HL Deb 03 May 1990 vol 518 cc1204-26

House again in Committee.

Lord Ennals moved Amendment No. 107ZC: After Clause 20, insert the following new clause:

("Recruitment and retention of NHS staff

.—(1) The Secretary of State shall—

  1. (a) prepare and publish a plan for the purposes of promoting the recruitment and retention of such staff as may be required by any regional, district or special health authority, health board or special health board, NHS trust or fund holding practice, within the terms of this Act;
  2. (b) keep the plan prepared under paragraph (a) above, and any further plan prepared by him under this section under review; and
  3. (c) prepare and publish modifications to the current plan at such intervals as seem appropriate to him.

(2) In carrying out any of his functions under subsection (1) above, the Secretary of State shall consult such organisations for employees and employers within the National Health Service as seem appropriate to him.").

The noble Lord said: This amendment is in the name of my noble friend Lord Peston, the noble Baroness, Lady McFarlane of Llandaff and the noble Lord, Lord Winstanley. This new clause will require the Secretary of State to develop a national plan in order to ensure that the NHS are able to recruit and retain necessary staff. He would draw up such a plan in consultation with NHS employers and employees and keep the plan under review. Obviously, the reason for this amendment is that the recruitment and retention of staff is likely to be one of the main issues facing the National Health Service in the 1990s and at a time when the NHS will rely on its staff as never before in order to carry out the proposed reforms, whatever we may think of them.

Low morale in parts of the service is leading to a high wastage rate while demographic factors are hampering the recruitment of new staff. The recruitment pool of young people—that is the nub of the whole matter—is shrinking fast. Because of the dramatic decline in the birth rate between the mid-1960s and mid-1970s, the number of school leavers will fall to a mere 600,000 in 1995. That means a smaller recruitment base for the NHS. It also means a smaller recruitment base for everyone. It will draw the health service into even closer competition with every other potential employer of school leavers.

The retention of staff is also becoming more difficult in the NHS. For example, trained laboratory staff are reportedly leaving the NHS at a rate of 22 per cent. a year in order to go into private industry. It is estimated that about 10 per cent. of qualified nurses (approximately 30,000) also leave each year. A survey carried out by the Institute of Management Services revealed wastage rates varying from 10 per cent. to nearly 20 per cent. a year among the professions allied to medicine.

I have concentrated on nurses in particular because they form the largest group within the NHS. There is a major wastage rate affecting the other professions allied to medicine. I have a particularly close interest in occupational therapy. In that profession the wastage rate is about 18-2 per cent. based on the 1987-88 figures. If the matter is looked at from another point of view, the profession is roughly 22 per cent. below establishment. The independent commission which has been looking at the occupational therapies says that we shall need to have an increase of as much as 18 per cent. over the next 10 years. There will be tremendous competition.

I shall not go into the situation affecting other professions all of which have the same problem: I am thinking of physiotherapy, radiography, dietetics and chiropody. It is a major problem. It is not one that we can shrug off. If the Government accept this amendment and the Secretary of State prepares and publishes a plan which keeps the situation under review I am not suggesting that that will solve the problem. Unless he does that and we are assured that the Secretary of State has this matter high on the agenda, then whatever this Bill does to the health service, there will not be the staff effectively to implement the new measures. I beg to move.

Baroness Hooper

I understand and sympathise with the objective underlying this proposed amendment. I realise that its intention is to guarantee the continued provision of high quality health care. We entirely share the concern, but we do not believe that the situation can be dealt with by statute.

The current arrangements for manpower planning do not have a specific statutory basis but are, and will continue to be, covered under the general statutory requirements on health boards and National Health Service trusts to provide a comprehensive health service. Health authorities will be expected to continue the current practice of producing plans which integrate manpower with service provisions and finance through the annual short-term planning process.

At present district plans are monitored by regions and those of regions by the Department of Health in order to ensure consistency between services, finance and manpower and between the demand and supply elements of manpower plans. It is envisaged that monitoring will continue under the new legislation. A national plan for the purpose of promoting recruitment and the retention of National Health Service staff would transfer the responsibility for manpower planning to meet their own specific needs from employing authorities to the centre.

That would have a depressing effect on the many innovative schemes at local level. As the Committee is aware, one of the objectives of the proposals in this Bill is to give employing authorities, and in particular National Health Service trusts, more responsibility and discretion in this area. In addition, a national plan could not address the particular needs and circumstances of employing authorities and their own local labour markets: neither could a national plan respond quickly enough to changing circumstances and to short-term shortfalls.

Each health authority will need to find its own solution to the problem. They are fully aware of the demographic and labour market situation to which the noble Lord, Lord Ennals, drew our attention. In fact, we have been much encouraged by the spread of locally managed initiatives. For example, there is the idea of flexible working arrangements, return-to-work training, child-minding facilities, youth and employment training and staff benefit schemes.

In all these matters we consult with the royal colleges and the national bodies at local levels which are involved in a number of these schemes and arrangements. However, the Department of Health takes a leading role both in the planning process, as I have mentioned, and in central recruitment and retention initiatives. Recent examples of central initiatives include the excellent example that we have already discussed this evening; namely, Project 2000 for nurses. Other examples are the healthcare assistance project to provide training and assessment schemes for support staff and the drive to increase the uptake of youth training in the National Health Service.

There are local schemes for encouraging nurses to return to nursing after having had a break. In addition there are in-service schemes to encourage nurses and other medical staff to deal with all the advances in technology. The department has received extensive feedback from the National Health Service, and indeed the professions, on its proposals which have been developed as part of the intended implementation of the Bill in relation to the future recruitment and training of professional staff. At the request of the department, regions and districts are currently drawing up detailed human resource strategies to take them well into the 1990s. They will be assisted in that process by a number of centrally initiated studies.

I believe that the current combination of central drive and initiatives and local flexibility and innovation are the best way forward to meet the future staffing needs of the National Health Service and that the amendment would not help in that process. Therefore, I hope that the noble Lord will feel able to withdraw it.

8.30 p.m.

Lord Ennals

There were several initiatives mentioned by the noble Baroness during her reply which I very much welcome. I am much in favour, as I think we all are, of more flexible working arrangements such as, job-sharing schemes, opportunities for people to return to work on a part-time basis, in-service training, and so on. Those initiatives are all good and necessary, but we need to go much further down that road than we have gone thus far.

I do not see how the involvement of the Secretary of State at the centre of what is proposed would have a depressing effect. The problems we face in this respect are at every level. For example, they are at district and regional level, as stated in the amendment. Regarding the situation at health board level in Scotland, all the NHS trusts will be facing such problems. I should have thought that the co-ordinating role of the Secretary of State would have a stimulating effect rather than a depressing one.

As the noble Baroness already knows, what really worries me to a great extent is the Government's commitment that NHS trusts will be able to compete financially in this respect. They will be able to break national agreements and set their own wage levels so as to attract nurses, doctors, occupational therapists, and so on, away from the non-NHS trust hospitals or health service provision. That would create, as I said on a previous occasion, a two-tier service; that is, the elite with the higher levels of pay and the rest of them in the rest of the health service. That is a thoroughly unsatisfactory way to proceed and it would create, as I said, a two-tier service.

I shall not press the amendment at this stage. I shall read the noble Baroness's reply with all care. As I said, except for the few initiatives which I welcomed, I am rather depressed with the Government's attitude. I beg leave to withdraw the amendment.

Amendment, by leave, withdrawn.

Baroness Ewart-Biggs moved Amendment No. 107ZD: After Clause 20, insert the following new clause: ("Childcare provision: code of practice

The Secretary of State shall issue a code of practice for the purpose of—

  1. (a) giving practical guidance to any person or authority employing staff to fulfill duties under this Act with respect to any arrangements for childcare provision for employees; and
  2. (b) promoting desirable practices by such persons or authorities for the establishment of new childcare provision where none exist.").

The noble Baroness said: The amendment provides for a new clause which would place a duty on the Secretary of State to draw up a code of practice designed to encourage health authorities to make arrangements for child care provision for employees. That seems a very necessary provision in view of the fact that at present the National Health Service provides creche facilities for as little as less than 0.5 per cent. of its staff. That is slightly better than the national average, but the National Health Service is the United Kingdom's major employer for women: 90 per cent. of nurses are women and two-thirds of them are of child-bearing age.

There seems little doubt that a major expansion in employer-subsidised child care facilities is needed to retain the services of nurses with children. A further factor which brings urgency and which has already been mentioned by my noble friend Lord Ennals is the demographic change. It means that the number of 18 year-olds available for recruitment into the nursing profession will have fallen sharply. It will reach a low point of 600,000 in 1995.

That dwindling recruitment pool makes the task of improving the rentention of skilled staff in the National Health Service all the more urgent. As my noble friend said when speaking to the previous amendment, nursing has traditionally been a high turnover, high wastage occupation with 30,000 nurses leaving every year for a variety of reasons. The United Kingdom Central Council for Nursing, Midwifery and Health Visiting (UKCC) has estimated that the need for new entrants to the profession could be reduced by 6,000 per year if a 1 per cent. improvement in the wastage rate of qualified staff from 10 per cent. to 9 per cent. was achieved.

Moreover, in 1987 the UKCC estimated the net cost of training a first-level nurse at £13,000. Allowing for the transitional costs of the wastage process, calculated by the Institute of Manpower Studies at £1,000 to £2,000, and for wage inflation since 1987, the Royal College of Nursing believes that a replacement cost of £20,000 per qualified nurse is realistic. That seems a high figure.

If by providing a comprehensive network of workplace nurseries, subsidised childminding and low-cost out of school play schemes, the National Health Service could persuade 6,000 working mothers to remain in the service, the net saving to the National Health Service, after deducting the child care subsidy (which is thought to be about £2,000 per year) would be in excess of £100 million per year. In my view, that kind of figure produces a pretty compelling argument.

The amendment focuses on child care for National Health Service employees. However, I should like to emphasise the fact that on Monday this week the Princess Royal when opening the Save the Children Week reiterated the need for more child care provision throughout the country. She pointed out that public nursery places had fallen by one-half since 1945. She stressed the need for the present number to be increased.

Finally, I should like to point out how much it would help nurses to have child care facilities. Not only would it provide them with peace of mind that their children were being cared for very close to them; it would also mean that they would not have to choose when they could or could not work. At present they very often choose the times when their husbands are at home so that they are able to look after the children. Therefore, from that point of view—that is, the nurses' peace of mind—I think that the proposed clause to provide child care facilities would be most valuable.

From three points of view I think that the proposed new clause would be of the greatest importance: first, from the. general point of view that if the National Health Service provided child care facilities it would increase the very small amount of child care that exists in the country at present; secondly, from the point of view of retaining the services of nurses and also of acquiring more from the decreasing number of school leavers; and, thirdly, from the point of view of the benefit it would give to the National Health Service employees, both as regards their family life and the well-being of their children. I hope that this amendment, which suggests a purely practical and sensible change, will find favour with the Minister. I beg to move.

Baroness Blatch

There is no doubt that child care facilities can have a major impact on the ability of employers, including health authorities, to recruit and retain staff. They can also have an impact on the ability of women to combine raising a family with paid employment outside the home. It is only right, therefore, that we should be concerned, as is the amendment, with seeking to ensure that where child care is provided it is safe, caring and educationally stimulating. That is provided for in the Children Act 1989. The Act updates and modernises the regulation of both private and voluntary child care and childminding facilities for children aged under eight years.

Two of the new provisions concern quality. Local authorities must carry out an inspection of the day nurseries, playgroups and childminders on their register at least once a year. Secondly, authorities will have the power to cancel registration where they consider the care being given to a child is seriously inadequate. In order to implement the new legislation which comes into effect in October 1991, the department is currently working on guidance which will include advice about inspection criteria and standards. Health authorities are expected to comply with those standards. Furthermore, we have commended to all authorities the detailed guidance about arrangements for the establishment of childcare facilities for the children of NHS staff issued by the National Steering Group on Equal Opportunities for Women in the National Health Service. Further legislative provision is therefore unnecessary.

I wish to pick up one or two points which the noble Baroness made. She quoted the Princess Royal's comments made earlier in the week that there was less provision now than there had been. It is accepted that there were many local authority day nurseries in 1945, but private and voluntary sectors were not so active in that field. Today in England we have 73,000 places in day nurseries, 45,000 of which are in the independent sector. We believe that publicly funded provision should be concentrated on children in need. We believe in encouraging diversity of provision so that parents can exercise choice.

An example of a local initiative which is working well is the scheme established by the National Health Service and the Midland Bank. To assist authorities wishing to provide nurseries, the Government have agreed with the Midland Bank a joint NHS and bank scheme under which health authorities and the bank, at branch level, may enter into arrangements for the sharing of facilities. In January my right honourable friend the Minister for Health opened the first nursery under the scheme, at the Royal Berkshire Hospital. Since then, a second nursery has opened at the Derbyshire Royal Infirmary. Others are under discussion in different parts of the country. Also, some authorities are entering into arrangements with other private sector employers, while some are opening their own nurseries.

At the risk of being repetitious, we share the objective but we disagree about whether it should be on the face of the Bill and become a requirement for all NHS establishments or whether it should be left to local initiatives. Our view is that it should be left to local initiative, and therefore I ask the noble Baroness to withdraw her amendment.

Lord Ennals

Before my noble friend replies, if it is always left to local initiative, there will be variations in the carrying out. There will come a time—and I believe that that time is now—when, if we want to get nurses back, we must provide facilities. That often will not happen if it is left to local initiative.

8.45 p.m.

Baroness Blatch

It is fair to say that NHS establishments will not be able to neglect the issue if they want nurses back in their hospitals. If a need is proven, the schemes will be established. We say that it should not become a requirement on all establishments to set up such a scheme, because there is a cost. Where local need is proven, local schemes will be established.

Baroness Ewart-Biggs

I find it disappointing that the Minister has produced all the old arguments when the facts are strong. The NHS provides creche facilities for less than 0-5 per cent. of its staff. There is a long way to go. The noble Baroness suggested that the Children Act would provide a miracle and would change everything. I agree that it will make a start. However, when the Princess Royal said that there were half as many places now as in 1945 she was talking about public provision. I cannot help believing that nurses would be unable to use private nurseries because they are expensive.

I too am glad that the Midland Bank has been progressive and has made a start, but it is only a start. The noble Baroness talked about how important it is to have nurseries for those children who are most in need, but that means that children who have a problem at home or who have some disability will be put together in a nursery school. I find that we are falling badly behind when one compares our position with that of our Continental neighbours. It is disappointing that the Minister should refuse the amendment. The NHS, the nurses and their children will suffer. I am extremely disappointed, but I have no choice but to withdraw the amendment.

Amendment, by leave, withdrawn.

[Amendment No. 107ZE not moved.]

Schedule 4 [Amendments of Part HI of the Local Government Finance Act 1982]:

Lord Sanderson of Bowden moved Amendment No. 107A: Page 74, line 24, leave out from beginning to ("after") and insert ("In subsection (5) of that section").

The noble Lord said: I shall speak also to Amendments Nos. 107B, 108ZZA and 108ZZB. Under the terms of the Local Government Finance Act 1982, a person may be appointed by the Audit Commission as a auditor only if he is a member of one of the professional bodies listed in the Act or if he or she holds such other qualifications as may be approved by the Secretary of State. The proposals elsewhere in the Bill provide for the transfer of the existing Department of Health and Welsh Office to the Audit Commission. It is important for the success of the transfer of the audit function to the commission that that wealth of experience is used to good effect. There are a number of departmental staff who currently hold appointments as statutory auditors who have achieved that on the basis of their long experience and knowledge of the NHS audit.

Naturally the commission wishes to continue to recognise that experience. To allow that to happen, a provision has already been made in paragraph 3 of Schedule 4 which allows the commission to appoint a person for the time being approved by the Secretary of State acting on the recommendation of the commission. That is a transitional provision which will last until 1st April 1996. The transitional period allows the commission to make full use of existing expertise and provides time for departmental staff to seek professional qualifications if they wish. Those proposals have been discussed and agreed with the accounting bodies.

However, it is now recognised that the wording in the Bill as presently drafted does not make it entirely clear that people appointed under the transitional arrangement may continue to act as auditors beyond 31st March 1996. The amendment puts that point beyond doubt. It provides that any person who is approved before 31st March 1996 will continue to be so approved after that date. It also allows such approval to be withdrawn if necessary.

As I have said, the transfer of existing knowledge of health authority expertise to the commission will be an important ingredient in the success of the audit proposals. While it will apply to a small number of staff only, the amendment will do much to encourage staff to accept the challenge that the changes bring.

The amendments tabled in my name enable the Secretary of State for Scotland to withdraw his approval for an officer transferred from the Civil Service to the Accounts Commission for Scotland to act as an auditor. Amendment No. 108ZZB provides that any reference to the Accounts Commission in primary and secondary legislation shall be construed as a reference to the commission as renamed by the Bill. I beg to move.

Lord Ennals

From these Benches we are satisfied with the logic of the amendments that have been proposed by the noble Lord and will support them.

On Question, amendment agreed to.

Lord Sanderson of Bowden moved Amendment No. 107B: Page 74, line 26, at end insert: ("(3) After subsection (5) of that section there shall be inserted the following subsection— (5A) The Secretary of State shall not approve any person for the purposes of subsection (5) above after 31st March 1996 but, subject to the withdrawal of his approval after that date, any person who is so approved immediately before that date shall continue to be so approved after that date." ").

[Amendments Nos. 107C and 107D not moved]

The Deputy Chairman of Committees (Lord Grantchester)

If Amendment No. 108 is agreed to, I cannot call Amendment No. 108YZA.

[Amendments Nos. 108 and 108YZA not moved.]

Schedule 4, as amended, agreed to.

Clause 35 agreed to.

Schedule 7 [Amendments relating to Audit of Accounts of Scottish Health Service Bodies]:

Lord Sanderson of Bowden moved Amendment No. 108ZZA: Page 86, line 46, at end insert ("and whose approval is not (whether during that period or after its expiry) withdrawn by the Secretary of State acting on such recommendation").

The noble Lord said: I have already spoken to this amendment. I beg to move.

Lord Sanderson of Bowden moved Amendment No. 108ZZB: Page 89, line 11, at end insert:

("General amendment

15. Without prejudice to any express amendment made by this Act, for any reference in any enactment (including an enactment comprised in subordinate legislation) to the Commission for Local Authority Accounts in Scotland there shall be substituted a reference to the Accounts Commission for Scotland.").

The noble Lord said: I have already spoken to this amendment. I beg to move.

Lord Mottistone moved Amendment No. 108ZZC: Before Clause 21, insert the following new clause: {"Powers to promote continuing improvement of treatment.—(1) In section 1 of the principal Act (Secretary of State's duty as to health) there shall be inserted the following subsections— (3) The Secretary of State may by order determine the manner in which subsections (1) and (2) above are to be carried out, if he is satisfied that he cannot otherwise comply with his duty under that section to promote the continuing improvement of treatment. (4) An order made under subsection (3) above may contain such provisions as appear to the Secretary of State to be appropriate for the purpose and to safeguard the interests of those affected. (5) Any order made under subsection (3) above shall be made by statutory instrument." ").

The noble Lord said: This is a probing amendment, as I informed my noble friend Lady Hooper in advance. It seeks to introduce powers to promote the continuing improvement of treatment. The particular improvement that I have in mind might be to introduce compulsory treatment orders for schizophrenics who have been discharged from hospital As Members of the Committee will be aware, it is possible at the moment for schizophrenics and other mentally ill persons to receive compulsory treatment when in hospital but not when they are out of hospital.

The National Schizophrenia Fellowship, which advises me on these matters, remains concerned about the problems which arise when sufferers from schizophrenia discontinue their medical treatment and deteriorate as a result, sometimes with tragic consequences, when out of hospital. Proposals were made by the Mental Health Act Commission and the Royal College of Psychiatrists in 1986 and 1987. However, they have not led to any amendment of the Mental Health Act enabling treatment to be given in such a situation.

The latest information the fellowship had was that in October my honourable friend Mr. Roger Freeman answered a parliamentary Question. He said that he understood that the Royal College of Psychiatrists would be giving its view to the Department on the possible role of new legal powers to ensure compulsory treatment in the Community. We have heard nothing more on that.

The object of this amendment is to make sure that there is within the Bill the kind of provision which would allow the Secretary of State to introduce an appropriate order if the advice that he is given shows this to be what is generally agreed.

There have been many cases of great disaster as a result of schizophrenics not taking their medicaments. I suppose that the most world famous was John Hinckley, who attempted to kill President Reagan in 1981. There is an absolutely splendid book about this called Breaking Point, by Jack and Joan Hinckley, his parents. If Members of the Committee have not read the book, I can tell them that it describes the problem of schizophrenia when people get out of hand.

However there is another even more up-to-date case which was mentioned in The Times yesterday. We learned that Robert Sartin, who ran amok with a gun and killed one person and injured 17 others, was found by a jury unfit to plead because he had schizophrenia.

Another aspect is the case of Beverley Lewis. She died in conditions of appallling neglect in Gloucestershire, weighing less than four stone. She was 23 years old and blind, deaf and mentally handicapped. She had been cared for all her life by her mother, Thelma, who suffered from chronic schizophrenia. Thelma Lewis's behaviour became increasingly bizarre all through the years leading to her daughter's death. She would not allow health workers near the girl. In a disturbed state, she could barely look after herself let alone her chronically ill daughter. Beverley might still be alive, however, had her mother been compulsorily treated for her schizophrenia. While medication is no cure, it alleviates the more serious symptoms of the illness. With treatment, she might have been able to look after her daughter.

The issue of compulsory treatment is not straightforward. I do not think that the noble Lord, Lord Ennals, entirely agrees with my bias, nor do I agree with his bias, but it is a bias. I see quite clearly that it can be argued that it is an infringement of the individual's liberty and, constitutes an assault if one gives treatment to somebody who does not want it. If a person suffering from schizophrenia is not clear about what he needs, he may well say when he needs it that he does not want it. That is the problem of mental illness generally and particularly so in this case.

It is also argued that, faced with the prospect of a community treatment order, sufferers would simply disappear in order to avoid treatment. Moreover, many people are concerned about conferring these powers because the psychiatrists or community psychiatric nurses would not know whether to exercise their powers nor when it would be fair and right to do so.

Conversely, other groups such as the one I and the National Schizophrenia Fellowship support, argue that one should not allow an individual's condition to deteriorate to such an extent that he is a danger to himself and others. I have quoted some examples—and I have others which I shall not spend time tonight quoting—of how people do damage to themselves. More schizophrenics than other types of people—well above the average—commit suicide. Failure to recognise this condition and accept the need to be treated is often one of the symptoms of the illness which causes the condition to exist.

So there are two difficult problems. However, they must somehow be solved. When the vast majority of experts in the field come to a consensus and agreement—and I hope they will reach a consensus that a community treatment order should be possible—then it will be unfortunate if, this legislation having just passed through Parliament, the Secretary of State has no power to bring it into effect. I am not suggesting that the Secretary of State should do this without the best expert advice from the people who will have to use the power. However it is a safeguard to enable the legislation which I think is long overdue to be brought in as soon as the agreement comes about. I beg to move.

Lord Ennals

I congratulate the noble Lord, Lord Mottistone, on raising the issue and quoting such tragic cases as that of Beverley Lewis. I shall not respond to what was almost a challenge that I should put the opposite view. This is not a mental health Bill; there are controversial issues involved in the proposal for a community treatment order. I should like the House to hold a debate about precisely this subject. However, I do not believe that this is the right legislation on which to have such a debate. I do not believe that until the Secretary of State has had wide consultation, which is certainly not yet completed, there would be any basis for agreement. Therefore, I hope that the Government will not accept the amendment. I say that without in any way wishing to be critical of the noble Lord, Lord Mottistone, who never loses any opportunity of representing the interests of the people for whom he cares very much. I care for them too.

9 p.m.

The Earl of Balfour

Perhaps I may add a few words. While I sympathise with the idea behind the amendment, certainly in the case of Scotland it is only under the Mental Health Acts that a person can be detained in hospital or forced to take treatment. As I see it, the difficulty in producing legislation at the moment is that in most cases, almost irrespective of how ill patients are, they have the right to discharge themselves from hospital. Where do we say that they shall not have that right?

I fully appreciate what my noble friend Lord Mottistone has said, but I have the impression that the matter is very much under discussion by the psychiatrists and doctors involved.

Lord Mottistone

I am not sure whether the noble friend has understood me. I am not suggesting a compulsory treatment order to keep people in hospital. The suggested legislation would give power to the Minister to introduce an order dealing with their being given medicaments when out of hospital. The amendment does not seek to keep them in hospital.

The Earl of Balfour

I am grateful for the explanation. However, I feel that until the various branches of the medical profession get their heads together and decide exactly what they want to do, we cannot help with this legislation. However, my noble friend has raised a very important point.

Baroness Hooper

We are committed to providing the best possible arrangements for mentally ill people who, while no longer needing in-patient treatment, nevertheless require medication to remain well while living in the community. I fully recognise the points made by my noble friend in that respect. Despite all our efforts, on occasion mentally ill people refuse treatment after leaving hospital even if that is considered essential by the treatment team responsible for their care.

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 also been discussions within such organisation as the Mental Health Act Commission, the Royal College of Psychiatrists and MIND.

It is a complex area. There has been a long-standing debate on which no consensus exists. Important civil liberty issues arise. As the noble Lord, Lord Ennals, has demonstrated, there are stongly held views on all sides. Departmental officials are listening to the debate with close attention.

My noble friend Lord Mottistone referred to the fact that my honourable friend the Parliamentary Under-Secretary of State for Health said that the Royal College of Psychiatrists would be giving the department its views on the role of new legal powers to ensure compulsory treatment in the community. When we receive those views the department will explore the issue with all the interested parties involved. Without prejudicing the discussion, we would need to be both very clear about the benefits of compulsory treatment and confident that they could not be achieved through voluntary means before seriously considering asking Parliament to agree suitable provisions.

I believe that the introduction of the care programme approach in April 1991 will greatly improve continuity of medical care and should very much reduce the likelihood of patients being lost to care. In addition, the specific grant that has been agreed will increase the amount of social care available to people with a mental illness. Last but not least, the recently issued document produced by the Royal College of Psychiatrists on discharges and follow-up, which is being discussed with other professional bodies which have an interest in discharge, should also ensure that fewer patients would fall into the category in which compulsory treatment would be considered necessary.

I hope that those remarks show that continued consideration is being given to the matter and that we are giving careful thought to the future form of treatment in this difficult area of mental illness. I also hope that I have made clear that no changes will be made without full consultation of relevant bodies. I hope that my noble friend will not press his amendment.

Lord Mottistone

I am sorry that my noble friend the Minister does not take advantage of having powers without the action. I should have thought that it might be helpful to her to have the powers. Other people might think that I was giving too many powers to the Secretary of State which could go well beyond this particular issue.

I am slightly happier, but only just. I should like to ask my noble friend to suppose that two months after the Bill becomes an Act the Royal College of Psychiatrists said that it had agreed with everybody that compulsory treatment orders would be a good thing. How would the Government bring that fact into force having already enacted the Bill?

Baroness Hooper

If it was felt that that particular area had sufficient priority then government time would be found in order to pass the necessary measure in the usual way.

Lord Mottistone

That takes a longtime. Obviously I must not press the issue tonight. However, I should say in closing that the remarks that I made about the Beverley Lewis case were based on information supplied to me not by the National Schizophrenia Fellowship but by SANE, which is another charity which I support. I beg leave to withdraw the amendment.

Amendment, by leave, withdrawn.

Clause 21 agreed to.

Clause 37 agreed to.

Clause 22 [Distribution of general medical services]:

Lord Ennals had given notice of his intention to move Amendment No. 108ZZD: Page 23, leave out lines 7 to 21.

The noble Lord said: This is a probing amendment. When I tabled the amendment the noble Baroness had not tabled the amendments which follow. If yesterday I had had a little more foresight I might have suggested that they should have been grouped together. The Government have tabled their amendments on the distribution of GPs and have separated the provision for England and Wales. In addition they have conceded that imposing a manpower ceiling will be done on a national rather than a local basis. The situation therefore becomes clearer.

The British Medical Association is much concerned about the future of part-time GPs once the manpower ceiling is imposed. Part-time GPs all have a 24-hour, 365 day a year responsibility for their patients, so there is no such thing as a part-time GP. The Government have introduced a device to pay some GPs less money than others, but their responsibilities have not been reduced. That may be attractive to women doctors, but, because of the ceiling on the number of GPs as proposed by the clause, they can be stuck in a part-time commitment. The BMA is concerned that, once the Bill is law, doctors who have opted for a half-time or three-quarter time contract will not be able to return to a full-time contract without approval. That approval will be subject to the Government's overall ceiling. I therefore hope that the Minister will be able to explain the position when she moves the series of amendments that follows.

The Deputy Chairman of Committees (Lord Ampthill)

I should remind the Committee that if this amendment is agreed I shall be unable to call Amendments Nos. 108ZA to 108ZD.

Lord Ennals

Perhaps it is best in that event that I do not move the amendment because I want the Minister's amendments to be accepted. Perhaps she will comment on the residual problems that I raised when she moves her amendments.

[Amendment No. 108ZZD not moved.]

Baroness Hooper moved Amendment No. 108ZA: Page 23, line 10, after ("specify") insert ("(a)").

The noble Baroness said: In moving this amendment, I wish to speak also to Amendments Nos. 108ZB to 108ZD and to Amendment No. 108ZKZ.

These amendments spring from further thought by the Government on the operation of the reserve powers provided by Clause 22. They follow consideration of the points made in Standing Committee in another place, which include the points made by the noble Lord, Lord Ennals, and further discussions which my right honourable friend has had with the Medical Practices Committee. This is another example of where we have listened to and acted upon requests for consideration.

The question arises of how the power should be used in the unlikely circumstance that it has to be used. Initially, it was our intention to ensure that limits could be set either nationally or at the level of the individual FHSA. However, after receiving representations and reflecting upon the matter further, we have decided that to leave open the possibility of local ceilings would place an unacceptable restriction on the work of the Medical Practices Committee and its Scottish equivalent. As the Committee may be aware, those bodies are charged with responsibility for determining the distribution of GPs throughout Great Britain. The Government believe it right that, should a national ceiling be set, they should be free to control the distribution of GPs within it, subject only to any directions that the Secretary of State may give on specific matters. I emphasise that the direction-making power itself will not allow the Secretary of State to impose local ceilings.

I hope that I have shown how the amendments directly respond to valid concerns of which the Government have taken account. The individual amendments make clear our intention of restricting potential use of the power to individual national limits for England and Wales and, by Amendment No. 108ZKZ, for Scotland. I commend them to the Committee.

Lord Ennals

So far as I can see, the Minister's amendments and her comments on them have met the principal concerns which I expressed. I should like to have the opportunity to read her remarks more carefully and to consult with the BMA to see what its feelings are. Perhaps I might enter into correspondence, if need be, with the noble Baroness. In the meantime, we welcome the amendments.

Baroness Hooper moved Amendments Nos. 108ZB to 108ZD: Page 23, line 11, after ("year") insert ("all the"). Page 23, line 12, leave out from ("England") to second ("may") in line 13 and insert ("taken as a whole"). Page 23, line 14, at end insert ("and (b) the maximum number of medical practitioners with whom, in any year, all the Family Health Service Authorities for localities in Wales, taken as a whole may enter into such arrangements.").

[Amendment No. 108ZDA not moved.]

Lord Henley moved Amendment No. 108ZDB: Page 23, line 37, leave out ("Committee") and insert ("Secretary of State").

The noble Lord said: The amendment represents the outcome of discussions with the Medical Practices Committee on the appropriate appeal arrangements for a doctor whose application for a GP practice vacancy has been refused by an FHSA. The committee has put forward some convincing arguments about the practical implications of the proposal in the Bill that such appeals should lie with it. We are therefore inviting the Committee to consider an alternative.

I should explain that Clause 22(2) provides that in future FHSAs rather than the MPC shall select the doctor who is to succeed to a GP practice vacancy. These will be singlehanded vacancies. In our view it is sensible for the people locally who are responsible for running the services to make these decisions in accordance with regulations and guidance on proper procedures.

Since the inception of the National Health Service unsuccessful candidates for practice vacancies have had a right of appeal to the Secretary of State against the refusal of their applications by the MPC. We have no wish to deny the right of appeal but, in the light of our decisions to devolve decision-making to FHSAs, it seems sensible for appeals against these decisions to lie with the MPC. We also intend that all job related appeals by GPs shall in future focus on procedural matters to stop second-guessing, unnecessary delays and the pretence that central bodies can make a properly informed judgment on the merits of rival candidates.

If an appeal is successful, the selection will be remitted to the body below for reconsideration. But there are practical difficulties involved in giving the MPC an appellate role on matters of procedure. The committee has no experience in this area and so has been unable to develop the necessary expertise. There will also need to be a substantial legal input which the committee does not at present possess and which would be costly to create.

In addition, it is not a matter that the committee could readily delegate to officers. So the members themselves could become disproportionately involved in their appellate function. We do not want to deflect the committee in this way nor to create bureaucratic difficulties for them. We have therefore brought forward these amendments which keep the appellate role on practice vacancies with the Secretary of State, subject to the requirement that these concern procedural matters.

This will retain access to the Secretary of State, which we know that the profession values, and will ensure that appeals can be dealt with efficiently and effectively in the light of proper professional advice. I beg to move.

Lord Ennals

I should be grateful if the noble Lord would say whether the BMA was consulted on the series of amendments that have just been presented. Can I have his assurance that the BMA was happy about them?

Lord Henley

I can give the noble Lord that assurance, that the BMA was consulted.

9.15 p.m.

Lord Henley moved Amendment No. 108ZDC: Page 23, line 39, leave out from ("the") to ("shall") in line 40 and insert ("Secretary of State allows an appeal under paragraph (c) above he").

Baroness Hooper moved Amendment No. 108ZE: Page 23, line 43, leave out from ("the") to end of line 3 on page 24 and insert ("word "but" there shall be inserted— (a) in granting an application shall specify, by reference to one or more prescribed conditions relating to hours or the sharing of work, the provision of general medical services for which the applicant will be entitled to be remunerated; and (b)"; and at the end of the subsection there shall be inserted the words").

The noble Baroness said: In moving this amendment I shall speak also to Amendments Nos. 108ZF to 108ZK and 108ZKA to 108ZKE.

The new arrangements for part-time working and job sharing for GPs in Great Britain stem from the commitments given in our White Paper Promoting Better Health and subsequent discussions with GP representatives. This also responds to concerns expressed by the noble Lord, Lord Ennals, when he moved his earlier amendment.

Our intention is to provide more flexibility in working patterns and open up new opportunities for doctors in general practice. The Bill clearly defines the role of the two MPCs (Medical Practices Committees) in relation to that, building on their existing responsibilities for admissions to the medical lists of FHSAs and health boards. We want to ensure that GPs are admitted to the medical list by the committees on conditions that are both appropriate and sensitive to their choice of working and that all parties know where they stand. The Bill provides for that and also allows the MPCs to vary conditions relating to working hours if a doctor's circumstances should change.

The amendments before the Committee seek to clarify and improve the new provisions. First, they make it clear that all doctors will need to be admitted to medical lists on one basis or another, full-time, part-time or job sharing. Secondly, they spell out that regulations can include provision for appeals to the Secretary of State on procedural matters against decisions of the MPC to refuse to vary the conditions on which a GP has been admitted. This is consistent with GPs' existing rights of appeal against other decisions of the MPC. Thirdly, they allow regulations to be made to safeguard the position of GPs already working on a part-time basis under locally agreed arrangements.

We have sought to respond positively to the wishes of an increasing number of doctors to work on a more flexible basis—I believe that that applies very much in particular to women doctors—and to put the new arrangements on a proper footing through the good offices of the Medical Practices Committee.

I hope that these clarifying amendments will find favour with the Committee. I beg to move.

Baroness Hooper moved Amendments Nos. 108ZF to 108ZH: Page 24, line 7, leave out ("(b)") and insert ("(a)"). Page 24, line 8, at end insert ("for the words "such conditions" there shall be substituted "conditions under paragraph (a) or paragraph (b) of subsection (4) above" and"). Page 24, line 16, after ("any") insert ("such"). On Question, amendments agreed to.

Lord Henley moved Amendments Nos. 108ZHA and 108ZHB: Page 24, line 23, leave out ("for") and insert ("after"). Page 24, line 24, leave out from ("be") to ("and") in line 25 and insert ("inserted").

Baroness Hooper moved Amendments Nos. 108ZJ and 103ZK: Page 24, line 31, at end insert ("including provision for appeals to the Secretary of State on a point of law"). Page 24, line 31, at end insert: ("(8) In the case of a medical practitioner who, on the day appointed for the coming into force of this section, is providing general medical services in accordance with arrangements under section 29 of the principal Act, regulations may make transitional provisions by virtue of which those services shall be treated for the purposes of that Act as provided subject to such of the prescribed conditions referred to in section 33(4)(a) of that Act as are determined under the regulations and, accordingly, for enabling any such condition to be varied in accordance with regulations under section 34(2) of that Act.").

Clause 22, as amended, agreed to.

Clause 38 [Distribution of general medical services]:

Lord Henley moved Amendment No. 108ZKZ: Page 44, line 20, leave out ("a Health Board") and insert ("all Health Boards taken as a whole").

Baroness Hooper moved Amendments Nos. 108ZKA to 108ZKE: Page 45, line 2, leave out from ("the") to end of line 8 and insert ("word "but" there shall be inserted— (a) in granting an application shall specify, by reference to one or more prescribed conditions relating to hours or the sharing of work, the provision of general medical services for which the applicant will be entitled to be remunerated; and (b)"; and at the end of the subsection there shall be inserted the words"). Page 45, line 12, leave out ("(b)") and insert ("(a)"). Page 45, line 13, at end insert ("for the words such conditions" there shall be substituted "conditions under paragraphs" (a) or (b) of subsection (4)" and"). Page 45, line 35, at end insert ("including provision for appeals to the Secretary of State on a point of law"). Page 45, line 35, at end insert; ("(8) In the case of medical practitioner who on the day appointed for the coming into force of this section, is providing general medical services in accordance with arrangements under section 19 of the 1978 Act, regulations may make transition provisions by virtue of which those services shall be treated for the purposes of that Act as provided subject to such of the prescribed conditions referred to in section 23(4)(a) of that Act as are determined under the regulations and, accordingly, for enabling any such condition to be varied in accordance with regulations under section 24(2) of that Act.").

Clause 38, as amended, agreed to.

Clause 23 [Limitations on right to be included on list of dental practitioners]:

[Amendment No. 108ZL not moved.]

Clause 23 agreed to.

Clause 39 agreed to.

Clause 24 [Transfer to DHA certain functions relating to private patients]:

[Amendments Nos. 108ZM to 108ZP not moved.]

Clause 24 agreed to.

[Amendments Nos. 108A and J08AA not moved.]

Lord Ennals moved Amendment No. 108AB: After Clause 24, insert the following new clause: ("Review of mentally ill hospital accommodation —(1) In consultation with such bodies as appear to him to be concerned, the Secretary of State shall conduct a thorough review of the number of places available for the mentally ill in long stay hospital accommodation. (2) On completion of the review under subjsection (1) above, the Secretary of State shall draw up a timetable for the phased replacement of such provision with community care services. (3) The Secretary of State shall fulfil his duties under this section in collaboration with any relavant local authorities charged with providing community care services under Part III of this Act.").

The noble Lord said: The amendment deals with the huge problem of the mentally ill in their hospitals and the need for treatment in the community. The amendment states: In consultation with such bodies as appear to him to be concerned, the Secretary of State shall conduct a thorough review of the number of places available for the mentally ill in long stay hospital accommodation".

That is the starting point. In 1961 the right honourable Enoch Powell delivered his famous speech calling for the closure of long-stay mental hospital accommodation. Thirty years on there are still over 100 Victorian asylums providing long-stay care for over 50,000 people whose lives are certainly not their own, who have very little say in their own future and who are very rarely consulted about plans for change. They live in circumstances in which none of us would like either ourselves or our families to live.

The hospitals are not in the main places for treatment. In a sense they are places for control. Often medication is used which is known to have long-term serious side effects. None of us can be happy with the present situation. We welcome the fact that the Government have plans for the closure of long-stay mental hospital accommodation. On many occasions Members on all sides of the Chamber have said that people should not be discharged from hospital until there is adequate provision in the community. Therefore, the second part of the amendment provides that the Secretary of State should draw up a timetable for the phased replacement of such provision with community care services. That task must be carried out. At present none of us can be satisfied that the provision of community care by local authorities, voluntary organisations and the private sector for the mentally ill is adequate.

Our thinking behind the amendment is that although it deals with the health service and the provision of local authorities in Part II, the issues should be brought together by the Secretary of State. We believe that 1990 is the time for him to set a target for ending the bulk of—I do not say all—such hospitals; say within the next decade and therefore by the turn of the millennium. That would require a major plan—it would not be on a one-by-one basis—requiring a careful look by the Secretary of State not only at hospital provision but also at community care provision. We believe that the Secretary of State should fulfil his duties in collaboration with the relevant local authorities charged with providing community care under Part III of the Bill.

I am certain that bodies such as MIND, the National Schizophrenia Fellowship and many other organisations concerned with mental health and the care of the mentally ill in hospital and in the community would welcome a new and positive approach by the Secretary of State. They hope that he will set long-term targets—the next 10 years is not so long term—which are achievable targets, so providing the impetus for the voluntary sector in the work that it is trying to do. I beg to move.

Baroness Hooper

Considerable progress is being made in this area, as the noble Lord has recognised. I do not dispute the fact that there is always room for improvement. However, I believe that the amendment is misconceived in the sense that it envisages that long-term hospital beds for the mentally ill can be entirely phased out and replaced by community care services. When better forms of treatment become available, that may of course be possible. However, at present many people regard long-stay hospital beds as an essential element of locally based psychiatric services; for example, as a means of providing asylum care. I recollect that in our debates about the homeless we were accused of turning out people from long-stay institutions and were urged to maintain them within the institutions.

However, even if it were generally agreed that all the existing long-stay beds could be replaced by community care services it would not be practicable to try to set a timetable for that. In 1986, the latest date for which I have figures, more than half the 60,000 beds in psychiatric hospitals and units were occupied by people who had been in hospital for a year or more. One-third of the beds were occupied by people who had been in hospital for five years or more. Inevitably it would take many years to make the necessary arrangements for such people to be treated in the community and often at higher cost than the current cost of their treatment. We do not believe that it is realistic for central government to give local government resource assumptions for as many years ahead as would be necessary; nor indeed for local authorities to commit themselves to particular timetables which could easily stretch for 10 years or more. Rather, we prefer to see a continuation of what has been policy since the 1975 White Paper Better Services for the Mentally Ill; namely, the development of locally based and community oriented services as health and social services authorities resources allow and the gradual reduction of beds in the old remote specialist psychiatric hospitals.

In view of the fact that we are moving in the right direction, I hope the noble Lord will feel that he does not have to press his amendment on this occasion.

9.30 p.m.

Lord Ennals

I am most grateful to the noble Baroness for her helpful comments on this matter. There was a little misunderstanding here. I did not suggest—nor does the amendment suggest—that at the end of the review conducted by the Secretary of State of the number of places available for the mentally ill in long-stay hospital accommodation there should be no patients requiring long-stay accommodation. I have no doubt that there would be some people—I do not know how many—who would not be able to be discharged into the community. That is part of the purpose of seeking that there should be a review.

I remember visiting many psychiatric hospitals 20 years ago when some of them had 50 per cent. or even 100 per cent. more patients than they have now to discuss with the consultants concerned how many of their patients they thought could be discharged into various types of accommodation in the community. The usual answer from a consultant who may have been there for many years was "None", or, "We do not think there really are any". In the course of the years that have followed an enormous number have, in fact been discharged. It has been possible to provide by voluntary organisations, sometimes local authorities, sometimes hospitals, accommodation with different degrees of support, whether in group homes, hostels or hostels within hospital grounds. There are all sorts of variations.

It is not the suggestion here that we should conclude that the review would decide that there was no need for any more long-stay hospital beds. I do not think that would be the case. It might be that it would be necessary to concentrate on a limited number of perhaps more modern hospitals, where people could live with the sort of protection or asylum, in its best sense, which many of them need for their own wellbeing. Without a review it is very difficult to know what the picture is.

The noble Baroness referred to the 1975 White Paper, which I well remember. Some of the drafting of that had been done years before, when previously I had been a junior Minister in the Department of Health. She said that 1986 was the last date for which she had figures of the numbers of patients in long-stay hospitals. It is staggering that she has to go back four years to be able to give the statistics of people who are in long-stay hospitals. That has proved to me that there is a need for just this sort of review, both to find the facts and to bring out a new version of the 1975 White Paper, which was a very useful White Paper. It set targets, some of which have been met and some not.

It would be very useful at this stage, 15 years on, to be able to have a review, so that those who have the responsibility in the community of providing the proper community care, with various types and different degrees of support for patients discharged from hospitals can do so. But at present the Minister has virtually accepted that the figures are not available on which to base a programme of effective community support for the roughly 50,000 people to whom I have made reference.

1 shall not press the amendment to a Division at this time, but nothing that the noble Baroness has said does other than convince me that the Secretary of State, whoever he should be, needs to take a grip on the problem now. He should have a look, start a survey, talk to MIND and all the other organisations concerned, together with the local authorities, and come up with a short-term and a long-term plan, bringing up to date the 1975 White Paper. The Minister has not convinced me. She spoke very nicely about this matter, and I am always glad to welcome the progress that has been made. I shall not press the amendment to a Division, and I beg leave to withdraw it.

Amendment, by leave, withdrawn.

[Amendment No. 108AC not moved.]

Clause 25 agreed to.

Baroness Blatch

I beg to move that the House do now resume.

Moved accordingly, and, on Question, Motion agreed to.