§ 7.50 p.m.
§ Lord Mottistone rose to ask Her Majesty's Government whether they are satisfied that health authorities are ensuring that any reduction in the number of hospital beds available for the mentally ill does not outpace the development of alternative community services.
§ The noble Lord said: My Lords, I wish to start by thanking my noble friend Lady Hooper for writing and explaining to me why she was unable to answer my Question on behalf of the Government. I should like to welcome my noble friend Lord Cavendish of Furness and trust that he will not find his brief to be too much of a strait-jacket. Recently, when I visited the mental wing of our new hospital in the Isle of Wight, I said to the senior psychiatric nurse that I imagined there would be some locked wards and some strait-jackets somewhere. He was shocked. He said, "We try to avoid those at all costs". I hope that my noble friend will avoid his brief at all costs if he finds that it is too much of a strait-jacket.
§ Perhaps I may remind noble Lords that I am advised on matters relating to the mentally ill by two charities; by the National Schizophrenia Fellowship and also by SANE. Your Lordships will have noted that my noble kinsman Lord Balfour of Inchrye has taken advantage of the debate to make his maiden speech. Due to the nature of debates on Unstarred Questions I shall not be able publicly to congratulate my noble kinsman on his speech. However, I take this opportunity to wish him every success in making it. Perhaps I may take the opportunity also to thank other noble Lords for taking part in the debate.
§ Over many years I and several other noble Lords have been repeatedly questioning the Government's policy of proceeding too fast with shutting down beds in mental hospitals and, indeed, in shutting down hospitals themselves before providing alternative services for the mentally ill patients whose numbers are probably increasing. I say "probably" because it is becoming obvious that many people—such as several convicted criminals and destitute people on the streets—who were hitherto treated as being wholly responsible for their actions, are in fact mentally incapable of coping with life. For example, in one of the large prisons on the Isle of Wight the senior probation officer informed me that around 25 per cent. of the prisoners, who are mainly in their early 20s, are pathetically inadequate and unable to look after themselves.
§ Those people need to be added to the number already recognised as needing care either in hospital or in the community. Therefore, there is evidence of a real need for communities in this country to appreciate that there are large numbers of mentally ill or inadequate people who require help. We used to 836 call it "asylum"; it is sad that that word has a bad name. At the same time the 150,000 hospital beds that existed in 1956 have shrunk to 37,350 today. That reduction has continued steadily over 30 years, initially for very good reasons but latterly mainly at the personal expense of a tolerable life for dedicated family carers.
That is now clearly appreciated by the Government. They somewhat belatedly told us that health authorities have received guidance making it absolutely clear that the run-down of mental hospitals should not proceed faster than the build-up of care services. Most recently that point was made by my noble friend Lady Hooper at Question Time on 29th January when she said:
My Lords, the run-down and closure of hospitals should not proceed faster than the build-up of alternative local services. Our guidance to health authorities makes that absolutely clear".—[Official Report, 29/1/91; col. 542.]
I could go on but I believe that that sufficiently makes the point.
§ The Government also enacted the National Health Service and Community Care Act 1990, which makes all the provision for assessment of mentally ill patients before discharge and care thereafter for which one could possibly wish. It is the implementation of those good intentions about which I ask. They seem to me to be sadly lacking.
§ At a recent meeting with the Minister of State for Health, Mrs. Virginia Bottomley—for which I was indeed grateful —I received the firm impression of three possible reasons for the lack of implementation of the Government's care policy. First, there is no machinery in the Department of Health for checking whether care facilities are actually being put in place to match the shut-down of hospitals. Secondly, health authorities only have to notify in advance plans to shut down hospitals, as stated by my noble friend Lady Hooper on 29th January to which I have already referred. Apparently health authorities can shut down beds without formally saying whether or not there are matching care facilities. Thirdly, if the Department of Health hears about the proposed shutting down of beds and warns the health authority against doing so, it never receives the publicity it deserves because it might embarrass those concerned.
§ An example which demonstrates the lack of enthusiasm by the department for having the information necessary to ensure that the Government's policy of closure and matching care facilities is followed, is illustrated by a Question in another place on 12th February by Mr. David Atkinson MP. The Question asked about the 32 mental illness hospitals planned for closure by 1996. It also asked how many beds and patients were now in them. Mr. Atkinson was told the hospitals' names but informed that the other information was not held centrally. When a similar Question was asked last year the numbers of patients in 35 mental hospitals planned for closure by 1995 was provided. If the information in regard to beds was available in 1990, why was it not available centrally in 1991? That just is not good enough. Furthermore, it does not enhance the Government's reputation for taking care in the community seriously. One would have thought that 837 the Government would be only too keen to insist on the necessary information being held at their fingertips to enable them to answer the kind of questions we are discussing, and so that they can restrain the regional and district health authorities from shutting down beds faster than the facilities in the community are provided to care for the patients.
§ I trust that my noble friend Lord Cavendish will be able to tell us that he and his ministerial colleagues will insist on receiving full information with regard to planned care in the community, and the planned matching of closure of beds currently in mental hospitals with that care.
§ 8 p.m.
§ Lord Balfour of Inchrye
My Lords, I rise, first, to ask for your Lordship's indulgence while I address the House for the first time and, secondly, to thank noble Lords for all the courtesy and kindness which I have received since entering the House last year. As a layman, I admit to considerable temerity in speaking from these Benches, which are often awash with noble Lords imbued with erudition, expertise and experience in the field of medicine.
My reason for participating in this debate is that, through circumstances, I have witnessed the lives of others racked, if not wrecked, by mental illness. I feel the need urgently to improve the quality of life of all those who suffer from psychological and emotional illness. I am fortunate in that I have never suffered from mental illness. However, when I have been asked what my profession is or how I spend my time and I reply truthfully that, first and foremost, I write music, I have noticed a strange look appearing on the questioner's face which suggests that possibly there is a stronger connection with Broadmoor than Broadwood. Many creative individuals have suffered from mental illness. But it is not primarily on their behalf that I am addressing your Lordships this evening, rather on behalf of the thousands of sufferers who are ordinary people endeavouring to lead normal lives yet burdened by the anguish of mental pain.
Last year some of your Lordships may have watched a television programme about just such a person. The victim was suffering from severe depression. I well remember the agonised expression on her face—a look that I have seen on numerous visits to National Health Service hospital wards and private nursing homes. It is a sort of hellish maelstrom raging in the head. But what to me was so satisfying about the programme was not merely its depiction of the victim's recovery but the fact that it was screened at all. I believe that for far too long the subject of mental illness has been swept under the carpet or, if talked about at all, in hushed, reverential tones. It is a taboo topic. That may be a legacy of our Victorian past but even today ignorance of and prejudice and intolerance towards the mentally disordered exist within our society.
Apropos ignorance, I remember a few years ago when studying the county cricket scores—I often turn to the scores as an antidote to our front page news—and reading of how a county had omitted a young player because he was suffering from depression. That 838 was an enlightened and laudable action. But what was the reaction of the cricket correspondent of a leading national daily newspaper? He said, "Oh well, we all get depressed". To me that was a somewhat fatuous and thoughtless response, though in the correspondent's defence it is only fair to say that he was only revealing the inadequacy of a term that spans everything from feelings of sadness to desperate illness.
What of prejudice? Let us contrast the attitude displayed towards patients suffering from physical as distinct from mental illnesses. While the former will receive cards, flowers and gifts from well-wishers, the latter receive precisely nothing. For the mentally ill the flowers are conspicuous by their absence. Fortunately, there are signs that the public is beginning to show some understanding of both the nature and extent of mental illness. A recent MORI poll, conducted on behalf of the Mental Health Foundation, shows that only one in 10 people still consider mental illness to be due to weakness of character. That is half the number of those who believed that to be the case when the poll was conducted in 1979. That is encouraging because it means that the "Come on, pull yourself together" brigade are on the retreat.
I should like to see a programme of health education to teach everyone about the character and consequences of mental ill health. In the eyes of the general public, while mental illness may have lost some of its stigma, by and large it remains an enigma. I shall give your Lordships some statistics concerning mental illness. The Mental Health Foundation estimates that no fewer than 6 million people in the United Kingdom suffer from mental illness in the course of a year. That represents one in 10 of the population, which is more than the total population of Scotland. I should point out that Ministers at the Department of Health differ in their interpretation of what constitutes mental illness from that advanced by the Mental Health Foundation. They consider the figure to be lower. However, I have it on good authority that the figure of 6 million sufferers is based on the number of people identified by general practitioners as suffering from a mental illness according to the international classification of diseases.
The great majority of those affected (4.5 million) are in the 15 to 64 age range—that is to say, the working population. A further 1.2 million are over 65, while, sadly, 300,000 children under the age of 15 are similarly afflicted. Mental illness is as common as heart disorder, three times as common as cancer, five times more common than mental handicap and 3,000 times more common than AIDS. Mental illness is not regarded as a killer in the same way as heart disease and cancer yet, in addition to the massive extent of suffering caused, it results in the deaths of a substantial number of people—up to 20,000 individuals each year. That figure comprises 4,500 suicides, which is 13 a day, 1,800 fatalities due to alcohol and drug abuse and 13,500 deaths from causes directly attributable to chronic mental disorder within the elderly population.
839 To put these figures into perspective, mental illness kills over four times as many people as perish annually in road accidents. That is not all. The cost to the nation of mental ill health is truly staggering. In 1989, of the 417 million working days lost due to sickness absence in the United Kingdom, 71 million (17 per cent.) were due to mental illness. By comparison, strikes accounted for 4 million days. Over the 10-year period from 1979 to 1989 working days lost through mental ill health increased from 33 million to 71 million.
Finally, the price we pay for mental illness is truly alarming. It was £6,825 million in 1989. If I were to be granted sufficient miraculous powers, there are three changes to our current mode of living which I should like to see made during the 21st century: first, a substantial decline in the world population; secondly, a reduction in the speed of many aspects of life; and, thirdly, a diminution of the noise that assails us everywhere. No doubt I shall be branded as naive, told that I am burying my head in the sand and putting the clock back and so on. To all those charges I plead guilty.
Of one thing I am sure. Unless we give some thought to the suggestions that I have made whereby we can somehow reduce the strain and stress of our daily lives, we shall continue to create the conditions in which mental illness thrives. Two years ago the then Parliamentary Under-Secretary of State for Health remarked:Mental illness is the single largest necessity for expenditure within the National Health Service".Although that is undoubtedly true, I consider that we need to be certain that sufficient resources are also being made available to care for those who are being returned to the community as a consequence of the continuing closure of our mental hospitals. It is surely not enough to care for 60,000 individuals who are resident in our psychiatric hospitals at a cost of £72 per day, when 5.9 million mental illness sufferers living in the community are offered 29p. a day—the price of a cup of tea.
I have personal knowledge of the closure of the external psychiatric unit of a London teaching hospital early in the last decade. Its closure and the subsequent inadequate provision for continuous care caused dismay to the practitioners and staff and distress to the patients and their families. I feel that, given the priority currently assigned to community care for the mentally ill, such uncertainty suggests that arrangements for on-going care may still leave something to be desired. I am therefore extremely glad that my noble kinsman, whom I thank for his earlier very kind words, has initiated the debate on this important issue in your Lordships' House this evening. I thank your Lordships for hearing me.
§ 8.9 p.m.
§ Baroness Elliot of Harwood
My Lords, it comes to me as a great honour to congratulate the noble Lord, Lord Balfour of Inchrye, on his maiden speech. I have heard many maiden speeches in my long life in your Lordships' House. I have never heard one so accurate, 840 so carefully thought out and so brilliantly produced. I congratulate the noble Lord very much indeed. He has done a wonderful job for those of us who are deeply concerned about the mental health situation. I hope that everyone will have the opportunity to read what he said. I am sure that it will be influential on the Government. I should like to say how grateful we are to you, sir, and I congratulate you on an admirable speech.
I am very glad indeed to support my noble friend Lord Mottistone. He and I have had associations with various of the mental health organisations. The National Schizophrenia Fellowship is the one with which I have had most to do since helping to start it not so very many years ago. I think that all such organisations have made people aware of these terrific problems which, as someone said just now, are apt to be swept under the carpet. They are vitally important to everybody in this country, whether one is a sufferer or simply an ordinary person. I am sorry that the debate has started at such a late hour. I am sorry also that it is taking place after a very long debate and that we do not have the support we might have had. Nevertheless, let us say the things we want to say and let us hope that the Government will pay some attention and that we shall get something done.
I am very much concerned about the reduction in the number of hospital beds. Have the Government provided enough care in the community for the mentally ill? I very much doubt it because it is a difficult thing to do. I was on my local county council for a great many years and I served on the committee with responsibility for the local health authority. I remember very well how difficult it was to get people to understand how to care for those mental patients who were not in hospital but were able to live in the community provided they had someone to look after them, someone to advise them and someone to care for them. Do we have enough care for those people who are being and will be put out of mental hospitals?
On 12th February the Government were asked about the planned closure of 32 mental hospitals—my noble friend Lord Mottistone said 35; he may be right, I do not know. No answer was given that care in the community would be available. I believe that 25,650 beds in hospitals for mental patients are being done away with. That is an enormous number. Is it possible to provide community care for all those people? Such provision involves local health authorities, as I know from my experience. It is not easy to provide trained social workers to cope with these numbers. Without trained social workers one cannot cope. It is vital that that should be one of the priorities.
I received information from the City of Westminster that 25 per cent. of those who are discharged from hospital are homeless. This is a hopeless way—I was going to say a wicked way—of dealing with the matter. Those who are turned out of hospital with no care find themselves in despair and often become involved in petty crime, which can result in imprisonment. Whatever the result, it is the wrong way to treat mental illness, especially schizophrenia.
841 Those of us who in one way or another are concerned about mental health care are deeply worried by this turn of events. We press the Government very strongly not to allow any mental patient to be without care in the community. In other words, we must relate hospital care and community care to the enormous numbers which have been cited in this debate and which are well known. I beg the Government to take this matter extremely seriously and do something about it now.
§ 8.14 p.m.
§ The Earl of Longford
My Lords, we have listened to three excellent speeches, all by people who have in different ways done a great deal for the cause of the mentally ill. Two were made by established Members of the House and the third by a newcomer—not a chicken, if I may put it that way, but new to this House. There must be some magic in the Bench on which the noble Lord is sitting. His neighbour, the noble Lord, Lord Acton, made a brilliant maiden speech last week and now the noble Lord has done so today. I sat there once in 1961. I do not know if it worked for me: others will have to judge. The debate was on Christian unity. There were two very bigoted Members of the House on the Front Bench—one was Lord Alexander, who was against it, and I was favourable to it. It was thought by our colleagues that we had better adjourn so we both spoke interminably from there. That was my only experience of speaking from that Bench.
I was looking up the record of the noble Lord, Lord Balfour. It would take a long time to do justice to it. It mentions composing, writing, drinking—there is a reference to drinking which I do not take seriously —and dreaming too. There is one concrete statement here that the noble Lord wrote a book on famous diamonds. Unless he is careful he will turn into a famous diamond himself. At any rate, we are very pleased to have heard him speak.
I am absolutely in line with the sentiments expressed in the debate. I only hope that if we keep pegging away eventually we shall achieve something or at any rate obtain some information. It may not be very easy to obtain it even from a Government full of good will or at any rate from a Minister full of good will. When I last spoke on these matters I suggested that community care was a disastrous term. It was full of ambiguities. It is a great pity that it was ever invented. However we are stuck with it and I shall not spend time splitting hairs about it tonight.
Most of us, whether we are talking of schizophrenia or any other form of mental trouble, will have some experience of the gallant and dedicated efforts made to help in the community in the widest sense people who have been in mental hospitals. I venture to recommend noble Lords to visit the hostel attached to the Maudsley Hospital. It is described on the document which I have been studying as 111 Denmark Hill, Rehabilitation Hospital, Hostel Ward. Last Friday I found there 14 men and women, long-stay patients. It is to be hoped that some of them will leave eventually, but there is no emphasis on that. Some of them may stay there indefinitely. The whole emphasis 842 is on the hostel being a home. The ratio is quite good. I do not know whether it is better or worse than is found in mental hospitals. Perhaps the noble Lord, Lord Ennals, will tell us. For 14 patients there are, roughly speaking, 14 people there to help them. It is a ratio of one to one. Undoubtedly the people there enjoy themselves very much. I greatly commend the hostel.
I do not know how much one can deduce from that. Only 14 people stay there and we know that vast numbers of mentally ill people need some sort of care in the community. So for a start one would need to increase the number of such places. That is one way of making a start. The beauty of this place, if I may say so, following something I said in a previous debate on these matters, is that it links the hospital and the community. It springs from the hospital and yet these people are free to move about. They are voluntary patients and they play their part—not a very large part —in the community. That is one way of dealing with the matter. The more often that example is followed, the better it will be for everyone.
Of course there are many different forms of mental trouble or mental situations; indeed, the varieties are unlimited. Therefore, enormous imagination, organising power and energy must be brought to bear in order to work out a national scheme. I do not for one moment think that any collective thought is being used to solve the problem. If that is not the case, I should like to hear examples to the contrary. However, during the course of many debates in this House, I have seen no sign of collective thinking on the matter.
The example of the Maudsley hostel raises a relatively easy issue. It is one of the most famous hospitals in the world and there is no question of its closure. However, if one considers an area where the hospital has been shut down, the whole problem becomes much worse. I have mentioned before —and I do not apologise for repeating it—the situation which will follow the total shutting down of Hellingley Hospital in Sussex. At one time it held 1,400 people, although it was originally intended for 1,000. At present there are 100 people in the hospital, but soon there will be none because the place is being closed. It is not the same as the Maudsley Hospital, because the latter provides a nucleus for aftercare. But, in the case of Hellingley, there will be no provision whatever when the place is closed. One is bound to ask what will happen in such a situation, or indeed in any other, where the hospital is being closed.
As regards Hellingley, I tried to look into the matter. Bearing in mind that there would be 1,000 people in that hospital if it were not due to close, I managed to trace 200 people in one district or another who would normally rely upon the hospital. Therefore, it is a matter of 200 people being placed in smaller units, against 1,000 former places —although, to be fair, there are plans to provide a further 200 places in smaller units. However, that will amount to only 400 places. The majority of the people who were in the hospital will not be catered for in those smaller units.
843 I gained a very favourable impression of one of the smaller units which I visited. In such units, which provide for about 40 people, it is possible to lead a much more constructive life than in a large hospital. I am not for one moment saying that the ideal is to keep these larger institutions open. I think we all agree that we must produce alternative accommodation for these people, whether it is in smaller units or some other form of aftercare.
I have given the Government notice of a few questions that I wish to ask. I hope that they will be able to provide answers. First, do we have any idea of the amount of alternative accommodation which is provided? In the one area I mentioned, I talked about 200 or possibly 400 places against 1,000 possible places in the hospital. It may be said that some sort of community care will be provided for the other people either at day centres or in their homes and so on. Taking a national view, can the Government give us any idea of the scale of the provision at present? Can they tell us, even in the roughest terms, the amount of community care which is being provided in place of the care received in the hospitals which are to be closed? If it is not possible to measure the number of people who are helped in the community in that way, can we perhaps look at the matter in financial terms? For example, how much money has been saved in the past 10 years, or during any other period which appeals to the noble Lord, by closing mental hospitals and how much public money is being spent on community care? That question will not go away. The Minister may or may not have an answer at his fingertips. In any event, we shall keep returning to it.
There is one other aspect of the matter which was referred to by the noble Lord, Lord Mottistone, in his excellent opening speech. He quoted a statement made by the noble Baroness, Lady Hooper, on January 29th. In fact, I believe that she replied to me in the same way during a subsequent debate in February. She said that the Government would not allow the closure of mental hospitals in the future. I am not sure whether what she said to the noble Lord was as definite as what she said to me:No hospital closures will be approved unless it can be demonstrated that adequate alternatives have been developed".—[Official Report, 13/2/91; col. 184.]I have a further question for the noble Lord, who I am sure will handle the matter with much sympathy. I have given him notice of it. Can he say when this new policy—a healthy one, at least on the face of it—was introduced? It was certainly not introduced until fairly recently. Further, how will the policy be enforced? We must be told whether there is an effective way of implementing it. It is taking rather a negative view to say that there will be no closures until adequate alternative accommodation is available. What steps are the government taking—this is the nub of the matter—to ensure that adequate accommodation is provided? It is not enough to say, "Well, if there is no accommodation we shall not allow any closures". The Government have a plan—a vision, if you like—of alternative accommodation, but what steps are they taking to promote its availability?
844 Every time I reconsider this matter I find something new and horrible about it. I shall not mention a particular case tonight because it may not help the individual concerned. I have not given the noble Lord notice of my next point, but I cannot help wondering whether the position today in England of a long-stay patient is that he cannot make use of the National Health Service without being subject to a means test. Is that the situation in this country? It is true that that is the case in some places. Finally, I should like to express my support for all that has been said thus far in the debate.
§ 8.25 p.m.
§ Baroness Cox
My Lords, I join other noble Lords in thanking my noble friend Lord Mottistone for raising this extremely important question. It is one which reflects widespread concern that well-meaning policies of discharging patients suffering from mental illness into the community do not turn into a nightmarish reality of loneliness, neglect and physical and mental deterioration.
My noble friend has comprehensively highlighted key facts and figures indicating the extent of reductions in the number of hospital beds. The noble Lord, Lord Balfour, in his moving maiden speech highlighted very powerfully the size and poignancy of the problems of mental illness. I shall, therefore, just mention three issues. The first concerns problems associated with the general policy of community care; secondly, I shall give one specific example which illustrates, tragically, the nature of these problems; and, finally, I shall put forward a related issue of the training of social workers who will be the key professional staff implementing social care as responsibility moves to local authorities and social service departments. That point was touched upon by my noble friend Lady Elliot.
Several years ago, when I was lecturing in the social sciences, the concept of community care began to feature prominently on the agenda of policies for people suffering from mental illness and mental handicap. I was then deeply ambivalent about the concept, and I still am. The problems of long-stay institutional care have been well documented. Those of us who have worked in institutions are familiar with them. I refer to problems of depersonalisation, dependency, loss of initiative and so on. By contrast, community care at its best can provide a quality of life better than that which may be possible in traditional large institutions. Indeed, some examples of good community care have transformed the lives of people who have been hospitalised for many years, thus giving them new-found and previously almost inconceivable freedom, dignity and independence. We should be very thankful for that fact.
But, tragically, discharge from hospital does not always have such a happy outcome. In the first place, hospitals can be very effective asylums, in the best sense of the word, to people suffering from mental illness. Indeed, they can be happy places. Moreover, on the other side of the coin, provision in the community is already proving to be inadequate to meet the needs of some people suffering from mental 845 illness. So far, those who have been discharged have been those deemed to be most ready to adjust to life in the community. Subsequent discharges are likely to be less obvious candidates for adjustment from the asylum of hospital care to the challenges of life in the community, for the community can be a lonely place, and it is much easier for people suffering from a mental illness to slip through the interstices of care in the community than it is in the relative safety of a hospital. Moreover, community care cannot, and must not, be a cheaper option than institutional care. Although many relatives are willing to take on responsibilities for the care of people with a mental illness, it may place a great strain upon them, and they need adequate support. There is again evidence that many are not receiving that support and are under great stress.
That brings me to my second point. I offer one vignette which I am afraid is typical of many and it is a true story. Following bed closures in a large hospital, a middle-aged man suffering from schizophrenia was discharged into the community. Accommodation was found for him in a bed-sit flat, but he was told that he had to leave it. He became agitated. He went to a day hospital where he broke a window and set off the fire alarm. He was arrested and sent to prison on remand for three months. The manager in charge of mental health for that locality said that there had been several unsuccessful attempts to provide more satisfactory placements but that there were gaps in the current service provision for patients who exhibit what he called "challenging behaviour", and that the absence of "challenging behaviour facilities" led to great pressures on the carers of people with such problems. He also said that he had not approached other mental health facilities in his region because they would have been in no better position to assist with the containment of problems presented by that client. The man vas eventually accommodated in a private hospital at a considerable distance from his elderly mother who has great difficulty travelling to visit him.
That sad case illustrates a pattern that is becoming disturbingly widespread: a pattern of clients who have been discharged from mental hospitals and who have encountered difficulties of accommodation, isolation and anxiety which have perhaps prompted them to indulge in behaviour which lands them in trouble, or which relegates them to the ranks of the homeless and the destitute. It is no accident that one-third of the homeless in our country suffer from some form of mental illness. Demographic trends are likely to exacerbate the problem as more of our elderly population become more elderly and more prone to associated psychiatric problems such as dementia. There are already too many cases where appropriate institutional care cannot be found and where carers are suffering intolerable stress.
Before I finish I wish to touch on a different but related topic; namely, the shift of responsibility for the provision of social care to local authorities and social service departments, where the lead professionals will be the social workers. My anxiety is whether they have all beam adequately trained to assess the needs of 846 people suffering from mental illness. That anxiety is based on my perception of trends in the theoretical basis for some social work courses which have a strong bias against the so-called "medical model" of diagnosis and treatment.
Perhaps I may refer briefly once again to the days when I was lecturing in social sciences. I remember being deeply worried by courses leading to degrees and professional qualifications in social work which gave virtually no knowledge of the clinical basis of mental illness and which taught that medical treatment was a form of "oppression". In its most extreme form, such radical social work was represented by a movement called Case Con, with a journal of the same name. In one issue, typical Marxist approaches to mental illness were identified: one saw mental illness as "false consciousness" with the remedy lying in the acceptance of a Marxist analysis. Another taught that mental illness is merely a product of bourgeois propaganda in a society where people who threaten the bourgeois order are coerced into institutions and where psychiatry serves as a tool of the oppressors. I am not paranoid and I am not hallucinating.
I have sat in on lectures where those theories were being taught in all seriousness. Worse than that, I am aware of situations where social workers would not identify clients with psychiatric problems as mentally ill because of a commitment to such ideological approaches to mental illness. I have read courses leading to qualifications in social work which do not study mental illness at all and do not give those social workers any knowledge of the key insights and facts relating to mental illness, but focus merely on critiques of the medical model. I must emphasis that those direct experiences are not recent, but they were real; and many who undertook those courses may now be in practice.
I talked to the National Schizophrenia Fellowship, and I am sad to learn that it, with its direct experience of people suffering mental illness, is even now deeply worried about the lack of clinical knowledge of many social workers and the ideological bias of some who still see medical treatment as a form of oppression. I talked recently to a professor of social work and I was interested to note that he was worried that in his experience too many social workers seemed to forget that their clients had bodies with physical needs.
Those worries were endorsed by a report from the CCETSW last year which recounted findings of a national survey of approved social workers qualified to work with the mentally ill in which it was recognised that the most strongly felt deficits of knowledge were those relating to mental illness and matters directly relevant to the mentally ill which are, they admit, almost certainly under-taught in basic approved social work training. So serious are those deficiencies that the NSF has recently run 14-day training courses in different parts of the country—and is still running them —to help social workers become more knowledgeable about the condition of schizophrenia and the needs of those who suffer from it and those who care for them. It seems a little anomalous that it should fall to a charitable organisation to make 847 up a deficit in professional training for professional social workers who are to be the lead professionals in providing community care.
I conclude by asking my noble friend the Minister for reassurance that not only will there be adequate provision for people discharged from hospital in terms of essential facilities and support services, but for reassurance that the staff who will be responsible for designing and implementing the so-called packages of care will be adequately qualified in terms of clinical knowledge to ensure that patients' mental health needs are met. Unless those basic provisions can be assured, we may see suffering of unprecedented proportions in the form of lost, lonely and homeless people, or of carers who are burdened beyond endurance. Such outcomes would not only be a travesty of a policy which was designed to bring a better quality of life to some of our most vulnerable citizens; it would also be an unforgivable blight upon the conscience of the nation.
§ 8.39 p.m.
§ Baroness Robson of Kiddington
My Lords, I too should like to thank the noble Lord, Lord Mottistone, for raising this subject for debate because it is one of the most important subjects affecting our society. I also take the opportunity to add my congratulations to the noble Lord, Lord Balfour of Inchrye, on joining our debate. We look forward to hearing from him many times in the future.
The noble Lord, Lord Mottistone, and the noble Baroness, Lady Elliot, mentioned various figures relating to hospitals which are likely to close within the foreseeable future and how many bed closures there would be affecting the mentally ill. There were different figures: 32 hospitals, 35 hospitals—
§ Lord Mottistone
My Lords, perhaps I might intervene in order to clarify this point for the noble Baroness and for my noble friend. It is 32 hospitals this year and it was 35 hospitals last year. They were different quotes.
§ Baroness Robson of Kiddington
My Lords, I am grateful to the noble Lord; but I have also been given a figure to say that this means there will be a loss of something like 12,500 beds.
I was delighted, as I am sure were many of your Lordships, when in September the Government announced a specific grant of £30 million for mental health care to local authorities to improve their capabilities in providing care for the mentally ill. It is estimated that will provide care for about 3,000 people. At the moment local authorities spend £200 million on mental health care, and so the £30 million is an increase of 15 per cent. As I said, it will provide care for about 3,000 people. However, the Government admit that there are 25,000 people suffering from schizophrenia. Therefore the finance available to local authorities is not by any means adequate. The £30 million is only available to local authorities if they can put up 30 per cent. Many local authorities have already announced that with the community charge and the capping in regard to the 848 community charge, they are unable to find the 30 per cent. As a result, they cannot take advantage of the £30 million.
There is another interesting figure. Over the past 10 years the ratio of expenditure between hospital care and community care has hardly changed. For every pound spent on mental health 10 years ago, 12p was spent on community services. That amount has now risen to the enormous sum of 15p, and in my view the ratio should be completely reversed.
Not so very long ago I was chairman of the South-West Thames Regional Health Authority. The pressure for allowing people back into the community had already started, and therefore the transfer of resources from the big institutions to community care had begun. I argued with the Secretary of State, including the former Secretary of State who is now sitting on the Labour Front Bench, about the impossibility of transferring any resources from the hospital service to the community without getting bridging loans from the Government.
You cannot save money by closing part of a hospital, or closing some wards, and allowing the people with the greatest possibilities to live on their own out in the community. You are then left with patients who need the most enormous amount of care. You probably need more staff because in the past some of the fitter patients did quite a lot within the hospital to help their friends who were not as well off as they were. Therefore certainly the same staff, if not more, are needed; and you cannot let the rest of the hospital buildings fall down. The bridging loans were desperately necessary, and without them resources to the community cannot be transferred.
Last year the Government announced capital bridging loan finance for health authorities to the tune of £50 million. That was for mental health and handicap services. That was also very welcome. However, immediately that was announced, 140 health authorities applied for the bridging loan finance, and 10 of them were granted it. That amounted to £30 million. Therefore £50 million is by no means enough. The Social Services Select Committee in another place have estimated that the bridging loan fund, it it is to be of any help, should be £267.6 million.
It is a tragedy that we cannot organise our finances to help this transfer. We are all convinced that with the proper services in the community it is better for people to live like normal human beings. It is also true that for a very few of them the institution is home, and they should not be pushed out if they are not ready to leave.
We have failed abysmally in creating the right community services. This is pointed to by the fact that 80 per cent. of admissions to psychiatric hospitals are people who have been admitted before. It is not wholly the fault of lack of community services; but I cannot help feeling that that is one of the most important reasons. I am connected with a charity called Crisis, and I am one of their trustees. In particular in London we have found an enormous increase in the number of people suffering from mental disability. This creates great problems in hostels and day centres because these mentally afflicted homeless people create 849 enormous disturbance in the hostels and day centres because the people are not being properly cared for by the rig ht kind of services. To a certain extent, that puts off homeless people who want to use the day centres because it is too difficult to cope.
We had one or two terrible examples in Crisis at Christmas. For example, a woman became too violent and could not be kept at the centre. We took her to the Maudsley Hospital. She was examined and considered not to be insane. We then took her to a night shelter, where she apparently became just as violent. The police were called in, but they did not take her to the police station. They asked her where she wanted to go and she said, "King's Cross". They took her there and just dropped her on the corner. That should not happen to anybody in that state. It was only about three weeks later that she died.
All community workers must have very special training in order to look after the homeless mentally ill. These people are in a very special class. They have no connections with society; they are not registered with a GP, and they do not have any people of their own supporting them in the community. Quite often they have had bad experiences in a hospital or they do not like the hospital. They are also very unlikely to keep out-patient appointments or to take medication. This is an enormous problem and it must be addressed.
I was particularly pleased to hear the noble Baroness, Lady Cox, talk about the training which is necessary for social workers. I could not agree more. I do riot know how many members of the medical profession we have in the Chamber at the moment, but I emphasise that the same point applies to general practitioners. There are many general practitioners who do not understand how to deal with the first signs of mental illness. They are not prepared to take the time to probe why a patient has come to see them, complaining of some minor illness, when in fact they want the doctor to take time with them, and they want to be able to talk to someone about their problems.
We need to concentrate, both in our medical education and in our post-graduate training, particularly for general practitioners, on learning more about how to detect what is really behind a person's plea for help. That should also be included in social workers' training.
Many things need to be done, and there is much goodwill among the voluntary organisations and among people in society, but unless we get our finances right we shall not be able to solve the problem.
§ 8.50 p m.
§ Lord Ennals
My Lords, I am sure that the whole House feels grateful that we have had a wealth of well-informed speeches this evening from people who know what they are talking about and who have taken trouble with their presentation, not least from the noble Lord, Lord Balfour of Inchrye, in his maiden speech. He has started very well. I hope that he keeps it up.
850 There is a great need for people who have an understanding of mental health problems in Britain to speak up, stand up, and in a sense fight against ignorance and prejudice, but perhaps more against the sense of apathy, that this is someone else's problem.
I am grateful to the noble Lord, Lord Mottistone, for his raising of the issue today, and also for his constant concern about this issue. I share his worries about the gross disparity between the rate of closure of long-stay mental hospital beds and the inadequacy of community care. I touched on this in the debate which we had on 13th February when I referred to mental hospital beds having been cut by 40 per cent. in a period of just two years, which was too much. Then I said:thousands of long-stay mental patients have been discharged from long-stay hospitals, landing up in prisons or sleeping rough, because the Government will not provide money for good community care;"—[Official Report, 13/2/91; col. 120.]The Government accept that some mental hospital beds will be required even when the closure programme is completed. When the Minister replies, I wonder whether he could say something about that. What is their present calculation? What are the criteria on which any calculation is made? I hope the Minister will also reply to the valid points put by my noble friend Lord Longford.
I also share the concern of the noble Lord, Lord Mottistone, that figures of beds closed and beds still required are not held centrally. That is a very unsatisfactory situation. Unless the information is available to the department from the regions, through the districts, there is no way in which the department can effectively monitor a programme on which Ministers can come to this House and another place to answer questions. I am always dissatisfied to hear the answer "This information is not centrally available". On this issue the information must be centrally available; otherwise we cannot follow what is going on. In a sense, it is an abdication of responsibility for the carrying into effect of policies which concern us all.
Principally, I want to say that it is more important to put more resources into good community care than to turn back the clock. I agree with the noble Lord that we must keep the closure of mental hospitals in sync, but I do not want us to turn back the clock. My noble friend referred to "community care" as being words he did not like. I find it to be a satisfactory concept. Providing it is effectively carried through, providing the range of options is very wide, and that there is proper supervision and training for those involved, it is a far better provision than that found in hospital, except for a limited few.
The noble Lord, Lord Balfour of Inchrye, was right to point out that 99 per cent. of all people with a diagnosis of mental illness live in the community, that is, nearly 6 million as compared with under 60,000 who are actually in hospital. But community care services offer a better quality of life than do hospitals, even for people who have been institutionalised over many years. Recent research on the Care in the Community programme sponsored by the 851 Department of Health found there were improvements in social contacts, morale, the use of shops and other local facilities, at a lesser cost than the £30,000 per bed per year expended on a psychiatric bed. Generalisations are always dangerous, but most users of community care services also say that they prefer those services to going back into hospital.
Of course, as hospitals close, and as there is increasing recognition of the needs of the community, the needs for community mental health services are growing. Yet health expenditure continues to be concentrated heavily in hospital services, especially in the acute sector. Eighty-five per cent. of all the combined health authority and social services budgets devoted to mental health is channelled into hospitals; in other words, 85 per cent. of the budgets go on 1 per cent. of the population in need. Since 1979–11 years ago—this has dropped by a mere 3 per cent. from 88 per cent. to 85 per cent. The low priority accorded to community services in general and to mental health in particular means that it is common for mental health budgets to be raided to cover overspending in acute medicine. This is something that the department must tackle.
In the absence of ring-fenced mental health budgets, savings made by closing psychiatric wards can be, and often are, used to bail out acute sector budgets rather than to enhance community mental health services. This is an intolerable situation. If the department does not know about this it is because figures are not kept centrally and they are unable to monitor it.
Community care reforms have consistently taken second place to general NHS reforms since the NHS and Community Care Act was passed last year. This is true of the community care reforms as they affect local authorities. In a leaked letter dated September 1990 it became clear that the former Secretary of State, Kenneth Clarke, had offered to reduce his community care bid to the Treasury from £50 million to £4 million, and that he additionally offered to reduce his personal social services capital bid by £22 million, of which the bulk, £15 million, was to come from the community care capital budget.
More recently, it has become clear that the community care reforms expected of health authorities are also being starved of the necessary resources. Regional health authorities have been informed by the NHS management executive that changes arising from Caring for People—the community care aspects of the reforms—will have to be met from within existing resources. This can be a recipe for inaction. Moreover, the new care programme approach means that from April this year health authorities will have to assess and devise a care programme for people leaving psychiatric hospitals with no new resources, in order to fulfil an absolute commitment. They do not have the resources to do it. The noble Lord, Lord Mottistone, makes the bid—and it is a bid that I make —that people should always leave hospital with a care plan, and always after assessment. The money has to be provided to enable that to be done.
I argued the case against the mental hospital as a 852 desirable place to live for most people. I once spent a spell in a mental hospital, and I can say that hospital life is a life limited by segregation, by an institutional regime which by its nature cannot accommodate individual wishes and needs. Long-stay psychiatric hospitals are unpopular. A research report entitled I hated it there but I miss the people by Nigel Gouldie found that 70 per cent. of ex-long-stay patients had no wish to return, even though the support they found in the community was in no way sufficient. Later reports have put the proportion much higher. One report put it at 96 per cent. That research was carried out by J. Oliver and K. Wooff and published by the Department of Health.
A glance at some of the headings under which community services in Torbay operate shows that a comprehensive mental health service does not necessarily need a hospital base. Community mental health services, acute care, psychotherapy services, services for people with longer-term problems, services for elderly people with mental health problems, and even the asylum function which is often claimed for psychiatric hospitals, do not necessarily need a hospital. The example given by my noble friend Lord Longford of the Maudsley was a good example of that.
The problem basically concerns money. Part of the resistance to hospital closure is that the closure of any service risks becoming a cut. Cuts have been made in Nottingham's mental health services to meet an acute unit overspend, while Exeter MIND's extensive efforts to find out what happened to the funds released by the closure of Digbeth and Exminster hospitals have shown how difficult it is to keep track of health authority finances. Diverting funds saved through hospital closures away from mental health services is indefensible, but the way to stop this kind of asset stripping is not by ending the closure programme. The Department of Health should not only state that proceeds from hospital sales must be used to develop alternative services, but it should also require authorities to publish what happens to their assets. I shall repeat that. It is absolutely essential that the Department of Health should require health authorities to state that proceeds from hospital sales must be used to develop alternative services, and to make it clear to the department how those savings have been spent.
If community care is to be a reality—in 1986 the Audit Commission suggested it could be a reality—the transfer of resources from institutional to community care services must be made. That is our principal plea to the Government. In my view the reason for service gaps in the community is, at root, that no adequate mechanism has been found to transfer resources from hospital to community.
I tried to do this in a modest way by joint funding. That enabled health authority money to be used by social services departments. I wish I was clear on where we stand on joint funding now. Slowing or halting hospital rundown can only exacerbate the difficulty and the deficiency in this area. Money must be put into community care. The Government must find ways not of moving backwards but of moving 853 forward. I hope the Minister will say something that will encourage the noble Lord, Lord Mottistone, myself and all those who have taken part in the debate.
§ 9.3 p.m.
§ Lord Cavendish of Furness
My Lords, I wish to join other speakers in congratulating the noble Lord, Lord Balfour of Inchrye, on a compelling and well informed speech. The noble Lord spoke with humanity and transparent sincerity born of personal experience. I, like other noble Lords, look forward to hearing him speak again and again.
Contrary to popular belief, the development of mental health services is not aimed primarily at closing hospitals. No suggestion has been made this evening to that effect. Rather, health authorities in collaboration with local authority social services departments are seeking to develop locally-based networks of health and social care services for people with a mental illness, including both short-term hospital beds and longer-term provision for rehabilitation and asylum. This is a useful debate on an important and topical issue, and I am glad to be able to reiterate the Government's reaction to some of the problems arising during what is a transitional period when the traditional mental hospitals, including the Victorian asylums, are becoming redundant and are being run down with a view to closure. Our guidance to health authorities makes clear that the run-down of beds and closure of hospitals should not proceed faster than the build-up of alternative local services. Neither should there be any question of patients being discharged from mental hospitals until their needs have been assessed and arrangements have been made with local authorities and other care agencies for those needs to be appropriately met.
§ The Earl of Longford
My Lords, I am sorry to interrupt the noble Lord. Will he tell us when that policy was decided upon? It certainly has not been applied over the years.
§ Lord Cavendish of Furness
My Lords, I am not sure exactly when the policy was decided upon. It will come to final fruition on 1st April. Perhaps that point will become clear as I continue with my remarks. If that is not the case, I shall certainly write to the noble Earl.
There is no simple arithmetical formula for ensuring that the run-down of the old facilities does not outpace the development of the new. It is very much a matter of judgment. We would not claim that, in all parts of the country, and at all times over the past 15 years, the run-down has never outpaced the build-up of new facilities.
I do not dispute the difficulty mentioned by my noble friend Lady Elliot of Harwood, nor the fact that mental illness continues to lead to great tragedies and sorrow. I cannot claim that those tragedies will cease. They are a fact of life. The noble Baroness, in referring to bed reductions of 25,000, asked whether the community could cope with the situation. I should make the point that the number of beds has reduced gradually at a rate of between 2,000 and 3,000 each year or, put another way, between 10 to 20 beds per health district.
854 Our anxieties in this matter are one of the reasons why we have introduced improved new arrangements that will come into effect in April. At this point perhaps I should clear up a statistic. It has been asked how many mental illness hospitals closed last year and how many are planned for closure. I am informed that one hospital was closed in 1990 and 32 hospitals are planned for closure by 1996, subject to suitable alternative provision being made.
The key initiative is the introduction of the care programme approach. As my noble friend knows, my right honourable friend the Secretary of State for Health has asked district health authorities to introduce that approach from 1st April. The essential elements are the establishment of systematic arrangements for assessing the health and social care needs of patients who could potentially be treated in the community. They include the identification of a key worker to keep in close touch with patients and specifically to monitor the delivery of agreed health care and social care.
On the subject of bed closures, my noble friend Lord Mottistone, the noble Earl, Lord Longford, and other noble Lords sought greater reassurance that the number of beds is not reducing faster than the rate at which mentally ill patients are being discharged into the community, backed by figures on bed closures and their replacement. Such figures are not available until statistics are collated at the end of any one year. That is because the situation is dynamic. Bed numbers shift in an uneven pattern and although the trend has been consistently downwards the rate of fall is uneven from year to year and from region to region.
Nor would such statistics help noble Lords very much. In different areas there are radically different approaches to treatment which affect bed occupancy. Furthermore, a well-publicised decision to reduce bed numbers in any one mental illness hospital could be reversed suddenly and unexpectedly to reflect local needs. Such statistics would therefore tend to be misleading. We believe that it would make no sense for the Government to interfere with that process.
My noble friend Lord Mottistone queried a hospital bed statistic. The figure of 37,350 mental illness hospital beds quoted by my noble friend is not correct. That is no fault of his; I believe that it arises from a misunderstanding. The total number of such beds in 1989–90 was 59,290. The figure of 37,350 relates largely to long-term provision as well as to beds in secure facilities.
For many years now there has been a decline in the number of such beds. That has occurred gradually as community services have developed. Improving services for people suffering from mental illness is one of the Government's priorities. I should like to give an illustration using figures. In this country there may be as many as 6 million people suffering from mental illness of one kind or another. The scale of the problem was borne out by the noble Lord, Lord Balfour, in his speech. Of those 6 million some 2¼ million people may be described as seriously mentally 855 ill. Of those 2¼ million seriously mentally ill people there will at any one time be only 60,000 in hospital, of whom more than half will be long-stay patients.
Of the approximately £1.5 billion of health service budget devoted to mental illness, one half is spent on those 60,000 patients. The Government's policy is to change that through the care programme, monitoring carefully as the programme proceeds. It remains to be seen what precise effect that will have on resources and whether or not the new policy will give rise to a need for new additional funding.
We accept that there have been cases in which patients with mental illness have been discharged from hospital without adequate arrangements having been made for their continuing health and social care. An illustration has been given tonight in your Lordships' House. We are therefore requiring all health authorities to introduce from 1st April more systematic arrangements for the care programme approach to ensure that no one is discharged from psychiatric hospital unless his or her continuing health and social care needs can be met.
Health authorities will need to ensure that any further reduction in hospital beds does not outpace developments in community services. For that reason we have introduced a completely new specific revenue grant to local authorities of £21 million next year towards new services, at a total cost of £30 million. That will make a significant difference to the level of local authority expenditure on services for people with mental illness. It is impossible to give the precise figure for the current level of such expenditure but the highest estimate is around £200 million. The new grant would allow 15 per cent. real growth on that figure and contribute significantly to meeting the costs of local authority services for mentally ill people.
The noble Baroness, Lady Robson, said that many local authorities cannot find the 30 per cent. Other noble Lords also made that point. I dispute that statement. The latest information is that 105 out of 107 authorities will take up the grant. One authority —Salford—appears to have decided not to take it up; we wait to hear from the other one, which is Bromley. Early indications are that there will be a take-up of well over 90 per cent.
The centrally funded portion of mental illness specific grant is 70 per cent., as it is for personal social services specific grants. The 30 per cent. which local authorities must find is taken into account in their RSG settlement and to that extent is provided for from central government. If the specific grant were to be funded centrally at a rate of 100 per cent., it might be viewed as a disincentive to local authorities to make the most efficient use of the funds available.
§ Lord Ennals
My Lords, perhaps the noble Lord will give way. Would he accept that the final determinant cannot be made until it is known which local authorities will be charge capped? If they are charge capped they may have to revise the decision taken and an early priority might be taking up their share of the specific grant for mental health.
§ Lord Cavendish of Furness
I am not aware, my Lords, of anyone having provisionally made that bid and therefore I assume that a number of authorities which have already got into the bid will be charge capped. But I understand what the noble Lord says.
To help local authorities finance the capital elements of the new social care services we are offering supplementary credit approvals of £10 million in 1991–92. Clearly, finance from mental hospital sites provides valuable capital for replacement facilities such as hospital hostels but these facilities are needed before hospitals can be vacated and therefore have to compete for resources with other priorities within capital programmes.
To tackle that problem we introduced the capital loans fund at the beginning of the financial year 1990–91 to provide bridging finance to allow health authorities to develop community services in advance of closing old mental illness and mental handicap hospitals. Bids were invited from all health authorities for payments from that fund. Repayments of the loans would be expected within a few years to enable the fund to continue as a rolling programme. We received over 140 bids. They were all carefully assessed to ensure that they were consistent with the aims of the fund and that the authorities had clear plans to repay the loans so that the process could be repeated somewhere else. In July 1990 we announced that £30 million was being allocated to 10 schemes over the next three years. Additional schemes will be adopted as the fund increases over the three-year period to make up a £50 million rolling programme, the fund being replenished by repayments from schemes in progress.
The development of mental illness services, including the shift to locally based services, is a regular feature of the annual accountability review meetings which Ministers and the NHS Management Executive hold with each regional health authority. The department advises on and monitors the development of services by local authorities through the work of its Social Services Inspectorate. Information is also obtained through the health advisory service, which regularly produces reports on services for mentally ill people.
The Department of Health is asking regional health authorities to confirm by the end of April 1991 that all district health authorities have introduced the care programme approach. The department will commission research to help evaluate its effectiveness. I understand that that will not bring entire satisfaction to my noble friend Lord Mottistone but we believe that we have the basis of serious monitoring. I know that my right honourable friend has every intention of ensuring that this vital element of government policy is made to work.
I turn to a couple of questions asked in the course of the debate. The noble Earl, Lord Longford, specifically asked what savings arose from the closure of hospitals. The answer is that there have been no savings. Put like that, I do not think that one could make sense of savings, in that no money has been realised and gone anywhere else. I speak nationally. It 857 may be that there has been a gain to one individual authority through sales. The gross spending on hospitals and community health services for the mentally ill grew by 34 per cent. in real terms between 1978–79 and 1988–89 to a total of £1.4 million. Expenditure by local authorities on mental illness services increased by 80 per cent. in the same period to £63 million.
The noble Earl, Lord Longford, said that he felt that community care might be disastrous. I am not sure whether he still thinks it disastrous.
§ The Earl of Longford
My Lords, I said it the last time I spoke and repeated it—it is a disastrous word. But as I said, we are stuck with it. I do not want to continue to argue about the word. We have more important things to consider.
§ Lord Cavendish of Furness
My Lords, I understand the noble Earl. However, there is a growing consensus that virtually all the professionals, patients and carers prefer that approach to the previous one.
My noble friend Lady Cox spoke of training social workers. She raised a very fair anxiety. Unfortunately I am not in a position to give a response this evening, but either my noble friend Lady Hooper or I will write to her.
§ Lord Mottistone
My Lords, will it be possible for my noble friend to send me a copy of the letter?
§ Lord Cavendish of Furness
My Lords, yes indeed.
Since I am not wholly familiar with the department, I became confused with some of the statistics given by the noble Lord, Lord Ennals. I shall read very 858 carefully what he said and respond. I am glad that he mentioned Torbay. It gives me a chance to pay tribute to that authority and to what it is doing.
The noble Lord also asked whether authorities would be required to return the proceeds from the disposal of hospitals to community care and account for those proceeds. Again I am not in a position to give a definitive answer. However, he raises an important point. I should like to draw it to the attention of my right honourable friend. Again he will receive a full response.
We believe that these initiatives will make both a significant contribution to improving the resources available specifically for mentally ill people and help to ensure that the reduction and closure of the old hospitals does not outpace the development of newer forms of service. We have asked regional health authorities to monitor the introduction of the care programme approach and we shall be looking to them to oversee the development of the new forms of service as part of their overall monitoring role. As a backstop we have made it clear that we shall not approve the closure of any mental hospitals unless it can be demonstrated that suitable alternative services have been developed. I hope that our approach will reassure all noble Lords, including my noble friend Lord Mottistone, and the National Schizophrenia Fellowship, which he so ably represents.