyone would have thought, listening to the noble Lord's speech, that absolutely nothing is happening in this field and that there is a great hesitation while we await consideration of the Griffiths Report, Lady Wagner's report and the interaction of the two, and the possible results of my right honourable friend the Prime Minister's review of the health service.

I suspect that the noble Lord moves around the country to an even greater extent than I do. He will know that all kinds of units are being built in the community. There are very impressive schemes in some parts of the country which we should all like to see duplicated elsewhere. It strikes me that many of those schemes are new. We will not put a stop to the innovation that is taking place around the country if we wait a little longer for the Griffiths Report and, as I said, get it right.

I should like to make two points about the Griffiths Report. For many years local authorities have been resistant to central government moneys being targeted at and spent totally on the services for which they are provided. It is my personal belief that local authorities are changing their ideas. However, before the Government come down on one side or the other in this matter, we must obtain the views of the local authority associations. I am very conscious that the people who run local authorities are elected locally. It is only right that they should have a major say in this decision.

As far as concerns which Minister, if any, should do the job and in which department he or she should be situated, the noble Lord, Lord Thurlow, gave us an amusing caricature of what may or may not go on in No. 10 Downing Street. He is right in one sense because it is indeed in the gift of my right honourable friend the Prime Minister to decide who and which department does what.

To come back to the central points of the debate, the noble Lord, Lord Winstanley, pressed for an indication of the Government's response to the Griffiths Report. All I would add to what I have just said is that I shall not ask my right honourable friend to rush his response, for the reasons I have given.

Local authority funding of mental health services was mentioned. I believe that we cannot look at that issue solely in terms of increased rate support grant support. Questions of the priority which local authorities attach to mental health services in comparison with, say, child health or the care of the elderly are—because they are elected—a matter for them. That funding is supplemented to a great extent from the rate fund and so it is up to them to prioritise.

The noble Lord, Lord Ennals, quoted a number of sources complaining about the discharge of mentally ill patients into the community. The Government continue to stress that patients should not he discharged without an adequate plan of care. I said that at the beginning of the debate, but I regard it as very important indeed. Many are short term patients who return to their existing home background. The future of long stay patients who are discharged must be most carefully assessed because it is the long stay patients for whom the state has been responsible for so long.

So far as concerns bridging finance, most regional health authorities have made their own arrangements in the district allocations. If this was the major problem that the noble Lord, Lord Ennals, suggested, regional chairmen in meetings with my right honourable friend would have continually pressed the Government for action on bridging finance. But that has not happened.

The noble Lord, Lord Thurlow, spoke of providing care for mentally disordered offenders on release from prison. That brought a new factor into this debate. It was one of the issues looked at by the inter-departmental working group on mentally disturbed offenders in the prison system. As a result, discussions are taking place and we are seeking further to encourage regional health authorities to develop a comprehensive network of provision to meet the mental health needs of mentally disordered offenders and to develop a network of services within the community for the chronically mentally ill who may lose touch with services and then commit petty crimes, whether or not they intend to do so (and that refers to another point that was raised), and find themselves in prison. Further, we are discussing ways of ensuring that those mentally disordered offenders on leaving prison can be put into touch with psychiatric services. Noble Lords remarked on the idea in the Griffiths Report of a named carer. I believe that this should come in here as well.

Many points have been raised. In all conscience I do not think, having spoken once, that I should refer to all of them; but I shall reply in writing. However, I should like to call particular attention to the very important role played by the voluntary sector in the provision of respite facilities and care attendance schemes. I should like to pay tribute to the enormous contribution made by a whole host of different people and organisations in this field. Together they form part of the long tradition of voluntary services in this country, which is one that Ministers are keen to see preserved. We shall continue to support the voluntary sector to best of our ability—by that, I mean giving organisations both moral and financial support.

In the mental illness field, for example, we shall spend nearly £1.5 million on grants this year to over 20 voluntary organisations. These and other organisations make a vital contribution to the total provision of community care services. We greatly admire the imagination and resourcefulness that enables the voluntary sector to provide a level and quality of service that belies the limited resources available to them.

I can tell my noble friend Lord Mottistone that I am well aware of the imbalances in the Government's mental health budget for voluntary bodies. This is largely for historical reasons. I had a naughty thought when listening to my noble friend that some of this imbalance may be reflected in the fact that the noble Lord, Lord Ennals, was particularly interested in this area and could—I put it no higher than that—have influenced it. However, I am seeking over a number of years to rationalise this situation. But my support, respect and gratitude for charities in the mental illness field come second only to my feelings for those who appear for and support the needs of sufferers of mental handicap and their families. In the last financial year I was able to authorise grants totalling more than £800,000.

It has been quite constructive in this debate to find that the only person to zero in, as it were, on the problems of the mentally handicapped in the community was the noble Lord, Lord Allen of Abbeydale. I know of his interest in this area and of his new appointment at MENCAP (in which we are all extremely interested). I do not know whether the noble Lord was in the House yesterday when I answered a Question on the Independent Living Fund; but I think he will find that some of his questions today have already been answered. There is one question of great interest which I did not answer, and that concerns the £5 million which is the Government's start-up money. The Government believe that it will be more than adequate for the first year; but, if it is not, clearly we shall top it up. So far as the time is concerned, I gave three to five years for it.

Finally, in response to one point made by the noble Lord, Lord Prys-Davies (of which he gave me previous notice for which I am grateful) I sympathise with the concern of parents about future provision for their mentally handicapped sons and daughters when the parents are no longer there to provide a home. The MENCAP Homes Foundation, with help from the department I have the honour to represent, has led the way in helping parents make provision for their children along the lines that the noble Lord has suggested. But I shall certainly consider whether there is anything further that we can do to help, either within the direct or the indirect public sector.

Your Lordships may feel that I have spoken quite long enough for one afternoon. Perhaps I may conclude by thanking all noble Lords and again the noble Lord, Lord Basnett, for introducing this fascinating debate.

6.14 p.m.

Lord Basnett

My Lords, there remain for me only two tasks to perform. First, I join the Minister in thanking all those who have taken part in what, as he says, has been a fascinating debate, but which equally has been a well-informed and caring one. Secondly, I should like to withdraw my Motion for Papers.

Motion for Papers, by leave, withdrawn.