Schizophrenia After-Care Bill [H.L.]

HL Deb 12 April 1989 vol 506 cc326-64

8.8 p.m.

Lord Mottistone

My Lords, I beg to move that this Bill be now read a second time.

I should like to start by congratulating the speakers in the previous debate for managing to finish within three minutes of the stated time. I am most grateful to them for doing so.

The purpose of the Bill is, so far as practicable, to ensure appropriate after-care for persons who are discharged from hospital after receiving medical treatment for schizophrenia. In the report of the Chief Medical Officer for Health for 1987, published in October 1988, he stated, in the penultimate paragraph on page 69, that over half of those admitted to hospital with a diagnosis of schizophrenia are, left with significant residual symptoms and seriously impaired social functioning, which needs long-term treatment and care". The. Bill seeks to provide a mechanism for meeting that requirement. It concentrates primarily on schizophrenia patients because they comprise the single largest group of mentally ill. About one person in 100 will suffer from schizophrenia at some time in their lives.

The Bill will also enable the Government to encourage health authorities and local authorities to provide the facilities necessary to meet the requirements for assessment and aftercare for a specific group of mentally ill people and to learn from that what might be needed for a more comprehensive coverage of the mentally ill with a view to extending legislation later.

With regard to what view the Government may take, I have been much encouraged by an article by Mr. John Lewis published in The Times of 30th March which indicated that my right honourable friend the Secretary of State for Health considered that the matter of care for the mentally ill was comparatively simple and should be dealt with in advance of a detailed response to the Griffiths proposals. It also said that health authorities were expected to be given direct responsibility for the care of the mentally ill and the mentally handicapped, thus implying that local authorities' present responsibilities for those groups of people will be relinquished. If that report is authentic—which I would welcome—I hope that the Government will feel that, with amendments to leave out some local authority references, the Bill is a move towards their intended course of action.

Regarding how the Bill might fit in with other legislation, Section 7 of the Disabled Persons Act 1986, when implemented, will give little help to schizophrenics, mainly because it covers only those discharged after six months in hospital, and most schizophrenics are in hospital for a shorter period. For example, in 1986 fewer than 2,000 of the 26,077 schizophrenics discharged from English hospitals would be covered by Section 7. The remainder would not. Mentioning English hospitals reminds me to tell your Lordships that the Bill applies to the whole of the United Kindom except Northern Ireland, for technical legislative reasons.

I shall now briefly describe the Bill. Clause 1 requires the manager of the discharging hospital to give 14 days' notice in writing, with a summary of the case, to the health authority of the district or area where the patient is likely to live, with concurrent notification of discharge to the local authority concerned, probably the general practitioner if practicable, and the nearest relative. The health authoriy concerned is required to make arrangements for the assessment of the after-care needs of the person, in consultation with the local authority.

Clause 2 requires the health authority and the local authority, in co-operation and continuously, to provide all the specific after-care services that the assessment shows to be necessary until such time as the health authority is satisfied that the person no longer requires such services or moves to another district or area.

If the person for whom the assessment has been made does not turn up in the expected health district or area, or moves unexpectedly, the health authority is required to make efforts to trace him. If the person moves openly, or is found in another district or area, the health authority is required to pass the information about the case on to the new district or area which then has to assume continuous responsibility for after-care. Finally, Clause 2 requires the health authority concerned to review each case annually and to decide whether care should be altered or ceased.

Clause 3 is technical. Clause 4 calls upon the Secretary of State to issue guidance on the implementation of the Bill and to publish information about the provision of after-care under the Bill. Clause 5 makes financial provision; and Clause 6 gives definitions and other interpretations. Clause 7 establishes that the Act shall come into operation six months after it is passed.

As your Lordships can see, this is a simple Bill which meets a real need that grows in importance as efforts are made to place schizophrenics in the community. If such people are not cared for by public resource, they place an ever-increasing burden on their nearest relatives, who are often old and require care themselves.

All too frequently, schizophrenic people resist family care even when offered. Without some communiy care they resort to sleeping rough; to crime; to suicide; or to all three. Crime at least gives them a police roof over their heads. I can elaborate on those options and the effect of a lack of care but I hope that those speaking in the debate will do that.

I should like to thank the National Schizophrenia Fellowship for providing the basis of the Bill, and in particular Mr. Graham Pitt for drafting it with such skill. I should also like to thank the many who will contribute to the debate, and to those who have stayed behind at a late hour for a Wednesday to listen to it. There are not as many noble Lords present as I thought there might be when I prepared my speech; but perhaps they will take their places later. I also express my genuine thanks to those noble Lords (there are at least 10) who have written to me expressing their regret at being unable, owing to other unavoidable commitments, to be here in order to support the Bill. If they had been added to the 18 or so speakers, some of your Lordships may have been a little worried about the length of our debate. I should also like to thank my noble friend Lord Cromartie who has sadly been unwell since the new year and has been unable to attend the House since then. I should like to send him wishes for a speedy recovery from all of us taking part in the debate.

In addition, I should like to thank the Mental Health Foundation, whose president (the noble and learned Lord, Lord Elwyn-Jones) I am happy to see on the Front Bench opposite, for its support; the Manic Depression Fellowship and the Salvation Army which have also indicated their support. The Salvation Army probably has more knowledge than any other organisation of the sad schizophrenics who are lost and deprived of formal after-care. Its support is especially meaningful. I hope that my noble friend on the Front Bench will take note of it.

I should also like to thank SANE (Schizophrenia a National Emergency) of which I have the privilege of being the chairman. It is a new charity which I hope will raise vast sums of money for the care of schizophrenics and for research into the malady.

Finally, I should like to thank my noble friend Lord Henley, whom I welcome to the Front Bench in this role, for undertaking the task of replying to the debate on behalf of the Government. I hope that he can be encouraging. I beg to move.

Moved, That the Bill be now read a second time.—(Lord Mottistone.)

8.20 p.m.

The Earl of Longford

My Lords, I rise to support very strongly the remarks of the noble Lord, Lord Mottistone, who has brought forward this essential Bill. Some years ago I was chairman of a committee funded by the Richmond Fellowship which was concerned with the after-care of mental patients generally. There was a debate here on a Motion of the late Lord Beswick, who did so much for so many social causes and who will always be remembered by many of us.

Like every other Member of the House, I have naturally been interested in various aspects of the subject. I opened a debate last autumn on mental offenders. Like the noble Lord who has just spoken, I owe my main material to the National Schizophrenia Fellowship. I have also benefited a great deal over the years from the advice and friendship of Mr. Peter Thompson of the Matthew Trust. As I have said before and shall say again, he has done more for mental patients than any other layman.

In addition, I had the privilege of discussions during the last few days with Lady Wakehurst, the sister of the noble Baroness, Lady Elliot, who will address us later. At the age of 89, Lady Wakehurst is an example to some of us who are faltering in our early eighties. As some noble Lords and certainly the noble Baroness, Lady Elliot, will know, she is one of the founders of the National Schizophrenia Fellowship and has done an enormous amount for it. I asked her tonight whether there was any message and she said, "Caring is everything". No one has given a better example of caring, as the noble Baroness knows, than her sister, Lady Wakehurst.

I shall concentrate briefly on one aspect of the subject; namely, the schizophrenic mental offenders. With the help of the National Schizophrenia Fellowship I shall bring before the House the results of a five-year study of 334 male offenders remanded by the courts to Winchester prison for psychiatric reports. They were therefore what one might call psychiatric cases. The reason for mentioning this study—and I cannot go into details—is that of the 334 men, 242 or 72 per cent. were diagnosed by the hospital doctors as having schizophrenia. For those who had already been in hospital, after-care was not providing them with anywhere to live in many cases. Nor did they have the support they needed to be able to look after themselves.

Without accommodation, continuing care and appropriate treatment, these schizophrenics and people like them will not manage outside hospital. They will offend again, as such people are liable to do. They will often offend in quite petty ways in order to get food or shelter. They will keep reappearing in the courts and prisons. That is one sector of the schizophrenics but they are obviously a very poignant group. I am told that the situation is likely to become worse rather than better, but that remains to be seen.

This Bill is vital. If schizophrenics are going to spend shorter periods in hospital than in the past, we must make sure afterwards that they no longer enter this frightful cycle which I have just dwelt on. We must meet their need for long-term accommo dation and long-term care and suppport. For those reasons I support the Bill.

Noble Lords will remember the passage in the Gospels when Jesus Christ addressed those who befriended the sick and the prisoners: In so much as you did it to the least of these, my brethren, you did it to me". I can imagine no members of our society whose plight demands that approach more than the schizophrenics, particularly those who have already been in trouble and found themselves unable to cope with society. I have the great privilege to support the noble Lord this evening.

8.25 p.m.

Lord Winstanley

My Lords, it is always a pleasure to follow the noble Earl, Lord Longford. It is a particular pleasure to do so on a subject on which he feels extremely strongly. Perhaps I may say to him that he is absolutely right to feel strongly since it is a subject which warrants strong feelings.

In addition, the noble Earl is very knowledgeable on the subject. That is every bit as important as feeling strongly about it. He referred to the committee of inquiry which he set up and which was sponsored by the Richmond Fellowship into the care of the mentally ill in the community. I had the honour to be a member of that committee of inquiry and it did some very valuable work. It came forward with some important recommendations, none of which, to my knowledge, has been implemented by this Government or indeed any other government. Nevertheless, the noble Earl has done a great deal of work in the field and I think we should recognise that.

I also recognise that we are privileged in this debate to have a list of speakers all of whom have a high degree of commitment to the subject and all of whom collectively bring a great deal of knowledge, expertise and wisdom to your Lordships' House and to the discussion.

We should be grateful to the noble Lord, Lord Mottistone, for bringing forward the Bill, which deals with the plight of quite a small number of people in a special situation. Their needs are unusual and rather different from those of other mentally ill patients. Some people may suggest that perhaps the noble Lord, Lord Mottistone, would have been wiser to await the Government's response to the Griffiths Report on community care. But how long would they have had to wait? In any case, I feel that the needs of this group of people are so special that frankly I doubt whether, when we see the Government's response to the Griffiths Report, that response will provide for the special needs of that group of patients.

Others may say that the noble Lord might have been wiser to wait for the full implementation of Section 7 of the Disabled Persons Act. We are promised that that will be implemented next year. Again, I think they are wrong because Section 7 of that Act provides that before a long-stay patient, is discharged from hospital his needs must be assessed. It does not say what has to be done about them or how those needs have to be met or who has to meet them. It refers to long-stay patients. However, Section 7 does not apply to discharged patients when they have not been in hospital for six months or longer.

The noble Lord, Lord Mottistone, mentioned in his introductory speech the fact that in 1986, the year he quoted—and I shall put the figures another way round—25,000 patients were discharged from hospital who had been there for periods shorter than six months. They therefore could not conceivably have benefited from the provisions of Section 7 of the Disabled Persons Act, had that been in force at the time. So I think that the noble Lord was right not to wait and to introduce the Bill.

If I may say so, community care is an extremely emotive subject—understandably, because it affects all of us in the community. There are few families who do not have some kind of contact with a person who needs care in the community. As the hospital closure plan gradually proceeds, more and more people will be concerned with it. We know that there are a great many so-called carers in the community who are landed with the job of looking after people who are handicapped, disabled or mentally ill. They carry a very heavy burden indeed. A sad fact is that there are smaller and smaller numbers of them.

Historically it has always been middle-aged women who have done the caring. If we examine what is happening demographically to the population, there are fewer and fewer middle-aged women, more and more old women and more and more young women. But they are not the people who do the caring, so it is an acute and real problem.

Community care is an emotive subject. Last night I had the privilege of attending a debate at the Royal College of Physicians. A number of noble Lords present were there, and some of them will speak later. It was a debate on primary care and inevitably it was about the new general practitioners' contract. There were a number of speakers. The principal speaker was Mr. Mellor, the Minister of State in the Department of Health. It was particularly informative for me to note that during that debate Mr. Mellor, speaking on behalf of the Government, said three times that it should not be forgotten that the White Paper and the eight working papers attached to it were consultation and discussion documents. He said they were not graven in stone, and that if objections were raised persuasively, and if the Government were persuaded of the need for changes, the Government would make those changes. It was very encouraging that the Minister made that point three times. Perhaps there will be changes.

I found it particularly interesting that the most enthusiastic applause during the course of that debate on the very important subject of primary health care was reserved for a lady who was representing the community health councils and who asked when the Government were going to publish their response to the Griffiths Report. This is a very important subject. I do not wish the Government to be hurried into producing a response which is wrong. I do not suggest for a moment that the Government will swallow Griffiths hook, line and sinker and do everything which Sir Roy Griffiths recommended; but they must do something. They must come forward and say precisely what they are going to do.

I am trying to make the point that the needs of patients suffering from schizophrenia are unlikely to be met by whatever the Government provide in their final response to the Griffiths Report, unless perhaps they are persuaded by the presence of this particular Bill which the noble Lord, Lord Mottistone, has brought forward. We are talking about a very special, or rather an unusual disease, which fundamentally is a disorder of perception. It often affects young people, but it can also affect people of all ages, as we now know. There is no cure; but in many cases the condition can be controlled, and the patient can be kept in a state whereby he can be looked after at home. But one thing which is characteristic of the schizophrenic patient is that it is almost diagnostic of him that once out of medical control, he stops taking his medication. The inevitable result of that is that the condition then worsens and breaks down, and the patient has to go back into hospital. Such patients do not come under Section 7 of the Disabled Persons Act because they are in and out of hospital.

I noticed that the House of Commons Social Services Committee stated: there is a body of people, some of whom are known to the psychiatric services, and may at some time be in-patients, who drift between resettlement units. homelessness, hospital and prison". Many of those people are patients suffering from schizophrenia. It is interesting to note that the London Salvation Army hostel study which covered many men in Salvation Army hostels, found that over 30 per cent. of the occupants of the hostels suffered from schizophrenia. Those are the kind of people we are talking about. There is something like a quarter of a million sufferers from schizophrenia in British society. They have special needs in hospital, but they have even more special needs when they are discharged from hospital.

What does this Bill seek to do? As it states in its Explanatory Memorandum, the Bill aims: to improve the provision of after-care services for persons discharged from hospital after having received treatment for schizophrenia". We know perfectly well that many patients who are discharged from hospital, after having received treatment for schizophrenia, receive virtually no after-care services at all. I brought up such a case in a debate on an Unstarred Question in your Lordships' House not very long ago. It was the rather sad case of Sharon Campbell, a girl suffering from schizophrenia who was discharged from hospital without the necessary after-care services. The consequences of that was that Sharon Campbell murdered a wholly innocent social worker called Isabel Schwarz. An inquiry was conducted into that, largely as a result of the very close interest taken in that case by the noble Baroness, Lady Trumpington, who was then the Minister responsible for such matters.

An inquiry was set up under Mr. John Spokes, QC. I remember the debate we had on the report of that committee of inquiry. I and the noble Lord, Lord Mottistone, said there were two recommen dations in the Spokes Report that we felt should be implemented at once. I quote those recommendations from the report, which stated: 17.22 We recommend that health and local authorities, in co-operation with relevant voluntary agencies, should have a duty jointly to provide suitable after-care for former informal hospital patients who are, or have been, suffering from a mental disorder until those authorities decide jointly that the need no longer exists". That is what the Bill of the noble Lord asks for. The report continues: 17.23 We recommend that the Secretary of State issue to health and local authorities a written summary clarifying their statutory duties to provide after-care for former mentally disordered hospital patients". The noble Lord, Lord Mottistone, and I and others asked for the implementation of those recommendations after the report was published and after it had been debated in your Lordships' House. That, in essence, is what the noble Lord, Lord Mottistone, seeks to do with this Bill. I have said nothing, and will say nothing, about the resource implications of the Bill. However, I have no doubt that those resource implications will be very close to the heart of the Minister who is to reply. However, things have to be done, whatever the resource implications.

It is a fact that carers looking after ill people in the community—including many patients suffering from schizophrenia—save the country £25 billion a year. That figure has been calculated very carefully. In reality they do not save the Government that figure, because no government would spend £25 billion a year. But what the carers provide would cost £25 billion a year if it were to be provided from official sources. I am under no illusions regarding providing adequate after-care for this very special and vulnerable group of people. I know it would be expensive. But failing to provide that after-care for that vulnerable group of people would be very expensive, and in the end it would be deeply damaging to the community in which we live.

8.37 p.m.

The Lord Bishop of Sheffield

My Lords, to future generations our general failure to cope, with sympathy and kindness, with the problems of the mentally ill, will seem one of the more astonishing features of our age. However, that is not the subject of this Bill. As we have been told and know, the Bill deals with one specific set of problems. I lead a more sheltered life than some other Members of this House, and my experience has not been so much directly with schizophrenics as with their families who deal with those who have this appalling problem of not knowing where they are, who are in and out of hospital and who bear the uncertainty of what horrors tomorrow will bring. Those problems have already been mentioned.

I earnestly hope that we do not allow ourselves to be deflected from the course which this Bill represents. It is so tempting to believe that because we cannot help everyone, we must help no one. Yet the Bill gives practical relief to families and to victims of this illness. I hope noble Lords will forgive me if this illustration is fanciful. I see us as being in a situation not entirely unlike the situation where some distressed person goes to a medieval king while he is on his journeys round the kingdom and stops the king's horse, seizes the hem of the king's garment and begs for justice and for help. If the person is fortunate and it is a good day, the king, who cannot solve all the problems in the kingdom, will do something to solve that supplicant's problem.

I see ourselves in that situation. We cannot help everyone, but this Bill could help some. I hope it may be able to do so. Like the noble Earl, Lord Longford, I dare to refer to scripture. The piece of scripture I wish to refer to is curiously politically controversial. It concerns the parable of the Good Samaritan. I see the schizophrenic as the person who has indeed fallen among thieves and who is in the most desperate need of help. I hope we are not among those who pass by on the other side.

8.40 p.m.

Baroness Elliot of Harwood

My Lords, I, like all other speakers, wish to congratulate the noble Lord, Lord Mottistone, on putting forward this admirable Bill. It is a Private Member's Bill: it is very difficult to get time in your Lordships' House to bring forward such a Bill. Yet the noble Lord has succeeded. I am sure we shall all support the measure; it concerns a vital subject.

My association with the treatment of schizophrenia goes back quite a long time. As the noble Earl, Lord Longford, said, it was my sister, Lady Wakehurst, who started the Schizophrenia Fellowship. She was helped by Mr. John Pringle and Mrs. Pike Lees. They started the fellowship from the humblest beginnings. Nobody understood or knew anything about the subject. However, they had been in contact with schizophrenics and knew what was happening. From those humble beginnings it has today become a recognised association which operates in many parts of the country and, I think, abroad.

I do not know how many of your Lordships watched Esther Rantzen's television programme last Sunday. The programme was all about mental illness and schizophrenia. I thought it quite excellent. It was marvellous propaganda, if one considers the thousands of people who watch television on Sundays. The programme will have done as much good for public understanding of the disease as almost anything that we could have done.

While, as the noble Lord on the Liberal Benches has said, schizophrenia is now a recognised mental illness, it is still being analysed and studied by doctors who are experts on mental health in an attempt to find the right treatment. At present a total cure seems impossible. With the provision of care in the community many schizophrenics could live at home or in the community.

In 1986, 25,046 patients were admitted to mental hospitals. On analysis, 90 per cent. of those were found to be re-admissions. That shows how vital it is to provide care outside the hospitals—in homes and in the community where schizophrenics live—in order that they should not return to hospital.

In 1986, 26,077 schizophrenics were discharged from hospital. Of those, 13,307 were discharged in under one month following admission, and 10,814 between one and three months afterwards. Those 24,121 discharged schizophrenics would not be covered by any after-care. That is a devastating state of affairs.

The reason why 92 per cent. have to be readmitted to hospital is that once they return to the world and the community there is no one to care for them. They cannot care for themselves. That is not their fault. They are still ill. If there were day centres or accommodation with a social worker in charge, a large proportion of those sad people would be able to carry on their lives more or less normally.

That would not only help the patients. It would save the National Health Service thousands of pounds. Any money spent on preventing people having to go back into hospital is a help to those who are well and who have to pay taxes, as well as to those who are ill.

As I think your Lordships know, I am very interested in the prison service and the treatment of offenders. I was appalled to read in the brief accompanying the Bill that nearly 80 per cent. of the people picked up by the Metropolitan Police under Section 136 of the Mental Health Act have some mental disability and need care. Thirty-three per cent. had been admitted to hospital three or more times. There is more that I could say, but that is convincing evidence of the vital need for after-care.

This Bill ensures by law that schizophrenics receive after-care on discharge from hospital for as long as they need it. That will help families to cope with a member who is schizophrenic and save much unhappiness and difficulty. It could help to prevent crime. Many mentally ill people are involved in crime and then sent to prison. Prison will not cure any mental state.

The Bill is another attempt to prevent family breakdown, to prevent crime—however small its impact—and to help people to help themselves. For some reason, I never know why, so much legislation is reserved for people after they become ill and their illness has brought endless trouble and difficulty to families and those suffering mental illness. If the care was available before people became so ill and before those disasters happened, they would not have to go into hospital. They would be so much better off.

This Bill presents a real opportunity to help. I press the Minister to follow up this debate by helping the Bill to become law as soon as possible.

8.47 p.m.

Lord Henderson of Brompton

My Lords, I am particularly glad to follow the noble Baroness in this debate in that she drew attention to the admirable television programme last Sunday by Esther Rantzen. That gives me the opportunity to congratulate the noble Lord, Lord Mottistone, on his timing. Perhaps he will benefit from the glamour of Esther Rantzen's programme (and perhaps some publicity will be given to this debate), which focused her general concern with mental illness on this particular problem which, as we have heard, affects over a quarter of a million people in this country. That is a huge constituency.

Like the noble Lord, Lord Winstanley, when I first saw this Bill I too thought that perhaps it was superfluous and that Section 7 of the Disabled Persons Act 1986 would, if implemented, cover this issue. I believe that it is a first priority of the Government to implement the unimplemented sections of that Act. However, the noble Lord, Lord Mottistone, was quite right; that would not do because the section refers only to those who have been in hospital for six months. That is by no means always the case with those who suffer from schizophrenia.

Equally I thought that perhaps we ought to wait for Griffiths. However, like the noble Lord, Lord Winstanley, I accept that one cannot wait for ever. I congratulate the noble Lord on introducing the specific provisions of this Bill to deal with the vast number of people who suffer from the condition.

I wish to make only one suggestion. I feel very strongly about the matter and I hope that the Minister will take it on board and that the noble Lord, Lord Mottistone, will see that it helps in the implementation of his Bill. I believe that a very great deal could be done by hostels as a half-way house between hospitals and care in the community. The noble Lord, Lord Winstanley, has already mentioned two voluntary organisations which provide hostels —the Richmond Fellowship and the Salvation Army. As the noble Lord has said, the Salvation Army finds that a high proportion of its customers —at least 30 per cent.—suffer from this condition. Those people have not been picked out, they merely represent a sample of those who lodge with the Salvation Army.

We have heard from the noble Baroness that the same is true of those who sleep rough. The condition of schizophrenia has largely been the cause of their plight. If it is the Government's policy to close the majority of hospitals with places for such people, it is not enough simply to rely on care in the community. There must be some provision between the devoted work of carers on the one hand, who need relief from the strains of looking after these people and, on the other hand, return to hospital. I strongly urge the Government to think seriously of the need to find places in hostels where such people could be looked after responsibly. I place special emphasis on the word "responsibly". The wardens could notify local GPs so that they would share the duty of supervision. Between them they could ensure that the patient was prescribed the right medication and, as mentioned, have the important duty of making sure that the patient took the medication.

Good hostels can and do provide not only food and accommodation but show genuine concern for those who lodge with them, including concern for their general welfare and help with finding jobs. Places in hostels are almost always cheaper than beds in hospitals. They offer sheltered places in the community, and are frequently better than the provision offered by hospitals or distracted parents. Good hostels can and do attract volunteers, who could befriend sufferers.

As we have heard from the noble Earl, Lord Longford, the worst cases of schizophrenia may lead to destitution which in turn leads to stealing for food and shelter and to prison. As the noble Baroness said, prison is by far the worst disposal for them. It is not fair on the prison system, the prison officers or the prison medical service, let alone the other prison inmates. It is of course the last place which it is fair to send the unfortunate sufferer. It is unfair also on the sufferer's friends, parents and relations if the individual is lucky enough to have them. Here again hostels could provide an infinitely better home than prison for such people. It may always be right that they should go first into hospital for proper medical assessment before being sent to such hostels. I strongly recommend that such hostels should be available.

I have a number of brief case histories supplied by very old friends of mine who are the parents of a schizophrenic son. However, I will not relay them in the interests of time. Although they support excellently the principle of the Bill proposed by the noble Lord, I do not wish to bring them before the House because they criticise a local hospital fairly severely. I think that it would be preferable merely to draw the Minister's attention to the criticism so that, if he thinks it right, he can pass it onto the health authority. I think that that is a better course than giving the name of the hospital.

I also have a number of detailed but relatively small criticisms of the Bill. Perhaps the noble Lord, Lord Mottistone, will consider them after the Bill has had its Second Reading.

It remains for me to thank the noble Lord again for bringing the Bill forward and to wish it speedy progress through Parliament.

8.53 p.m.

Lord Graham of Edmonton

My Lords, I wish first to thank the noble Lord, Lord Mottistone, for his excellent timing and for the deep care that he took in opening the debate on Second Reading. He set the scene for those noble Lords, of whom I am one, who are not as closely in touch with the issue as he is. I hope that the Minister and his colleagues fully recognise the timing of the Bill and the necessity and value of it in the totality of the problem. I was grateful to the noble Lord for indicating that there could be a wider application in regard to after-care attached to the Bill in respect of other sufferers in this field. It is clearly a difficult situation. We are here to fight and plead a corner, which it is right and proper to do. I cannot believe that there are many other issues or priorities of greater importance than what we are debating tonight.

I want to ask: what are we about, not only in the Bill but in this debate? I believe we are entitled to say that we are airing a condition and a situation of which I believe the vast majority of the public are unaware. They may well be aware of schizophrenia and of the move to bring people out of institutions back to the community, but I do not believe that they are aware of the sadness, despair and depression in this respect.

If I may speak directly to the Minister, I hope that what we are about is to reinforce not only his views but the views of the Government in this matter. We want the Government to understand what we in this House and Members in another place wish to do. We want to let the Minister see that. if he legislates along these lines, he will have our support. I believe that that reinforcing role is important.

Another reason for supporting the Bill is to give hope and comfort to patients and carers. There are noble Lords who are willing to spend their time doing research and standing up and 13aying what we are saying today. I believe that hundreds of thousands of people outside the House will be grateful for the debate.

Like other noble Lords, I am grateful to have received the document entitled Slipping through the Net, which says: Mental hospitals are being run down and closed, and seriously mentally ill people, such as those with schizophrenia, are being put out into 'community care' with a 'safety net' of services to support them. But how good is that net?". I think that this will prove to be a valuable record of what happened last year and will be much used in the future.

Doctor John Kilgour, Director of Medical Services, HM Prisons, at page 23 says: My colleagues and I find ourselves having to handle people who are inappropriately committed to a custodial sentence, due, to put it bluntly, to the failure of the community to provide suitable facilities for them". The community is not the Government, social service departments, hospitals or political parties; the community is all of us. We are all guilty to some extent for allowing this to happen.

I wish to give a particular illustration. I am pleased to be able to refer to a statement by a Member of another place. Mrs. Gillian Shepherd, Member for Norfolk, South West, who in February 1989 said: There is no excuse for any group of patients ever to be disadvantaged because of faulty co-operation between agencies or professionals, yet this is precisely what can happen to people with schizophrenia". I should like to draw to your Lordships' attention a very sad case about which I have been told. I received a letter that begins as follows: Dear Lord Ted, I come to you in the greatest despair and with the fervent hope that you will be able to help where all else has failed". How often have Members of this House and indeed others heard that phrase or a similar one when people have come to them? They believe that all help has failed.

The letter continues: In 1977 we had to have my son, Jason, admitted to … hospital". I shall not give the name of the hospital. The letter goes on: not because we thought it was a suitable place for him but because it was all that was offered and as we had no financial resources there were no options … Jason was then 12 years old and was cerebral palsied but he had no behavioural problems and was a fun-loving, affectionate boy. He is also severely physically handicapped (caused by neo-natal asphyxia) and was becoming too much to cope with at home. Also, I divorced his father, and these factors combined to put him in a place which I considered then was completely unsuitable. I have never had any reason to change this opinion, which has been confirmed by everyone who has visited him there". There follows a further history. It is almost asking the House to believe the impossible—that not for five years, not for 10 years but for 12 years this woman has sought to have her son placed nearer to her home and in a better situation.

I have here a letter written by that woman's Member of Parliament, who is a caring and compassionate man, as I should like to put on record. I shall not mention his name. For more than 10 years he has raised this issue on behalf of her son. For over 10 years he has repeatedly and persistently pursued the matter. This letter is dated October 1979.

The nub of my remarks is that there is apparently some difficulty between two authorities—the health authority and the local authority—in coming to terms on the precise financial arrangements that need to be entered into in order to arrange a satisfactory transfer. I should like to read very quickly part of a letter received from a social worker in Enfield and written to that woman in December 1985. It says: I have now received a letter from … Social Services Department, who has confirmed that his Authority is happy to hand over responsibility for the case management of your son, Jason, to my authority. This will include the handing over of monies from the Health Authority should my Authority be able to find a suitable alternative placement". I also have copies of other letters from which it seems that everything is going well. However, then comes a letter of May 1986 in which it is stated: it was with regret that I learned that your Authority will not be in a position to transfer funds to a community placement for Jason at present, but there is some consolation in that funds are likely to be available in 1987/1988 … I realise that this will be a bitter disapointment for [this lady] who for a long time has been campaigning for her son". A letter from the authority concerned written in 1986 states: The Regional Health Authority has issued a draft policy for consultation on the transfer of resources from the long stay hospitals on the discharge of patients. Initially the consultation period was to be from January to March but this has now been extended until the end of June. Consequently the policy will not be operational until the next financial year". There are other letters. Finally comes a very sad one from the local authority dated February 1989, which is more than three years after the prospect was given of a transfer to a better place for someone who ought not to have been where he was at that time. It states: I deeply regret that we are not yet, as an Authority, able to provide the placement for Jason as agreed. I can only repeat my earlier correspondence that Jason's place is subject to negotiations between the Local Authority and the District Health Authority in terms of re-provision for people living in long-stay hospitals. I am, however, optimistic that the Agreements that are required to be signed will be signed in the not too distant future, therefore allowing us to commence the alterations to the flat". The prospect for that young man was of being moved into a flat with two others. That letter was written three months ago. I saw the woman last weekend to check the facts and learnt that there had been no further information. So there is a lady who for 12 years has been fighting for her son, and an agreement between her and the authority which is more than three years old. It concerns a young man of 26. Most of these people are young. He is able and willing, as are the two authorities, but they are unable to find a financial formula to solve the problem. That is a disgrace, is it not? I ask the Minister to say whether he believes that this is a disgrace and deeply disturbing. I have told the Minister's advisers that tomorrow I shall send him the appropriate correspondence. At the very least I hope that he will take those responsible and knock their heads together. I do not know whether they are politicians or bureaucrats. We know, however, that the sufferers are this lady and her son. There are thousands of others in the same position.

I hope that when he responds the Minister will confirm that he cares and is concerned about this situation. It is disgraceful that in Britain in 1989 there is such anguish being suffered not only in one household but in thousands. The very least that he can say is that if it concerns a question of formula or agreement he will make it understood that such a situation must not arise again. If it is a matter of resources, we still ask him to say how such resources can be made available. The Jasons of this world are not so few that we can ignore them, but even if there were only one Jason in this country he is a human being who is entitled to the compassion, care and concern that everyone on this earth is entitled to receive, especially in our Britain of 1989.

9.6 p.m.

Lord Campbell of Croy

My Lords, I join with earlier speakers in expressing gratitude to my noble friend Lord Mottistone for having introduced the Bill and provided an opportunity for us to discuss what I believe is an important and urgent subject. I am the patron of the National Schizophrenia Fellowship of Scotland and during the International Year of the Disabled in 1981, when I was the chairman for Scotland of the International Year, we especially tried to extend public awareness of mental disability.

Schizophrenia is the most prevalent mental illness in this country. However, unless one has had the misfortune of having a member of one's family or a close friend as a victim, it is still little known and much misunderstood. Schizophrenia is widely thought to be simply a defect of split personality—a Jekyll and Hyde phenomenon. That is a misapprehension of what in reality is a serious and disabling mental illness. It is an illness for which no cure has yet been discovered. Its cause is still not known for certain, though it is thought to be connected with the chemical content of the brain. It seems that the condition is present from birth, though a strange feature of schizophrenia is that it does not strike individuals until they have reached their teens, usually between the ages of 14 and 18. Before that, there are no visible signs.

Families are therefore hit unexpectedly by this unkindest of blows. We who are taking part in this debate are familiar with this illness. It is important that we get messages to the world outside, to the public and the media. For example, the symptoms and characteristics of schizophrenia do not constitute split personality. The main ones are other signs of mental disorder: for example, hearing voices, complete unpredictability, incapacity to cope with daily life, intense anxiety about meeting people or taking part in even the smallest social gathering, and, more serious, the temptation at times to suicide.

I believe that Marjorie Wallace and The Times newspaper performed a great service some months ago in the enlightening articles explaining the subject. Thirty years and more ago the more acute sufferers were placed in asylums, whether they were correctly diagnosed with schizophrenia or some other serious mental illness. Since then, due to advances in medical science, treatment and medicine can control the illness, not cure it. Many sufferers can live nearly normal lives in the community, outside hospitals and institutions. Usually they are on regimes of tablets and injections adjusted as necessary. They still need supervision, the degree depending on the circumstances of the case. This, I believe, is the best arrangement for all concerned. It is to be commended and encouraged. However, it can work only if the necessary supervision and care are available in the community. It is essential that the sufferers continue with their prescribed medication.

Some sufferers will need to return to hospital at times and the means of fielding them and recognising their condition must be there in the community. What we must avoid is schizophrenics being discharged from hospital with no arrangements for care in their area of residence. Many are completely unable to fend for themselves without help and attention. Very often parents cannot help. This is another unfortunate and poignant feature of the illness. Medical advisers—psychiatrists—at times have the unenviable task of telling parents that a son or daughter cannot and should not come home and that the parents must not try to make contact. This can be for a period of months or even years. This goes against all the instincts of parents although it has proved to be clinically correct. It makes the availability of adequate care in the community all the more necessary in such cases with this illness.

I turn briefly to what is known as the Italian experience. That was an extreme case of emptying mental hospitals. As a result of the Italian Law No. 180 of 1978, large numbers of mental hospitals were closed. The reasons were that there had been much criticism in Italy of grim conditions in those hospitals and alleged incidents of indignities and abuse concerning the patients. The exodus was ordered, however, before any proper alternative services had been created in large areas of the country. Dreadful situations and horrifying episodes occurred which must never be allowed to happen here.

In this country it is now possible for more sufferers from schizophrenia to live in the community rather than in institutions, as in the past. That surely is to be welcomed. However, unless proper care in the community is available related to the individual cases, there will be tragedies and there will be distressing sagas concerning aimless, homeless and ill people.

9.14 p.m.

Lord Hankey

My Lords, we are greatly indebted to my noble friend Lord Motttistone for introducing this well drafted and well thought-out Bill. The problem of schizophrenia is horrifying. My noble friend Lord Campbell of Croy made an excellent contribution. Much too little is known about the cause of the disease or its cure, in spite of a great deal of devoted research. Almost all noble Lords will know someone, or a relative of someone, who suffers from the disease.

Now that so many mental hospitals are to be run down or reduced in size and scope, there is a real danger that the number of helpless people sleeping rough outside or under bridges will increase. The danger is not only to those people but to the rest of the community, as we have heard explained in the debate. That is an additional reason why the Government should take this subject seriously.

My first major point is that we must not—I repeat, "must not"—discharge mentally ill people into the community unless there is someone (a relation, parent or organisation) to help and care for them kindly, intelligently and with experience.

I hope that this excellent Bill will reach the statute book. It should ensure that the right people are informed before patients are discharged. Without being an expert in the field, I wonder whether we yet have in place the necessary network of community care orgainisations which will ensure that all schizoprenia patients discharged from hospitals can be adequately cared for everywhere. I believe that that requires a great deal of initiative and kindly work at local level, together with much helpful backing and finance from local authorities. My noble friend Lord Henderson made an excellent contribution to our thoughts in his reference to hostels. The work of the Salvation Army bears that out.

It is not enough to leave the provision of adequate community care to chance or to the occasional local genius. There needs to be an energetic push from central government. I should be grateful for the Minister's reassurance on that subject.

I hope that the reduction in the number of mental hospitals is not regarded as another way of cutting government expenditure. I feel certain that it is not. As sure as I stand here, proper community care will not in the end be cheaper than good mental hospitals. However, I accept the fact that if—I repeat the word "if"—it is well done, community care may, in modern conditions and with the new drugs properly administered, prove to be better for the patients. That is another reason why I believe that we should "go for it" seriously and actively.

I turn to the local problem for individual patients. The key here is that good, experienced and continuing advice should be available to the patients and to their friends and families. I do not believe that we should overload our hard-worked doctors, although that will be necessary on occasions. There is need for many more community psychiatric nurses (CPNs) who can get to know discharged patients and become familiar with their individual history and state of mind. They can also advise families and friends looking after the patients. That is an expert job. It requires development of central government policy and certainly some expenditure. At present there are only 2,000 community psychiatric nurses. I am told that we shall need approximately 10 times that number as the Government's policy develops and as the increased number of psychiatric patients have to be constantly and expertly looked after in the community. I should like an assurance from the Minister that that key problem will be earnestly considered and properly dealt with.

Returning to the local organisations for community care, I have heard of a remarkable development at Southsea near Portsmouth. An inter-agency forum, established by the local health authority, has drawn in the social services and various voluntary bodies such as MIND and SANE. The whole closely-knit organisation works with enthusiasm and efficiency in order to provide a better integrated service for the mentally ill. I hope that central government can spread that excellent idea if they approve of it. I should be glad to know of the Government's views. Sadly, we have to recognise that schizophrenia patients are prone to relapse and have to go back for a time to hospital. I seek an assurance from the Government that enough beds will be retained in our mental hospitals so that we can be sure to meet that sad need because it is very real.

Speaking strictly as a Cross-Bencher, perhaps I may make the following slightly political point. I enormously admire what the Government have done to release the spirit of enterprise in our economy. They have done a marvellous job despite the present economic difficulties. Unfortunately, not everyone can take advantage of the new prosperity. I suggest to the Government that it is precisely on health questions and problems such as discharged schizophrenia patients going into a system of well organised community care that they can again show that they truly care about the well being of people, especially those who cannot easily make the grade in our enterprise economy.

What is more, I believe that some seed money will lead to disproportionately good results among our many kindly and caring countrymen. Perhaps I may recommend that approach to the Government and again say how much I hope that they will find time for this excellent Bill to go through Parliament.

9.21 p.m.

Lord Rea

My Lords, it is a pleasure to follow such an excellent and constructive speech as we have heard from the noble Lord, Lord Hankey. I particularly welcome his emphasis on the need to create an after-care network and to strengthen it and also to quintuple the number of community psychiatric nurses because they are absolutely fundamental. I very much congratulate the noble Lord, Lord Mottistone, on introducing this worthy and very well intentioned Bill.

I consider that there is a certain parallel between his Bill and my own Private Member's Bill to regulate and restrict the hours of junior hospital doctors which went through all stages in your Lordships' House. I believe that there should have been no need for either piece of legislation. Both are being brought in—or were brought in my case—because of the frustration amounting at times to despair caused by the failure of the Government to achieve the widely desired aims of both Bills over the years, despite acknowledging the need.

There is no doubt—and almost every speaker so far has emphasised this point—that the policy of discharging mentally vulnerable people into the community has not been matched by the provision of the services which they need. Their needs are quite well understood, certainly by their families and by the social and health professionals responsible for their care. Also, the needs are often understood by the patients themselves when they are in a good state of health which is being maintained by their treatment. They know that they need the help of a constant and caring person. They know that they need a secure home, a roof over their heads, and that they need a satisfying and constructive way to spend their days.

In certain districts facilities and staff for after-care are far better than in others. I am a general practitioner who works very constructively and in a very professionally satisfying way with community psychiatric nurses and with residential care social workers with a number of very disabled patients. However, I was very sad to read in some of the briefing material which we have received that in eight health districts no community psychiatric nurses were appointed and another 17 had five or less. Even in my district of Bloomsbury, where there are 20 psychiatric nurses, six psychiatric day centres, two day hospitals and four sheltered hostels for discharged long-stay patients, the provision is inadequate. Many vulnerable patients are left to fend for themselves. Admittedly Bloomsbury is a special case. It is the end of the line for ill patients who have drifted away from their families, who come from all over the country and from other countries. Therefore, our need per head of population is greater than most.

Many of these severely sick patients might not be covered by the Bill. We have already discussed how it would be desirable for the Bill to be widened. Such patients would not be covered, first, because there are many mentally ill patients who are not diagnosed as schizophrenic but who are severely ill. For example, there are manic depressives, those with severe personality disturbances and many others with less easily classified conditions. In fact, these outnumber the classical schizophrenics. I hope that in Committee we will able able to consider this aspect in more detail. Perhaps the Minister himself will be able to bring forward an amendment. We shall be interested to have further discussion on that point.

There are also patients in the community who need the help which would be provided by the Bill—perhaps severely mentally ill people—who have for various reasons recently been discharged from hospital. There are many sick people living in the community who need follow up assistance, some of whom have never been admitted to hospital. Others have been discharged—possibly too early—because of present policies and decreasing bed numbers; perhaps some time in the past, but they are still dependent. I recognise that it might be difficult to decide which of these patients should be included. Some would much resent receiving care under a legislative framework. I can see a problem. If the Bill were to become law there is the possibility that the existing staff and the buildings might be fully occupied coping with discharged patients covered by the Bill to the detriment of those already receiving care in the community. This simply emphasises the need to increase provision in the community.

I am a little worried about the lack of provision in the Bill for the involvement of patients themselves in decisions affecting their future lives. If they are to be given the maximum opportunity of reintegrating themselves, even in a limited way, into the life of the community the provisions of the Bill would have to be applied in an extremely sensitive way. Patients need to be given choices about housing and their day care. That is less likely under a statutory provision than if the facilities and carers were provided as part of adequate health and social service arrangements and used the existing and soon to be implemented legislation.

I understand the reasons for insisting on adequate follow-up and surveillance in a Bill such as this. At the moment they are not being provided when there is no requirement. The health authorities may need to have legislation before they increase their staffs to such an extent that they can implement a proper follow-up policy. I echo the noble Lord, Lord Winstanley, that if the recommendations of the Griffiths Report were to be accepted and implemented by the Government:—or most of them—we might be moving in the right direction; at least so far as the accommodation and day care part of the problem is concerned.

The need has been mentioned to increase greatly the number of community psychiatric nurses, and I believe that is extremely necessary, if proper after-care is to be given. That point is not addressed directly by Griffiths.

Those are a few thoughts from a practising GP in an inner city with a large number of vulnerable and mentally-ill patients. I fully endorse the urgency of the problem that this Bill is attempting to address. I wish the Government would move so rapidly in dealing with it that the Bill becomes unnecessary. I have very little hope of that. I fully support the Bill, which needs to be amended as I have suggested. I hope very much that noble Lords will give it a second reading.

9.30 p.m.

Baroness Macleod of Borve

My Lords, I also congratulate my noble friend Lord Mottistone on introducing this excellent and necessary Bill. I am grateful to follow the noble Lord, Lord Rea, because he has expert knowledge in very difficult areas. I know that the noble Lord, Lord Pitt, also has that expert knowledge. I know a little of the excellent and exceptional work that the noble Lords perform. It has been said that the large mental hospitals are pretty awful places. In many cases they are vast Victorian mausoleums, and they are gradually being run down. In that process it is incorrectly presumed that there will be care in the community of all the people who are leaving such hospitals. Up to the present moment that is not so. A number of people are leaving these hospitals and becoming homeless. If they are lucky they go to hostels; if they are luckier still they return to live with their families. That is often very difficult for all of them.

I do not believe that anyone has mentioned violence. I believe that noble Lords will agree that often these patients are very violent and can be very disruptive both to their neighbours but usually to the people whom they love most; namely, their parents.

Lord Campbell of Croy

My Lords, I am grateful to the noble Baroness for giving way. It is only a proportion of schizophrenics who are violent. The large majority of them are very calm and quiet people who would not be violent to anyone.

Baroness Macleod of Borve

My Lords, I am sure that the noble Lord has a much greater knowledge of this subject than I. I have a large number of letters in my hand. In all of them the families say that they are frightened of their sons who are often 19 or 20 years of age and they are frightened of living with them. That is one of the problems. I hope that the noble Lord and I will agree to differ on this point.

Lord Winstanley

My Lords, I am grateful to the noble Baroness for giving way in order that I may intervene on her side of this argument. I referred to the sad case in which a patient suffering from schizophrenia murdered a social worker. Therefore, let us not go away with the impression that we_. are unaware that such people can be violent. They can be violent if proper after-care is not provided.

Lord Campbell of Croy

My Lords, I do not differ from the noble Baroness, but I do not wish the impression to be given that all schizophrenics are violent. That would be a pity. I accept that unfortunately a proportion of them are violent and that is a problem. It would be wrong to give the impression that all of them are violent.

Baroness Macleod of Borve

My Lords, is there any other noble Lord who wishes to interrupt me? I shall be very willing to sit down because the hour is late. As other noble Lords have said, when these people have left hospital it is absolutely vital that there should be a follow-up to the health authorities. The schizophrenics should be monitored by the community psychiatric nurses who are able to give them the medication that they need and also oversee that they are taking it.

Local authority social workers are not suitably qualified people to look after those suffering from schizophrenia. The Griffiths Report seemed to think that social workers and the service managers whom they advise us to have could give the help and service required. I do not think they could. I have received many letters from the parents of young people living at home. I shall quote briefly from one. They are all tragic, but in this letter a lady refers to her two sons, both of whom suffer from schizophrenia. She says: I am seventy and half years old. It hurts badly that I could no longer care for them. Six young men whom they knew—two were friends—suicided in the last four years. They did not have hostel accommodation. They were on their own. Please, please help". I have also received many letters from psychiatrists who are worried about these people who are now outside the community.

The noble Lord, Lord Graham, will be familiar with the Enfield Health Authority. I was talking only yesterday at Chase Farm to one of its excellent service managers. She has a long history of looking after psychiatric patients. She is now, luckily for them, the service manager. She told me that by 1993 both Claybury and Friern will be closed. Her unit will have to take in 150 extra patients. Wards will be provided because the authority is already starting to build wards to take in those patients. Unfortunately, some of the beds needed for local mental patients are taken up by elderly patients. She says that she needs more community psychiatric nurses. She has 16 and needs 30. She also needs day centres for these people to go to so that their parents can have some relief and also for those who do not have hostel accommodation. She needs a 24-hour psychiatric team to be ready in case things blow up in the home. She also says that a register of patients must be kept by the health authority.

I should like for a moment to move away from schizophrenia and deal with psychiatry. I am president of the housing association for Napsbury, which has a large psychiatric hospital. I should like briefly to tell the House what is happening there. It has a good way of dealing with those who are able to go into the community. They are chosen, six at a time, to go into flats within the confines of this vast hospital. They live together, six men and women, for about three months to see whether they get on. One does all the cooking and the housework and the others go out to work. They are not schizophrenic because, as we know, schizophrenics can hardly ever go out to work. These are psychiatric cases. They are then housed by local authorities. There are 12 local authorities. We now have 12 houses in which six people live on a halfway basis. They then go on to live outside the confines and some marry. They are then considered to be all right and are not a burden to anybody. That is a wonderful way of dealing with people who doctors and nurses think are able to live in the community. That is the way of the halfway houses.

However, in this debate we are discussing the illness of schizophrenia. I hope that the Government will listen to what we all have to say because I feel that schizophrenia is different from the other kinds of mental illness. In my view, schizophrenics need more constant help and more constant medication. I also hope that the Government will give this Bill a fair wind.

9.40 p.m.

Lord Thurlow

My Lords, I strongly endorse the description of the Bill as expressed by the noble Baroness, Lady Macleod, as both excellent and necessary. I very much hope, as previous speakers have said, that the Government will take this matter on board and, if possible, find time for it. However, if that proves not to be possible perhaps they will at least take it as a model for their own legislation for which we have been waiting for a long time and which we keenly expect.

Clause 2 of the Bill would provide all the necessary services that after-care requires. However, you can lead a horse to the stream but you cannot make it drink. I should like to confine my remarks to an aspect which was referred to by the noble Lord, Lord Winstanley; that is, cases where discharged patients with serious schizophrenia refuse, or are unable or unwilling—deliberately or otherwise—to take the medication which their doctors have prescribed for them.

In such cases, as the noble Lord, Lord Campbell, said, the symptoms inevitably recur, usually very rapidly. I myself, with a member of the family to whom we used to have to give care, have experienced the speed with which failure to accept medication results in recurrence; that is, recurrence of hallucinations, of voices and—in this case—of violence and depression. This generally creates circumstances in which the caring family just cannot cope. Those symptoms derive straight away from the nature of the disease.

The reason the discharged patient does not avail himself of the medication services is built into his condition. One of the central features of schizophrenia is the erosion of the powers of normal responsibility for your own welfare; you just do not bother about what you need. Moreover, you are unable to adhere to a routine and you are liable to forget and ignore the prescriptions.

On discharge the lucky patients are able to go to hostels. I warmly endorse what the noble Lord, Lord Henderson, said about the value and importance of hostels. Please may we have more of them? I understand that there are places for only one in 10 of those who require hostel treatment, and so most of those discharged return to their unfortunate relations for them to do the best that they can, to bed and breakfast accommodation or perhaps to solitary flats, and often, as we have been told, to live rough on their own resources. They often resent attempts to help them.

The refusal of patients to do what they should in the way of medication is likely to be one of the most difficult themes for the code of practice which Clause 4 so usefully provides. There can be no cut-and-dried solution because all the cases are to some extent different from one another. There must be individual treatment. It is necessary to contemplate a spiral of the different forms of special action that may be necessary to induce those patients to get the treatment, or to help them to get the treatment, that they should have. The first recourse is for the CPN or the social worker to persuade the patient to do what he should do. If one visit is not sufficient, there should be recurrent visits with such help as he or she can get from members of the family or friends. It may still be impossible to persuade the patient to do what he should do. Apart from the problem of his unwillingness, there is the problem of access to patients who are living rough. With the best framework in the world, how on earth shall we succeed in keeping in touch with patients living rough? I find that difficult to imagine, but we must do our best.

There is then the extreme case of the persistent and deliberate refusal of medication, despite clear and responsible prescription. In theory it is then possible again to go through the elaborate procedures for certification and enforced residential treatment, but that, after all, runs counter to the whole philosophy of community care and, in ally case, there are always likely to be practical difficulties, if only through the shortage of beds.

Do we not need to work out a new half-way house to confinement? It could be a new mode of carefully considered certification by responsible doctors to authorise the health authority to administer compulsory treatment, whether in day centres, clinics or elsewhere without the need for residential confinement. There would of course have to be safeguards. The rights of patients must be most carefully respected, but without some such fallback position I do not see how even the ideal framework of after-care which the Bill sets out to provide can fail once again to allow a considerable number of serious schizophrenics to slip through the net, with grave damage to themselves, to their relatives and to the carers in the community

9.50 p.m.

Lord Pitt of Hampstead

My Lords, like other speakers I wish to congratulate the noble Lord, Lord Mottistone, on introducing the Bill, the provisions of which are admirable and a marked improvement on Section 7 of the Disabled Persons Act 1986. If applied, those provisions will go a long way towards meeting needs.

However, I am very doubtful about the wisdom of legislating on the basis of a diagnosis. I hope that the mover of the Bill will agree to amend it to cover mental illness. There is a danger that one psychiatrist, in order to make sure that his patient is looked after, might automatically diagnose schizophrenia. There could also be the risk of the direct opposite—some very sticky psychiatrist who feels that there is a legal consequence from labelling somebody schizophrenic. He may be very slow to make that diagnosis. Both dangers exist in the Bill. If the truth be told, schizophrenics are the people who benefit most from its provisions even if the Bill were to apply to all mental illness.

We have here an illness which at its mildest can mean that a fellow is merely awkward and unsociable; at the other extreme there is the bizarre behaviour to which attention has been drawn. That behaviour includes violence on which there has already been a debate. There is also the disease in which relapses are frequent and remissions abound. There is another disease where the patient has no insight and so is very difficult about taking medication because he thinks he is all right.

Those are the people who will benefit most from the provisions of the Bill. I can therefore see no difficulty from the point of view of those who are anxious to look after schizophrenics. I recognise what the fellowship wishes and I can see no difficulty so long as the Bill covers all mental illness. I believe that that is the proper course and I hope that the House will give the Bill a Second Reading. I also hope that when the noble Lord, Lord Mottistone, has conferred with his friends he will agree to amend the Bill so that it covers all mental illness.

Many of the suggestions made earlier are admirable. There is no question about it: we need more hostels. The noble Lord was right about the need for halfway houses. If we are short of community psychiatric nurses we shall fail. That is a very important factor in the provisions. I put it this way: we are coming to an important era. What we ought to do is to agree tonight that we shall legislate along the lines suggested in the Bill. However, I hope that the noble Lord will recognise the need to extend the Bill to other mental illness.

9.55 p.m.

Earl Haig

My Lords, I wish to add my support to my noble friend Lord Mottistone and to the Bill which sets out to deal with very serious problems. The problems which we are discussing are aggravated by the closures of so many psychiatric hospitals, thereby scattering many pitifully mentally ill patients into all kinds of homes and hostels—and even on to the streets—without proper care. Resources are urgently needed to provide the after-care treatment which schizophrenics require. Many of them need care from psychiatric nurses, many of them need basic warmth, food and clothing, quite apart from accommodation in hostels and sheltered workshops.

People in this country are really beginning to care about the mentally ill. They will not countenance a policy which deprives people of their needed care which could be made available, given the money. Attitudes to mental health are changing, although, sadly, the advances that have been made in various fields of medicine have not included a cure for schizophrenia.

I must say that my family has had recent experience of schizophrenia, and although new treatments and drugs have been found there are so far no available cures. I shall put a few key points to your Lordships as I see them. Family doctors are not always as responsive to the signs of illness in patients, or to the pleas of relations, as they should be. If there are obvious symptoms, a case should be referred by the doctor immediately to a psychiatrist. If there is a delay, symptoms could get worse; and the longer the delay, the more difficult the treatment.

If the case is referred to a hospital for treatment, in due course the patient will either return to his or her family or it is to be hoped go into some form of community care. Then every precaution will be needed to prevent a relapse perhaps into depression or even into hallucination. All the prescribed drugs and treatments and the necessary psychiatric attention will have to be given to the patient when he or she begins a new life outside the walls of the hospital. It is vitally important that everyone involved, doctors, nurses and members of the family, make sure that the prescribed pills are taken and that alcohol is avoided.

The suggestion of the noble Lord, Lord Henderson of Brompton, that hostels can play a big part here is a valid one. The point made by my noble friend Lady Macleod of Borve about violence is valid in that so many of the gentlest people can become aggressive if pills are not taken or if alcohol is taken. After leaving hospital, patients are enormously vulnerable and many of them find it hard to cope with the simplest problems. Even having to decide to move from one part of a room to the other is hard. In that early stage of recovery some have inner needs for self-expression which should be channelled into something positive and creative by therapists who are equipped to help. Those are the lucky ones who will find freedom; others may need leadership for the rest of their lives.

Quite often family members are not wanted and people who are less close to the patients are better able to shoulder the responsibility. At this crucial stage when the first assessment has been made, the supervision of the health authority is particularly needed to make sure that the local authority co-operates and implements all the arrangements. Equally important is the need for the health authority which makes the assessment to get in touch with a patient's doctor and, whenever possible, a patient's family.

After a decision has been made as to whether the patient is to be helped within the family or in some other environment, or by a mixture of both, the health authority must make sure that the family is given some advice through a doctor or psychiatrist. Whether or not the patient is sent home, the family is still involved. Many families do not understand and are frightened by the situation. They must be given guidance and encouragement to help to remove any ideas of guilt about being in any way the cause of the illness. The cause of the illness is genetic and not environmental.

Section 7 of the Disabled Persons Act and its requirement that six months have been spent in hospital has been referred to. In most cases there is no need to stay in hospital for as long as six months, with unnecessary demands on beds or medical staffs concerned. The system of helping people so far as possible and as quickly as possible to use their minds and bodies within the community is a sound one. If that is so, and if the majority of patients are to be released in less than six months, then many more psychiatric nurses will be needed to look after them.

Those parts of the Bill which ensure continuing treatment and supervision and an annual review are most important. Equally important is the need to supervise moves from one locality to another and the need to trace patients who become lost.

All those measures will cost money. In view of the delay in the implementation of the 1986 Act, I hope that this Bill, if it is passed, will not take as long. Money is urgently needed now. In the case of my family the difficulties have been enormous; but how much greater they would be for families without private means.

I have tried to spell out, as other noble Lords have spelt out, the needs of thousands of men and women who suffer from schizophrenia. In the first place it is the Government to which we must look, and through them to local government, for the resources needed to provide help. Ultimately it will be the health authorities which will have to take the lead in making sure that all the necessary services are provided and co-ordinated. When help is available there will be some chance of these thousands of people finding relief and the opportunity to live their lives to their maximum potential. Theirs is a physical illness which has to be treated by chemical means, but it is triggered off by the exaggerated effects of strain and a wrong environment. So human love as well as psychological and spiritual guidance are needed to help people recover. Without proper treatment their future is grim.

As has been said, last year 50,000 families were in turmoil and despair. It has also been said that the Government invariably move to block Private Members' Bills that have public spending consequences. I pray that on this occasion the Government will prove that that is not so, for a civilized society is judged by the way in which it cares for its mentally ill and mentally handicapped. The Government and we as a civilized society have an inescapable responsibility to make sure that they are cared for.

10.3 p.m.

Lord Greenhill of Harrow

My Lords, it is very late and I shall speak very briefly. However, before doing so I should like to thank the noble Lord, Lord Mottistone, for his initiative.

I am ashamed to say that until this morning I had no idea that the Bill existed. Indeed, I should not have intervened in the debate had I not recently learned from family friends how inadequate, indeed disgracefully inadequate, are the pesent arrangements in certain areas for the after-care of these unfortunate patients. I therefore strongly support the Bill. But even if it passes into law I wonder whether the Government would allocate the necessary resources.

The case with which I have recently become familiar falls within the responsibility of the Hastings health district and the Rother authority. It may not be appropriate to consider the details of an individual case, but suffice it to say that in this case the ineffectiveness and indeed the indifference of the local authorities are matched only by that of the Department of Health. The net result is that a sick and often violent young woman is forced to drift uncared for in a town, robbed and abused, among drug addicts and depraved and homeless people. I would not have drawn attention to the case if I were not satisfied that every effort had been made by the mother to resolve the problem with the local authorities, but she has been rebuffed. I have not had a chance to speak to her today, but I wish to do so. With the Minister's permission, I would encourage her to get in touch with him.

No doubt noble Lords will have noticed a very balanced article by Amanda Mitchison in the Independent magazine of 11th March. There is a copy in the Library, to which I draw noble Lords' attention. It gives a more vivid account of the conditions in Hastings than I can. I understand that the conditions in other south coast resorts are not dissimilar.

I cannot believe that senior members of the Government while speaking legitimately of our national well-being can withhold resources from authorities with after-care responsibilities. No doubt some authorities give good service and facilitate co-operation between the groups involved in the public and private sectors, but I suggest that they are in a minority. I sincerely hope that the Government will consider the Bill in the light of the present deplorable situation.

10.7 p.m.

Lord Young of Dartington

My Lords, I hope that I may be allowed to say a word as an unexpected supporter of the excellent Bill of the noble Lord, Lord Mottistone.

There has been remarkable unanimity tonight among those who have spoken. The differences have been only on matters of detail that do not bear on the general support that everyone has given the Bill. I think that this is because all of us are aware that, as more mental hospitals have closed and are closing and money is saved on that account, there has been no corresponding build up of the community after-care services that are so needed. We all know that there are exceptions. I know the district of Exeter in particular. The district health authority under a very far-sighted general manager, David King, has built up a fine set of local services. As we know, in many parts of the country this is not the situation.

We know also that the Government have been dithering over the Griffiths Report for far too long. They seem prevented by their apathy as regards local government from proposing any close involvement of local authorities with the after-care of schizophrenic patients and those suffering from other kinds of mental illness. As a result, discharge too, often has meant a kind of disappearance.

The noble Lord, Lord Winstanley, mentioned the Sharon Campbell report published last year. Sharon Campbell had been treated in hospital for schizophrenia, and subsequently stabbed her social worker to death. The committee of inquiry asked the following question: how did the system allow Sharon Campbell to drop out of sight so far as concerns psychological care on each occasion on which she was discharged from Bexley Hospital?

One answer must be under-funding of the support services. The report referred to Dr. Brough, the consultant psychiatrist in the case. He is a man and doctor of excellent repute. But in his catchment area in Bexley there were 83,000 people. It was an area of severe housing problems and high unemployment. As one consultant psychiatrist for 83,000, when the recommendation is that there should be one for 40,000, he had a very heavy burden of work. So in that area did others concerned with such people: nurses, community nurses and social workers.

So it is in many parts of the country. However, not only is it a lack of money, resources and the facilities required, as we all know there is a lack of communication between all the different specialists, between hospitals and outsiders and all members of the teams which do not necessarily behave as teams because they are called that. This Bill is designed to improve that communication in a very practical way and ensure that schizophrenic patients receive proper community after-care. I am delighted to join with the other speakers tonight in supporting this Bill and wishing it a speedy passage through Parliament.

10.10 p.m.

Lord Ennals

My Lords, like other noble Lords, I want to congratulate the noble Lord, Lord Mottistone, for introducing this Bill and on the way in which he did so. He must have felt very gratified with the degree of support that he received from all sides of the House with speeches that showed deep understanding, often personal commitment and experience, and a sensitivity that will have touched us all.

Apart from my own family, I have been involved with this problem for 25 years, usually with voluntary organisations: the Cyrenians, St. Mungo's, the Peter Bedford Project, MIND, the Campaign for the Homeless and the Rootless, the Beacon Housing Association, Homes for the Homeless, and Care Trust. I pay tribute to the charities which bear such a heavy burden of care for some of the people of whom we are speaking today. The noble Lord, Lord Mottistone, spoke about the size of the problem and said that there were a quarter of a million sufferers from schizophrenia. It would be difficult to discover the exact figure because, as has been said—and I shall repeat it later—schizophrenia is often difficult to diagnose. The noble Lord pointed to a problem of massive proportions. There can be no one in the country who is not aware of the problem of the mentally ill in the community. But often when people see the image of the illness, they do not understand that the person who is behaving in a bizarre way is ill and not simply perhaps drunk or disorderly.

We see the problem of the mentally ill and the consequence of mental illness, which is homelessness, in our stations, in the Underground, under the bridges of London, at night above the air vents of hotels, in empty houses, in night shelters, on park benches, and in Salvation Army hostels. Sufferers go in and out of hospital, and back again into hospital. The readmissions are a revolving door which is sometimes a revolving door in and out of prison just as much as hospital. The growing army of the mentally ill who are inadequately cared for in our community is in my view an absolute disgrace to our society today.

The problem is increasing. There is no doubt about it. All the statistics show that. Over the past few years the numbers of these people, who clearly are not cared for, are higher than they have ever been. An analysis shows that a high proportion of them have been in hospital. I am speaking not only of men but of women too—people of all ages. So many young people are affected, all of them usually poor. They are sometimes dirty and neglected. Often they are hungry. Some of them are suicidal, sometimes successfully, sometimes not. They all need treatment or care. There are many others who are not on our streets but within their own homes causing tremendous problems, great havoc and often fear and frustration to their families who try to come to terms with this illness.

I do not understand how it is that in a supposedly caring, Christian society the Government do not appear to care more about the problem. The facts have been brought before the public time and again, month after month, year after year. We have had successive reports from the Audit Commission. I shall not quote from them, although I have them here. We know what the All-Party Parliamentary Select Committee in another place had to say in searing words, in critical terms, but in a very constructive way.

We know what the Griffiths Report said. We know that the committee was established by Mr. Norman Fowler, the Secretary of State for Social Services, because he saw the size of the problem. It took long enough for the report to be produced. After more than a year not a word has been said. I have to tell the Minister that this House has been misled on a number of occasions. We have been told sometimes that a response will be made this month, this year or next year. The last we heard, many weeks ago, was that it would be very soon. I believe that it was the Minister who used the term "very soon". It is now rumoured that the Prime Minister has decided to set up a special committee to look at the problem. If it comes up with proposals as unacceptable to those who have to operate them as the proposals by the committee set up by the Prime Minister on the National Health Service, I believe that we shall have reason to fear.

I support the initiative taken by the noble Lord. I hope that this Bill will not only have a Second Reading but that it will be effectively implemented and the resources provided to enable the job to be done, because I believe that the matter is urgent.

I share the views of my noble friends Lord Rea and Lord Pitt, who are GPs, concerning the broadening of this issue. My information is that it is often very difficult to diagnose a schizophrenic. Reference was made by the noble Lord, Lord Winstanley, to the Sharon Campbell case. In that case doctors were often very reluctant to diagnose schizophrenia when it seemed to others that that is what this person had. It did not seem to be easy to diagnose. Even if it were easy to diagnose, would we say, "Is this one a schizophrenic? Is this one a manic depressive? Is this one suffering a form of behavioural problems or some other type of psychosis?" How can we say that there is one level of service for one group of people who are mentally ill and another level of service for another group of undefined people? I believe that if the law is to be amended, as I hope it will be, we must decide to help all the victims of mental illness, with no form of discrimination.

I believe that the noble Lord was quoted on one occasion in a press release by the National Schizophrenia Fellowship. The words that he used in presenting his case were that he hoped the matter would be widened. The matter needs to be widened when this House deals with the issue in Committee. Otherwise there will be dangers, difficulties, unhappiness, and so on, that we ought to avoid if we possibly can. When the Minister replies I hope that he will have some positive words to say. He has to tell us where we stand now in relation to the Griffiths Report. What is happening within government? Where is the Griffiths Report? When will the Government reply? Has a special committee been set up, with the result that there will not be an early response? Is it some months off? It is not only we in this House who are entitled to know. Those who are responsible for planning the services—the local authorities, the health authorities and the voluntary organisations—are crying out for a decision by the Government. It is unfair to both those who need care and those who provide it not to have some kind of leadership from Her Majesty's Government. It sometimes appears to me that they do not care.

I hope that in his reply the Minister will not only show the same degree of sympathy which has been expressed by noble Lords on all sides of the House, but that he will turn that sympathy into reality. Soft words of sympathy, if they do not lead to action, are not much good. They will not butter many parsnips.

I hope that the Minister will see the nature, urgency and poignancy of the problem; that he will respond to the appeals which have been addressed to him; and that he will put forward a response worthy of Her Majesty's Government.

10.20 p.m.

Lord Henley

My Lords, I have listened with great interest to the debate which has taken place this evening, as have all noble Lords. Until recently I knew little about schizophrenia. The debate will prove useful in heightening public awareness of schizophrenia which is most important.

With that in mind, I was pleased that my noble friend Lady Elliot and the noble Lord, Lord Henderson, mentioned the Esther Rantzen programme televised last Sunday. Another noble Lord mentioned a programme by Marjorie Wallace which was televised last August. Both programmes were useful in helping to dispel the popular Jekyll and Hyde misconception mentioned by my noble friend Lord Campbell of Croy.

I was pleased to hear my noble friend Lord Mottistone pay tribute to the Salvation Army. I noted what he said and I am sure that all noble Lords will agree that it carries out valuable work. We are grateful to the Salvation Army for that. We are also grateful to the work of the National Schizophrenia Fellowship which, as my noble friend Lord Mottistone knows, the Government support with a grant towards its annual expenses.

I should say straight away that while the Government have the greatest sympathy for the problems faced by sufferers from schizophrenia, and particularly with their relatives—who represent a very large proportion of those with major mental illnesses—we could not support a Bill which is discriminatory and, as such, unwelcome in the context of the aims to provide a comprehensive package of care for all people who suffer from mental illness. There is no valid reason for singling out one category of mental illness and legislating for its treatment on a preferential basis.

The suggestion was made by the respected doctors—the noble Lords, Lord Rea, Lord Pitt and Lord Ennals—that such measures proposed in the Bill might be extended to other forms of mental illness. At present Her Majesty's Government are not in favour of any measure which introduces special legislative consideration to the needs of the mentally ill compared with, say, those suffering from a mental handicap or a physical illness. The thrust of a recent White Paper on the National Health Service, Working for Patients, confirms the stance taken by Ministers for several years. It is that within broad policy guidance from the centre, health authorities should be identifying their own priorities and developing local services accordingly. The same is true of local authorities. The requirements of the Bill would tend to skew this process which is intended to give health and local authorities the freedom within very broad policy limits to assess and meet local needs.

I am very well aware of criticism—and I could not but be aware of it having listened to this debate —which has been levelled at services for the mentally ill in the community. Modern forms of treatment have meant that patients are likely to need much shorter stays in hospital. The Government have always recognised that first and foremost, there must be a full range of local services, providing both in-patient and out-patient facilities, so that people with mental illness should have access to those services as locally as possible.

The provision of continuing effective care for those discharged from hospital treatment is also of central importance. Ministers are continually emphasising the importance of professional teams planning and agreeing individual care programmes with each patient, and where appropriate, with their families, before discharge. Once a patient is discharged, there must be proper monitoring and co-ordination of these programmes, especially for those who are chronically ill or are regarded as more vulnerable than others. This is good, professional, practice, and we do not see legislation as the means to ensure that this happens.

Further legislation would, in fact, be premature in the light of the programme of work which my honourable friend the Parliamentary Under-Secretary of State for Health described recently in another place. During the current year the department will be looking at the provision of mental illness services in each region. There will be discussions with regional health authorities, and the Social Services Inspectorate, and steps are being taken to link directly with voluntary organisations in order to get the reaction of both sufferers and their relatives. This will be a lengthy process and the Government will then consider what steps, if any, need to be taken to improve matters.

A significant feature in the department's deliberations will be in relation to the proposed closure of mental illness hospitals. Policy statements have long emphasised that mental hospitals should not be closed before adequate, alternative facilities have been developed. I am sure that your Lordships will agree that no-one would wish to return to the days of the very large psychiatric wards in the huge institutions of 2,000 or more beds. With new and improved methods of treatment, the decline in the number of elderly long-stay patients and the progress of community care has resulted in a steady reduction in bed requirements. Some rationalisation in hospital provision is a reasonable development but the Government's policy recognises the continuing demand for in-patient provision which must also take account of those sufferers who may need long-term care, including "sanctuary" or asylum. Ministers are currently looking at ways to ensure that there is a closer collaboration between the department and health authorities to ensure that any closures do in practice follow the principle that adequate facilities in the community are indeed there for patients once they leave the older institution.

I mentioned earlier the concern about continuing care for patients discharged from hospital. Departmental guidance, which is almost ready for issue, will emphasise the need for locally developed approaches. This is in support of the planning guidance, issued to health and local authorities in July last year, which requires that by 1991 each district should have developed a "care programme" to provide a system of co-ordinated continuing care, especially for people chronically disabled by mental illness. Emphasis was placed on the need for a consultant psychiatrist in each district to have special responsibility for rehabilitation and continuing care. Another major step is being undertaken by the Royal College of Psychiatrists which has agreed to draw guidelines to ensure minimum acceptable professional standards for assessing patients prior to discharge and for follow up action after discharge.

Lord Graham of Edmonton

My Lords, perhaps the noble Lord will give way. The noble Lord will understand that I listen to him with deep respect. However, does he understand that the reality on the ground is wholly contrary to what he has sought to tell the House? Will the Minister not understand that most people here tonight have refrained from going over the top from their personal knowledge of what is the reality? I can give a number of hair-raising illustrations of the bleakness in the prospects of the people that I seek to represent. Will the Minister carefully consider that he is giving a slap in the face to many people who desperately need his help?

Lord Henley

My Lords, we understand the problems, and I hope that I am not giving a slap in the face—as the noble Lord puts it—to all the people who are suffering. I hope that I have explained what the Government propose and are seeking to do.

I should also like to take this opportunity to mention the setting up of a small multi-disciplinary and independent working group to complete the task of drawing up a code of practice on the treatment and care of detained patients. The code, which is required under the Mental Health Act 1983, will aim to provide a common basis for treatment and care—an area where there seems to be wide agreement that the law is adequate but its interpretation by practitioners is at times not so. The group will be chaired by Mr. James Collier, a former deputy secretary in the department. The members all have wide-ranging experience of the operation of the Mental Health Act 1983.

I turn now to some of the points made by noble Lords during the debate. The noble Lord, Lord Winstanley, seemed to be under the misapprehension that Section 7 of the 1986 Act would be implemented next year. That is not the case. Discussions are continuing with local authority associations; and when they are complete (this summer) Ministers will have to consider whether to implement Section 7. If it is decided to proceed there will need to be a decision on when, but no time-scale has yet been given. I shall certainly write to the noble Lord if he wishes to have further details.

The right reverend Prelate the Bishop of Sheffield referred to the parable of the Good Samaritan, which he described as controversial. I never knew it was controversial. The National Schizophrenia Fellowship will, I am sure, acknowledge that the department is trying hard to get a full understanding of the problems. In the light of that, Ministers have made clear that they will act. But we do not think that this Bill is the right way forward.

We could not agree more with my noble friend Lady Elliot, in that it is vital for discharged patients to obtain continuing treatment; hence the action we have already taken on care programmes. We shall be considering what further initiatives we need to take during the course of the year and as our review of the position throughout the country proceeds.

The noble Lord, Lord Henderson, referred to case histories. If the noble Lord will give me the details, I shall look into them and bring them to the attention of my right honourable friends to see what can be done. That also applies to other noble Lords who raised individual cases. The noble Lord, Lord Graham, referred to a handicapped patient and I shall look into that case if the noble Lord will give me details. I thank him for advising my officials before the debate.

Lord Graham of Edmonton

My Lords, I am most grateful.

Lord Henley

My Lords, the noble Lord, Lord Henderson, referred to hostels. We very much agree that hostels are important. The department has funded research which shows how cost-effective they are. We look to see a continuing increase in the number of hostels provided by health authorities, and of course by local authorities and the voluntary sector.

My noble friend Lord Campbell of Croy stated that schizophrenia was the most prevalent mental illness. I am not sure that my noble friend is entirely right, though it is certainly one of the more common. Apart from that, I agree with everything that my noble friend said.

The noble Lords, Lord Hankey and Lord Rea, and my noble friend Lady Macleod, mentioned the number of community psychiatric nurses. The number of such workers working in the community continues to rise. During the period 1981 to 1987, the total number of staff employed in community psychiatric nursing services more than doubled from just over 1,000 to 2,700. We are continuing to look for further increases. We are also continuing to have discussions with the health authorities on this question.

The noble Lord, Lord Hankey, raised the question of the Portsmouth and South-East Hampshire health authority relating to Portsmouth and Southsea. I agree with the noble Lord that Portsmouth and Southsea is a good example of collaboration between health and local authorities and voluntary agencies providing services for mentally-ill people. I am pleased to say that there is evidence from many other parts of the country that have similarly developed extensive local services that care in the community policies can be implemented successfully.

My noble friend Lady Macleod does far less than justice to the skills and caring work of many social workers who work with the mentally ill. Since 1983 several thousand have received special training to practise as approved social workers for the mentally ill. The noble Lord, Lord Thurlow, raised the question of compulsory treatment in the community. Despite all efforts it may be that some mentally-ill people will refuse further treatment after they leave hospital even if it is considered essential by the treatment team responsible for their case. Legal measures to enable compulsory treatment to be given in the community have been suggested as one way forward with this small group of patients. There have been discussions with such organisations as the Mental Health Act Commission, the Royal College of Psychiatrists and MIND.

It is a complex area and important civil liberty issues arise. There are strongly-held views on all sides. Department officials are listening to the debate with close attention, but to date no firm proposals have been put to us and as yet little research is available from this country. No changes in this difficult area would be considered without full consultation with all those concerned with mental health.

The noble Lord, Lord Greenhill of Harrow, also raised a particular case. I shall be happy to examine the details of that if he cares to give them to me. I associate myself with the remarks made by the noble Lord, Lord Ennals, concerning the contribution of voluntary organisations. They are a most important element of the spectrum of provision. I wish particularly to acknowledge the long history of service provision by the voluntary organisations. Perhaps the organisation most closely associated with the noble Lord is MIND. I understand that the noble Lord and my noble friend Lord Colville are soon to become joint presidents of MIND. I offer my congratulations.

I now turn to an issue about which I believe that the noble Lord, Lord Ennals, will not feel quite so happy. I refer to the Griffiths Report which the noble Lord, Lord Winstanley, and others mentioned. Turning to the wider issue of community care, I should respond to the requests today for a government response to the Griffiths Report. I can assure you that the Government have not been idle on this issue. We are currently giving careful consideration to Sir Roy's report together with the numerous responses received to it. All recent reports in this field identify common problems, but recognise that there is no obviously perfect solution. We therefore need to look thoroughly at all the various options before us. We share concern that action should not be unduly delayed but it is vital that we reach the right solution in this important area. Again, I mention the remarks of the noble Lord, Lord Winstanley, who said that it was important that we did not rush too quickly into the wrong solutions. We hope to be in a position to bring forward our own proposals in the near future, as my honourable friends have repeatedly made clear in another place.

In returning to the issues raised by the Bill, I conclude by saying that, with the positive proposals concerning moves towards ensuring adequate provision of services for the mentally ill which I have outlined today, we are not convinced that the legislative procedures envisaged in the Bill are appropriate at this time.

10.40 p.m.

Lord Mottistone

My Lords, I am baffled. My noble friend has responded to everybody's speech except mine. He has made absolutely no comment on why he does not like the Bill. He has not said which points he does not like. Where noble Lords did not like it, they said so, but my noble friend said nothing. I do not blame him; I blame his department.

Lord Henley

My Lords, at the beginning of my speech I made it quite clear that we felt that the Bill was discriminatory in relation to mental illnesses. The noble Lords, Lord Pitt and Lord Rea, suggested extending it to all other mental illnesses. We felt that it would be discriminatory just to deal with mental illness and mental handicap and not deal with other disabilities. I think I made that perfectly clear.

Lord Mottistone

Yes, my Lords, I was about to come on to that point. However, that is only one point, which could be dealt with by amendment in Committee. I explained why we started off with one specific kind of mental illness. I am sorry that my noble friend did not take up my explanations regard ing that point, which he might easily have done because he obviously listened carefully to all the other speeches.

As to whether the Bill should apply only to schizophrenia or to all kinds of mental illness, I foresaw when we constructed the Bill that this point might arise. One of the purposes of a Second Reading is to find out how strongly people feel. My noble friend and the Government feel very strongly. It is the only thing about which they feel strongly. Those general practitioners who took part in the debate also felt strongly about it and others have felt much the same way.

I am willing for the Bill to be amended in Committee to take care of the wider coverage of mental illness. As I agree to that, I imagine that the Government will have no objection. They have expressed no objection to other parts of it. The Bill has had a jolly good reception by noble Lords on all sides of the House. Its principles were clearly understood by your Lordships. Anyone who wished to criticise the detail did so, and on the whole there was very little of it.

One of the most important contributions to the debate came from the right reverend Prelate the Bishop of Sheffield. He said that people might say that if one could not provide for everybody, one would help nobody. That was rather the view coming from the Government, but not altogether so. That is why I wanted to start with schizophrenia and then build on to later legislation to give the same arrangements, or modified ones, as experience showed. I am quite ready to start with mental illness as a whole. If we say that because we do not feel that we have all the resources to deal with mental illness, which is a much easier starting point, we should not start but should wait until finally we have everything ready for all the others, we shall never get there.

I shall not go through what other noble Lords had to say because the Minister has done that, although in my book he did not do it as well as he might have done. He did not pick up the more important point which is that everybody agreed with me. Therefore I think it would be most helpful to take the Bill a step further to see what we can achieve by way of amendment in Committee. No doubt those who are interested in the matter will be happy to discuss what kind of amendments may arise. We can then see how the matter progresses from there.

In the meantime, I hope that my noble friend the Minister will ask his ministerial colleague to read this debate—in particular, my speech— and also to read the Bill, so that he will see what we are really concerned with here. If the Government were to pick up the matter now when people want action—indeed, they have been crying out for action—they will not only help those people who are mentally ill, but they will also help themselves in regard to the many criticisms which have been made against them for not taking up the recommendations contained in the Griffiths Report. Such criticisms will remain, but they will not be quite so persistent while people see this matter being taken up.

I ask the House to give the Bill a second reading.

On Question, Bill read a second time, and committed to a Committee of the Whole House.