§ 7.56 p.m.
§ The Earl of Longford rose to ask Her Majesty's Government what steps they propose to take in response to the review of health and social services for mentally disordered offenders and others requiring similar services (Cm 2088).
§ The noble Earl said: My Lords, I rise to ask what steps the Government propose to take in regard to the most impressive report of the committee presided over by Dr. Reed on the treatment of mentally disordered offenders.
§ When I look at the list of speakers—it includes the noble Baroness, Lady Faithfull, at whom I am gazing directly—I remember what the Duke of Wellington is supposed to have said on one occasion. I suppose that after the military debate he is in the minds of all of us. Looking at his own troops, he said: "I don't know what effect these people will have on the enemy, but by God they terrify me". I am afraid that that is what I feel about my supporters this evening. I am particularly nervous of the maiden speaker, the noble and learned Lord, Lord Mustill, (I hope that he is a little nervous too). I am always frightened of Law Lords until I get to know them. Then I realise that they are much like the rest of us. I wish him every success in his maiden effort.
§ I hope that the Minister who will reply, who is so exceptionally well qualified for the task, will be as kind to me as usual. But I cannot hope that my luck in that respect will hold.
§ We can all agree that the report is a tremendous step forward in the attempt to co-ordinate the various efforts coming from so many different quarters to cope with mentally disordered offenders. I recognise, however, as the Minister knows, that two further reports from committees under the chairmanship of Dr. Reed are yet to come. They will be published later. Of those two, the one that is crucial for our purpose tonight is the one which deals with high security mental offenders—which means in practice, I suppose, that it is largely a question of taking a good look at the future of the special hospitals. That does not prevent the rest of us offering views which may be particularly appropriate. It may help the committee in its work. But I realise that it is too much to expect that the Minister will tonight say anything positive about that subject. Nevertheless, I hope that she will be able to be a good deal more forthcoming than the Government were, not surprisingly, when the report was first published.
§ In a general sense the Government are prepared to share the standpoint of the committee. The report says that the starting point for the committee was to determine the future services on a multi-agency basis. 718 It goes on to say that decisions should be based on clinical needs and public safety. That seems to me to be a reasonable approach to mentally disordered offenders. But if we were to speak of offenders generally, we would have to pay some attention to deterrents and retribution. I take it that in this case those factors are not considered appropriate.
In the foreword to the report M r. Yeo, Parliamentary Secretary to the Minister of Health, and Michael Jack, Minister of State, Home Office, say,
The Government has reaffirmed in the course of the review that, wherever possible, mentally disordered offenders should receive care and treatment from health and social services, rather than the criminal justice system".
I am sure that all those speaking tonight would agree with that. But the decision regarding who is mentally disordered and who is not is a delicate one. Sometimes one cannot help admitting that it is wrongly taken. It is taken on the advice of doctors and psychiatrists, who are not infallible.
§ The noble Baroness, Lady Cumberlege, has been kind enough before now to mention my book about mentally disordered offenders, Prisoner or Patient? which was published in April. In the book I describe a number of visits I paid to men convicted of murder and who are now in special hospitals after spending some years in prison. Obviously in their cases the decisions could be borderline. Nevertheless, we must make the best we can of the psychological and other resources available.
§ The House will be aware that the report contains 276 recommendations, and I shall not go through them all. I am sorry that the Reed Committee did not follow the excellent example of Sir Louis Blom-Cooper's committee which looked at Ashworth and which set out a number of recommendations which were to be given top priority. The Minister may correct me, but as far as I can see all 276 recommendations stand on the same footing. However, that is only a comment in passing.
§ The great majority of the recommendations could be put into operation without much or any increase of resources. In that sense therefore, the Government could have no defence or excuse for not putting them into operation if they agreed with them. They could not say that it would cost a lot of money. On the face of it most, but perhaps not all, of the recommendations which would involve the transfer of prisoners into hospitals, could be effected without an increase of resources. However, I realise that if the courts are allowed to insist that a specific offender be transferred to hospital, that would need more hospital space and inevitably some increase in resources would be involved. The question of how one transfers people from prison to hospital is an important aspect of the report and a number of valid speakers may deal with it.
§ Another matter with which I shall not deal is the increase of psychiatric facilities in prisons. We have discussed that before today and no one knows more about that than my noble friend Lord Ennals. I do not know what he intends to say but he may deal with that aspect. I and many other noble Lords have stated in this House that one cannot obtain a really satisfactory provision of psychiatric services in prison until the 719 prison medical services are integrated into the National Health Service. But that matter is for another day or another speaker.
§ I shall concentrate my remarks on those recommendations which, on balance, must ultimately involve a specific increase of resources. I shall mention four recommendations from the report which I believe will, in the end, produce a new scenario. The first recommendation is that a considerable number of sentenced prisoners—somewhere between 750 and 1,400—should be transferred from prison to hospital. Secondly, that a considerable number of patients should be transferred from special hospitals to conditions of lesser security. The movement would be from prisons into hospitals and from special hospitals to conditions of less security. Thirdly, the places for people in secure units should be increased from 600 to 1,500. That is the most striking feature of the report. Fourthly, community care for mental patients should be much improved both for existing mental patients and for a significant number who will be moved from mental hospitals into the community.
§ Other speakers may deal with community care. In my eyes it is often a farce, but it represents an ideal which I suppose most of us share. For what my opinion is worth and whatever the precise figure, I offer my support to the broad scenario outlined by the committee. Broadly speaking I agree with its vision. At the end of my speech I shall press the Government to indicate how far they accept the picture of movement from one form of custody to another and finally out of custody into the community. Do they agree in principle with the basic findings of the committee? I shall want to know what steps they are taking to begin moving in that direction.
§ I shall spend the rest of my time—I will not be speaking forever—discussing regional secure units. As I said, the committee wished to see an increase from 600 to 1,500 patients. One can only call that a dramatic—or even traumatic—development. Even 1,500 would leave us short of the 2,000 recommended by the Butler Committee in the mid-1970s.
§ What are the special virtues of the regional secure units? I am sure that at one time or another most noble Lords present will have visited one. I have certainly visited a number and recently I visited the largest one, the Reaside Unit near Birmingham, presided over by the eminent Professor Bluglass.
§ Were the professor speaking to the House I believe that he would give four reasons why he believes that the regional secure units should attract strong support. First, making a comparison with special hospitals as we know them today, the regional units are smaller. Secondly, they have regional rather than national links. That means that they are less remote from the patient's home. I was particularly impressed by the work being done at the Reaside Unit to keep in touch with patients in their homes after they have left the unit. Thirdly, the regional secure units provide a high level of specialised care. Fourthly—which may be controversial—staff are members of nursing unions rather than members of the Prison Officers' Association, about which I have spoken more than 720 once in your Lordships' House. The last issue is perhaps too hot a potato for me to deal with tonight. I shall leave such matters to the noble Lord, Lord Dean, who knows a great deal about the Prison Officers' Association.
§ I must say a few words on some of these points. Is there an ideal size for a regional secure unit? Professor Bluglass's unit has beds for 100 but when I visited it not so long ago only 77 beds were occupied. The staff had overflowed into the space which would otherwise have been used by the patients. The new building will eliminate that difficulty. There will be 100 there before long. One gets the feeling from Professor Bluglass that 100 is about the right size but in my own south-east Thames region, which is well known to the Minister, the regional secure units usually contain about 15 beds. That was true of Maidstone, which I visited not long ago, and I believe it is true of the others.
§ So, on the face of it, there does not appear to be an ideal size for regional secure units. In the south-east Thames region, 15 is the preferred number. Professor Bluglass prefers 100. I think that Professor Bluglass himself would say that it should depend on local conditions and that in country districts smaller units are more desirable. The Minister may have something to say about the desirable size of these units. It is fairly obvious that there is a wide range of choices.
§ One of the important recommendations of the committee is that patients in regional secure units should be retained for as long as it is necessary for their treatment. That has not happened up to now; it has not happened often enough up to now. In my opinion that would be a very desirable step in the future. In that connection, when I was at the Maidstone regional secure unit the idea was put to me that there should be two kinds of regional secure unit; those for fairly short-stay people—up to two years —and those for people who need to stay for longer periods. I mentioned that to Professor Bluglass who seemed to be in favour of the idea. Perhaps the Government will have something to say on whether people should stay in regional secure units for as long as it is judged necessary for their treatment.
§ The subject that I shall become involved in now is very tricky. I do not know whether the Minister, with all her resources, will be able to speak dogmatically about it. What about the ratio of staff to patients, including specialists such as forensic psychiatrists? I found it impossible to arrive at satisfying figures. At Reaside the total staff based on the centre were 300 and there were 77 patients. It may be said that that figure will rise to 100 but 300 is not a fair indication of the ratio because for one reason or another a good many staff have responsibilities outside the unit. That was also the position in Maidstone. I hope that the Minister will agree with the general statement—I do not know whether she will be able to say anything about the precise figures—that the ratio of staff is a good deal higher in regional secure units than it is in the special hospitals. If we are making a comparison between regional secure units and special hospitals we must realise that the regional secure units have a considerable advantage in staff and above all in specialised staff.721
§ It is right to point out, before I leave this point, that in an article in the British Medical Journal not so long ago Professor Bluglass looked forward to the disappearance of the special hospitals. He said that he would like to see them disappear altogether. He takes the view that that kind of high security is unnecessary for more than 100 patients, instead of the 1,700 now retained in the hospitals. In the British Medical Journal he certainly looks forward to the abolition of the special hospitals. He sent me word to say that those who cannot be transferred to regional secure units in the first place should be in regional high secure units. That is what he has asked me to indicate.
§ I have quoted one high authority, Professor Bluglass. I shall quote another, Mr. Charles Kaye, director of the Special Hospitals Service Authority. The House will not be surprised to hear that he disagrees with Professor Bluglass's desire to bring special hospitals to an end. I want to record that because noble Lords might say, "He would, wouldn't he?" or they might say that Professor Bluglass would naturally want to see an expansion of regional secure units. At any rate there is a difference of opinion between these two eminent men.
§ I shall not cover again the ground that I covered in the debate on Ashworth. I expressed then a belief that special hospitals reformed have a very promising future. I shall not go over that ground again.
§ Mr. Kaye has been kind enough to give me some idea of the evidence he has been submitting to the further Reed Report on high security patients. I wish that I were a fly on the wall and could hear the arguments going on between him and Professor Bluglass. There were rumours that they were drawing closer together, but if they are closer together they must both have moved a good deal since I interviewed them. At any rate there are these two eminent men. If asked I shall only reply what Winston Churchill said during the Spanish civil war when asked which side he was on. He said, "I am on both sides." Up to a point that is true about me, but I am not in favour of the abolition of the special hospitals.
§ Without going into details I wish to say briefly that Mr. Kaye defends the maintenance of special hospitals but not as they are today. He would look forward to a time when there might be more than half a dozen special hospitals, each with no more than 200 patients. Three of the existing sites could be used. They would not be special hospitals as we know them but they would still be special hospitals. Professor Bluglass says that in principle he does not object to that formulation. He is not going to commit himself as to the national form of organisation that would result. I should mention also that Mr. Peter Thompson, of the Matthew Trust, who speaks with poignant first-hand experience of these matters, would like to see the special hospitals continue more or less as they are now. So there are various views that can be held.
§ I shall not go any further as there are many experts to follow me. I have not dealt with a proposal which would certainly be very costly if it was carried out within the terms of the Reed Report. It represents a desirable long-term aim. The committee would like to 722 see the numbers of forensic psychiatrists more than doubled and it would like to see other major increases in the same field.
§ One could ask questions about the advisory body but my time is up. I shall only ask the Minister to be as forthcoming as she can when she comes to reply. I know that she would wish to be forthcoming. There are limitations on any government at the moment. I hope that she will be forthcoming because she cares, as we all care, so tremendously about this subject. I look forward greatly to everything that will follow.
§ 8.20 p.m.
§ Baroness Macleod of Bone
My Lords, I, and I am sure all noble Lords in the House tonight, are deeply grateful to the noble Earl, Lord Longford, for introducing this debate. Nobody in your Lordships' House could introduce a debate on this subject with more knowledge or caring than he. I would like to pay a compliment to him and thank him for all that he does. We shall have the pleasure of hearing the noble and learned Lord, Lord Mustill, making his maiden speech. It is a great honour for us to have him with us tonight. I am sure that we shall all listen to everything he has to say both now and in the future. I would also like to compliment Dr. John Reed and all the members of his committee, for this magnificent report. I found it not only illuminating but also sometimes absolutely riveting. Despite the 270 recommendations everything seemed to be pertinent. An enormous amount of time and effort has gone into the report. I offer my congratulations to all of them.
This report has opened our eyes to the possibilities of care in the community for mentally disordered offenders and others requiring similar services. But before looking at the proposals we should realise that there will always be people who will need in-patient care whether they are offenders or people who, through stress or other reasons, become mentally disordered. The health service and sometimes the Home Office, must be responsible for these people.
There are over 70,000 in-patient beds for people with mental illness or learning difficulties, but through the new government initiative more people are being released into the community.
One hospital that I know well—perhaps I should declare a non-pecuniary interest as president of its housing association—has had over 1,000 beds. The number now is just over 400. The men and women patients have not just been thrown out as some sections of the press would have us believe. Their release has been very carefully planned and organised by all the staff of the hospital, local authorities, social services and the voluntary sector.
There are two houses within the hospital grounds which are used to assess whether the chosen patients —usually six or seven—like living together. At the end of the probation period they are moved to a house outside the grounds. They usually work; they pay rent and always have their own front door key. The houses are provided by local authorities within the catchment area. Social workers and the support team are always on call if anything is needed. If absolutely necessary, they can always return to the hospital. However, if all 723 goes well and their reintegration into a normal lifestyle is complete, they then move on to independent accommodation. We now have 18 homes. Perhaps I may add that I am proud to tell your Lordships that the most recent home is now bearing my name.
§ Baroness Macleod of Borve
My Lords, I tell noble Lords about this because I believe that we should all be aware that a great deal is being done by all the dedicated professions involved. I have also been in touch with Rampton Hospital, one of the special hospitals which I expect most of your Lordships know. I was relieved to hear that the present number of patients is 521 of whom 120 are women. In the year 1990–91, 57 patients were discharged. Last year there was an increase to 71 in the number of people who were able to leave. The disposals included being returned to prison to await sentence; transfer to a regional secure unit which we have heard so much about from the noble Earl; transfer to a psychiatric hospital and discharge into the community.
I am assured that in all cases the authorities concerned are aware of the movements of the patients until they are granted an absolute discharge. But with the best will in the world, there will always be people who are not included in statistics and who have not been found; those who are lonely, depressed, often unemployed and who gradually become mentally ill. They are usually homeless as well.
They must be desperately unhappy. Crisis at Christmas, a charity for the single homeless, has an open Christmas at which we welcome up to 1,000 men and women for seven days and nights at Christmastime. Quite a number of our guests need medical and psychiatric help but have slipped through the net. It is our duty to help those people before they decline into a life of crime. The Government have supplied finance for many more housing units to try to accommodate those who are now sleeping rough. We hope that in time cardboard city will be a part of the past.
Taking care in the community in all these cases will involve people who genuinely do care. It will be a challenge to all of us and one which we shall meet. I am sure that we shall succeed.
§ 8.27 p.m.
§ Lord Mustill
My Lords, to make a maiden speech is an ordeal for anybody. My forebodings have been multiplied by looking down the list of speakers and seeing the names of noble Baronesses and noble Lords whose experience in addressing the House and in addressing the intellectual, moral and practical problems in the field of mental health are so much greater than my own. But appreciating seeing that the noble Earl, Lord Longford, was to bring a splendid report before the House tonight, I felt that I must take the plunge because anything that can be done for a mentally disordered offender must at least be attempted.
Maiden speakers are urged to eschew controversy. But there can be nothing controversial in suggesting that among all the shipwrecked of our society, the 724 mentally disordered offenders are as far away as any from a lifeline. They raise the most intractable human and professional problems; human because, unlike other unfortunates, they raise in the breasts of very few an instinctive tide of sympathy. They are doubly alienated from the ordinary world and they are sensed by many as a threat to the precarious balance of the society in which we have to live. So there is no widespread impulse to help them or indeed even to recognise that they need to be helped. They are also odd men out and odd women out. They do not fit into pigeonholes. Put bluntly, I suggest that to many professionals they are a nuisance.
Those who run prisons or bail hostels have a difficult task. They feel, understandably, that the presence of someone mentally disordered upsets the balance—often rather precarious—of their establishment and makes things worse not only for the staff, but for the non-disordered people for whom they already cater. Conversely, those concerned with the practice of mental health do not welcome the potentially disruptive presence of a convicted criminal. However magnanimous and sincere, I believe that there are many professionals who wish that the mentally disordered offender were somewhere else.
Again, the mentally disordered offender is nobody's job. One has only to list a few of the agencies with whom he or she may brush into contact; namely, the police, social services, the medical profession, the prosecution services, judges, the prison service, the probation service and voluntary agencies of various kinds. He or she has contact with these and more, but is nobody's business. No person or body has central responsibility for the mentally disordered offender. No single body or agency combines in itself the unique mixture of skills that this particularly difficult subject demands. These factors mean that the mentally disordered offender simply falls through the gaps between agencies.
These are serious problems, but they are essentially emotional and administrative and ought to be susceptible of cure in time by education and efficient reorganisation. But behind them lie much deeper problems of law and philosophy. The substantive laws governing the relationship between mental disorder and guilt, and governing the powers and duties of the sentencing judge, are outside the scope of the steering committee's report, and I must therefore say nothing about them, deeply unsatisfactory though they are.
But I may perhaps be permitted one brief comment on the philosophy of punishment. Unless society has at least some idea of what it is trying to do when sentencing offenders in general, and, just as important, why it is trying to do it, there is no chance of making a deep impression on the problem of the special class of offenders who are mentally disordered. The time when society formulates and agrees a consistent, comprehensible and democratically underpinned policy on those deep issues seems to me a long way in the future.
Meanwhile, the most we can look for are piecemeal and practical gains, and here at least the picture is much brighter, as the report makes clear. Three trends 725 are particularly encouraging. First, the confluence of two movements for change. That is to say, the long running impetus towards the non-institutional treatment of the mentally ill, and in addition the more recent emphasis on the non-custodial disposal of offenders. Acting together these two streams of movement have led to a commendable pressure for the treatment of the mentally disordered offender outside compulsory residential institutions.
I use that dry and contorted phrase as I prefer not to say "in the community". To liberate these people into the community and expect the community to sustain them unassisted will not be enough. They will sink. The mentally disordered offender will require continuous professional and administrative support, and if that is not made available on a proper scale his position will be worse and not better through the change, and the position of his fellow citizens will be worse as well. Nevertheless, I venture to repeat that the initiative is to be warmly welcomed.
The second theme is the diversion of the mentally disordered offender away from the criminal justice system before they ever get into it. Of course once they get into it the cogwheels of the system grind inexorably on, and once in you never get out. In principle that is fine and I applaud it, but I would briefly draw attention to a constitutional problem that seems scarcely to have been mentioned in the literature and the debates.
We have in this country a statutory system of criminal law, criminal courts, and penal measures that apply to everyone. What seems to be proposed is that some people will be short circuited out of the system before they ever enter it. This may well be the right way ahead, but it is possible that the House will think that if it is the right way ahead the system should be formally legitimised and that standards and mechanisms should be formally established even if informally administered, otherwise we shall get inconsistencies. And, as we all know, inconsistency is one of the most potent varieties of unfairness.
Finally, I would particularly draw the attention of the House to the importance attached in chapter 10 of the report to inter-agency co-operation. That is already well under way. The Home Office and the Department of Health have given a powerful impetus. Also, nationally and locally and at all levels, the bodies and persons concerned have taken to it with enthusiasm. But the enthusiasm needs to be guided, and the initiatives need a solid framework if they are to unite the efforts of all who want to help these unfortunates, and also—and this is important—to get rid of the fragmentation and incoherence that is the curse of provision for the mentally disordered offender.
The steering committee, in paragraph 10.4 of its report, states that the progress already made,needs to be nurtured and supported from the top.I venture to hope that Her Majesty's Government will put their weight behind this report, and carry forward the substantial gains which at long last are being made.
§ 8.36 p.m.
§ Lord Ennals
My Lords, it is my particular privilege both to thank and congratulate the noble and learned Lord, Lord Mustill, on his maiden speech. I suppose even for a very senior and experienced Lord Justice of Appeal it is perhaps still a certain task to make a maiden speech in this place. The noble and learned Lord has got it over now, and I hope that he feels comfortable and relaxed. I share the view of my noble friend Lord Longford that too many Lords all at once can be daunting, but it is frequent that we have debates in which we would like to have a legal input and we do not have it. So to have one all on our own just for this debate is a great privilege, and I hope that the noble and learned Lord will want to join in our debates again even after dinner time. It was a thoughtful and sensitive speech.
The subject introduced by my noble friend Lord Longford is one of growing interest. In the last two months I have taken part in two conferences on subjects relating to this report—something which I warmly welcomed. One of them was at the London School of Economics and the other was in Oxford organised by the College of Occupational Therapists, of which I admit to being president. But the interest in the subject owes a great deal to my noble friend Lord Longford. Month after month and year after year he has kept this issue before your Lordships' House. There have been occasions when I have been proud to follow him and there have been occasions when I have not been able to do so, but I and the whole House are grateful to him for keeping our eyes on this difficult subject.
I have to admit that reading the report brought back vivid recollections of my experience when I was Secretary of State for Social Services, and the time I spent prodding regional health authorities to construct regional secure units. Now, 15 years later, only three regions have in place the number of required beds in secure units—the North West, the South East Thames, and the South West region. Many are significantly below the target figure, and this must be of concern to the Secretary of State.
In this debate I declare my interest as president of MIND, which has made a great contribution to thinking, training and comment on this issue. MIND welcomed the report of Dr. Reed's committee and has called on the Department to secure as early as possible implementation of the bulk of the 276 proposals for action. It is an important report, and we should congratulate Dr. Reed on it. It is good news that he is to continue with an advisory committee. The review has uncovered a vast gulf between the treatment and care that individuals need and are entitled to receive, and in fact the level, range and extent of services currently available to provide this treatment.
The Reed Committee was able to draw on several important and recent studies. Paragraph 2.12 refers to the Efficiency Scrutiny of the Prison Medical Service (1990) whichproposed that health care should be contracted in to prisons, predominantly from the NHS".727 I entirely agree with the comments made by my noble friend on this subject. The paragraph also refers to the Woolf Report on disturbances at Manchester (Strangeways) Prison and elsewhere in 1991 whichmade far-reaching recommendations for the improvement of prison regimes".In addition it states that theChief Inspector of Prisons brought into sharp focus concerns about suicide and self-harm among prisoners".At its disposal the Committee had research suggesting thatupwards of 700 sentenced prisoners might require transfer to psychiatric care in NHS hopsitals".There is much else of value in the report. Paragraph 4.5 states that other offendersare in the wrong place (for example, in prison when they need a secure hospital place, in a hospital with higher security than their treatment requires, or in hospital when they should be in the community)".Paragraph 5.26 refers to special hospitals and to the 1,700 patients who are held in three locations. It points out:Recent research suggests that between 35 per cent and 50 per cent of existing patients may not require high security…although a number of sentenced prisoners may need to be transferred to such provision… In July 1992, about 100 Special Hospital patients were awaiting a move to a more local facility. About 40 of these had been waiting for more than a year despite the requirement for mentally ill and mentally impaired (or severely mentally impaired) patients in Department of Health Circular (88)".The report paints a picture of—perhaps it is not fair to use the word "neglect"—inadequate provision and of a provision which does not suit the needs of patients. Hundreds of patients are not receiving the treatment and care that they need. Taken together with the inadequate supply of medium-secure provisions, to which I have referred, we have a very disturbing situation which should be commanding urgent Government attention. Like others, I await the Minister's reply with eager interest.
The review blames restrictive legal provision and perverse financial arrangements. It also blames the development of the NHS purchaser-provider relationship. It concludes that although court-based psychiatric assessment and diversion schemes can assist in preventing inappropriate imprisonment, provision for the diversion of "mentally disordered offenders" is currently planned in fewer than half of all district health authorities. It is a very serious fact that half of all district health authorities have not yet made any such provision.
Some of your Lordships may have read a recent article in November 1992 in the British Medical Journal, headed, "National Survey of Current Arrangements for Diversion from Custody in England and Wales", which concluded:When diversion is necessary the commonest obstacle when cited by the NHS is the lack of resources. However, as the Probation Service frequently cites a lack of interest by the mental health services as a barrier to further developments, it remains to he seen whether lack of resources or interest is the real obstacle to the future development of services".I suppose that it is part of each, but we must not simply conclude that it is only a lack of resources.
MIND agrees with the review's conclusion that practice falls a long way short of what is desirable —desperately short for those people (and their 728 families) held for years in the wrong form of custody. MIND believes that current services, being excessively custodial and institutional, are often quite unable to address the individual needs of those required to use or to be detained in them.
We broadly support the review's proposals for reform and for the development of a range of services able to respect the human rights and health care needs of offenders with mental health problems and their families. I know that in his maiden speech the noble and learned Lord said that some people would prefer them not to be there, but they are there and we have to treat them with all the respect for their human rights, needs and welfare which they and their families deserve.
MIND also recognises the importance of introducing new mechanisms which will accurately assess unmet needs, ensure effective diversion from inappropriate custody, guarantee constructive joint working between agencies and authorities, remove legal and financial disincentives, and guarantee equal opportunities and freedom from discrimination on grounds of race and gender in the allocation or operation of services. It certainly welcomes the creation of a national advisory committee.
MIND hopes that the review's work will lead to a more effective and a fairer service and that important decisions will be taken. Health and Home Office Ministers must match the review's thorough and realistic analysis with commitments. I should like to list six. The first is to regulate strictly the NHS internal market, where necessary, to guarantee the purchase and provision of an appropriate range of local, regional and national services of high quality. The second is to make district health authorities assume financial responsibility for purchasing all secure mental health services, including those in high security. The third is to guarantee the creation of psychiatric assessment and diversion schemes to serve each magistrates' court area. The fourth is to fix a date by which mental health care in prisons will be entirely provided by NHS staff working to NHS standards. That was a point made in different words by my noble friend Lord Longford. The fifth is to maintain the momentum for change by publishing a five-year action plan with clear targets for reforms and service development. The sixth is to implement the recommendations to redress the racism and inequality which were described in the race and culture report.
No amount of its careful phrasing can conceal the human misery and waste that the Reed Report has documented. In prison, hospital and the community, current services have been shown often to fail the very people that they exist to help. Respecting their human rights may have a high price, but in a civilised society it must be paid. I hope that the Minister will respond in a positive way to the recommendations of the report and to the comments made by noble Lords.
§ 8.47 p.m.
§ Lord Mottistone
My Lords, we must all thank the noble Earl, Lord Longford, for tabling this important Unstarred Question at such a timely occasion. I congratulate the noble and learned Lord, Lord 729 Mustill, on what I would call—and what the noble Lord, Lord Ennals, has already called—a most thoughtful speech. I hope that we shall be able to hear him often in the future. Perhaps I should say that this is the first time in a debate of this kind that I have agreed with practically everything that the noble Lord, Lord Ennals, has said. I usually find that I disagree with him slightly and with MIND a lot. This time, however, I thought that what he had to say was splendid.
The Reed Report is indeed a most useful assessment of the problems facing us in the handling of mentally disordered offenders. Like others, I was keen that this debate should take place. I shall endeavour to pick out just a few points from what is a very comprehensive report but, before doing so, I must emphasise that I see Dr. Reed's report as most useful for future planning which, according to paragraph 1.4, was the intention. However, I do not see it as trying to deal with the present day situation in which there are clearly not the adequate or suitable facilities that are needed by many mentally ill people in this country, including many mentally disordered offenders. The noble Lord, Lord Ennals, made a great point of that, and I agree, but I do not see the report as tackling that matter. It is looking forward, rather than looking at the present and although it is not the subject of this debate, I feel that it is the present which is most important.
I had the good fortune recently to meet, at their request, the trustees of the newly-formed Isle of Wight Community Health Service Trust (which is starting up on 1st April) to learn about its activities generally. We touched upon the subject of this Unstarred Question as well as on other mental illness problems.
As regards the latter, I should perhaps tell your Lordships that during the past five years in my county we have shut down our 19th century mental hospital and opened a new modern one near to our new large general hospital. Sadly—and here I turn to present-day difficulties—I have been told that in planning the new mental hospital 10 years or so ago our district health authority and the region made a significant underestimate of the type and extent of accommodation needed. That is so notwithstanding the excellent arrangements that we have had for many years for care in the community in the Isle of Wight and for inter-agency consultation, long before it had become a statutory requirement. It seems that mental illness, requiring some in-patient treatment, including secure accommodation, is on the increase, certainly in my small part of the kingdom. Without speculating about its causes, I hope that the Government will recognise it as a fact.
I turn now to the comments made to me on the Reed Report by the Isle of Wight director-designate of mental health services. He drew my attention particularly to "next steps" set out in paragraph 10.16 of the report and commented that, fortunately, there seems to be widespread agreement on what needs to be done, but that is for the future. However, it is clear to me and to my adviser that services for the mentally ill generally are being stretched to full capacity. The Isle 730 of Wight does not now have specialist facilities for the care and treatment of persons exhibiting disturbed behaviour as a result of mental health problems.
It is becoming increasingly difficult to contain these people even for short times because of their recent dramatic increase, as mentioned earlier. I suspect that this applies elsewhere in the country as well. If more people are going to be diverted from the courts there will have to be more central government support to provide the increased facilities. My honourable friend, Mr. Tim Yeo, the Parliamentary Under-Secretary for Health, in presenting the Reed Report last November, said that capital expenditure on medium secure psychiatric units would be increased from £3 million in 1991–92 to £18 million. Sadly, from the current practical experience at local level, this is nothing like enough. But perhaps I can be more generous and say that it is a very good start, if only a start. I hope that my noble friend the Minister, in replying, will be able to enlarge on that and tell us that it is in fact a start and not the end of the moneys that are to be made available.
In the same way, I think we can say that the Reed Report is a very good start and that we can look forward to more helpful assessments of national needs for mentally disordered offenders and recommendations from the continuing advisory committees under Dr Reed's obviously excellent chairmanship.
§ 8.53 p.m.
§ Lord Acton
My Lords, I too should like to congratulate the noble and learned Lord, Lord Mustill, on his splendid maiden speech. I am most grateful to the noble Earl, Lord Longford, for asking this important Question on the Government's response to the Reed Committee's review of health and social services for mentally disordered offenders and others requiring similar services.
One of the five guiding principles set out in paragraph 3.3 of the Reed Report is that patients should be cared for,as far as possible in the community, rather than in institutional settings.The goal of care in the community runs throughout this admirable report. I draw your Lordships' attention in particular to paragraph 8.12 under the sub-headings of "Community Services" and "Local Authorities" on page 34. The paragraph states:We are particularly concerned that the transfer to local authorities from 1993–94 of social security funds currently used to meet the cost of accommodation should not work to the disadvantage of mentally disordered offenders.It continues:We welcome the intention of the Department of Health to issue guidance on 'ordinary residence' which may be helpful in some potentially difficult cases. However, looking at the broader issue, the concerns expressed to us by voluntary oganisations and others are such that we believe the Government may need to consider taking positive action, possibly through the introduction of a specific grant, to ensure that access to services is safeguarded.The transfer of funds referred to is under the National Health Service and Community Care Act 1990 and is to take place on 1st April, just seven weeks from now. The question of the "ordinary residence" of a special hospital patient in a local authority area may be fraught with difficulty and may lead to endless 731 disputes between local authorities as to where a mentally disordered offender is ordinarily resident. Take the example of a man who has been in a special hospital for a decade. Suppose he was born and brought up in Taunton; he worked for some years in Plymouth; he committed an offence in Wolverhampton and he was staying in London at the time he was detained. What local authority is responsible for him? Where is he ordinarily resident? A team of barristers specialising in the conflict of laws could argue the case for months. Local authorities are likely to maintain that the mentally disordered offender belongs to another authority. The intention of the Department of Health to issue guidance on "ordinary residence" is, of course, welcome. But apparently the department has not yet done so, and 1st April is awfully soon. Moreover, guidelines are only guidelines and are by no means guaranteed to resolve disputes.
For some mentally disordered offenders ready to be released from special hospitals, the resolution of "ordinary residence" is likely to lead to delay and thus delay the continued rehabilitation of the individual, which is of course the goal of the Reed Report. If a mentally disordered offender does establish ordinary residence in the area of a given local authority, he or she may require a place in a high-care residential home. The person will have to approach his or her local authority for an assessment of need. The local authority may then decide to pay for placing the patient in a residential home. However, the grave danger exists that many local authorities may decide not to pay for that accommodation. Mentally disordered offenders will have to compete with others in need for scarce local authority money. As the Matthew Trust, which in the last 17 years has given £195,000 to help former special hospital patients, says in its briefing:There is a problem of attempting to negotiate resources for a group of people, who many see as undeserving and of low priority in local authority community care planning".This point goes to the heart of the matter. The danger is that mentally disordered offenders will rank so low in a local authority's list of priorities that the high-care accommodation which is essential for the former patient's wellbeing will not be forthcoming. Presumably they will then swell the ranks of the homeless. Disaster is likely to ensue if former special hospital patients do not get the necessary accommodation and care. They may harm themselves; they may harm others; they may commit some other crime; they may go to prison; they may find their way into a mental hospital, or indeed a special hospital all over again.
What is a hospital supposed to do? If it rehabilitates the man or woman again and again releases the person to the local authority, the fear exists of an endless chain of release and return to an institution—much to the frustration of the institution and the mentally disordered offender alike.
In the past three years special hospitals have discharged a yearly average of 56 former patients into the community. An average of 51 former patients who will later be discharged into the community have gone 732 from special hospitals to regional secure units. Allowing for some individuals returning to their families, up to 100 patients each year will become the responsibility of local authorities.
There are approximately 1,700 mentally disordered offenders currently in special hospitals. They divide into two broad categories. The first group comprises those who are restricted and cannot be discharged unless the Home Secretary is satisfied as to a scheme for their future. Clearly, if no local authority will take responsibility for them or if the relevant authority will not provide the necessary accommodation, the Home Secretary should not release them.
The danger must exist that the whole system will silt up. The Reed plan that patients ultimately should be cared for in the community will come to nothing. The walls of the special hospitals will bulge and eventually more space will be required. As of February 1991 the Special Hospitals Service Authority intimated that each patient in its hospitals cost £826 per week. In the community the cost of residence for a former patient would be around £300 a week.
The second group coming out of special hospitals consists of those who are now legally unrestricted. If the Mental Health Tribunal is satisfied that such patients should be released they automatically will be. Released to what, my Lords? To homelessness and to the danger of consequent self-harm, of harm to others, of prison, or of return to hospital.
The special hospitals depend on voluntary organisations to provide much after-care accommodation. There is widespread apprehension that the transfer of funds after 1st April from the Department of Social Security to local authorities will lead to such a reduction of cash flow that the number of places available for mentally disordered offenders will greatly diminish. For example, the Inner London Probation Service points out that six hostels which are currently designated registered care homes will be at risk under the new system. Those homes provide inner London with 191 bed spaces.
The EFRA Trust takes a similar view. It put the number of relevant bed spaces in inner London at risk at the slightly higher figure of 200. Certainly, the outlook of the organisations on that aspect is profoundly gloomy.
I turn now to the suggestion in paragraph 8.12 of the Reed Report for a specific grant to meet the cost of accommodation for mentally disordered offenders. The argument in favour of ear-marking funds—or "ring fencing", in the current jargon—to provide residential care facilities for those suffering from alcohol and drug problems applies with equal force to the unpopular but desperately needy former special hospital patients. Without ring fencing they risk being squeezed out by other groups of the needy.
I have read ministerial speeches, press statements and copies of Hansard about ring fencing. If I understand it aright, the Government argue that because they are ring fencing the total amount of community care funds they no longer see any need to ring fence funds for the accommodation of individual groups such as those suffering from alcohol and drug problems.
733 Applying that reasoning to mentally disordered offenders means that the local authority may say to the individual former special hospital patient, "We have decided not to pay for the cost of accommodation for you. But be of good cheer, the Government's total community care fund is ring fenced." How that is supposed to console the former special hospital patient is beyond me. So vital is accommodation for those individuals, and so short is the time before 1st April, that I ask the Government to consider with utmost speed ring fencing the funds given to local authorities for this purpose.
An alternative that the Government could consider is a centrally administered specific grant. Specific grants have been made in recent years for the targeted homeless mentally ill initiative and for the rough sleepers initiative. Thus, precedents do exist. If the Government preferred that solution the obvious way ahead would be for the Special Hospitals Service Authority to administer a specific grant centrally. After all, the authority is already concerned with the patients and that related role would save overhead costs.
If local authorities fail to pay for accommodation for former special hospital patients the Matthew Trust and other voluntary organisations simply are not in a position to raise the necessary funds. To avert the dangers that I have spelled out the Government should urgently either ring fence money given to local authorities for this purpose or set up a centrally-administered specific grant.
§ 9.7 p.m.
§ Baroness Faithfull
My Lords, we all read the Reed Report with interest, admiration and respect. We read it in conjunction with the report entitled The Health of the Nation. We are deeply grateful to the noble Earl, Lord Longford, for bringing the debate to this House. However, I fear that I shall disappoint him because I do not propose to talk about the individual recommendations in the report, which were so ably supported. I am grateful to the noble and learned Lord, Lord Mustill, for his speech, particularly as I hope to take up a number of points which he made.
During the speeches of noble Lords who have spoken on the recommendations of the Reed Report, I have realised that I want to talk about planning and structure before the recommendations of that report are implemented. I do not believe that they can be implemented until there is a background report which deals with the overall situation in this country regarding the mentally disordered.
First, there appears to me to be no up to date co-ordinated overall government policy for those suffering from a mental disorder. The departments involved are the Department of Health—health on one side and social services on the other—the Home Office and, to some extent, the Department of the Environment, which is responsible for housing and the problems of homelessness.
Secondly, a structured policy should be based on an overall inquiry and statistics. The noble and learned 734 Lord, Lord Mustill, made reference to the many organisations and people concerned. They need to be brought together in one co-ordinated policy.
I tabled a Question for Written Answer in Hansard some weeks ago which asked how many of those convicted of an offence and sent to prison had been previous patients in a mental hospital. The Written Answer was that the figures were not available.
§ Baroness Faithfull
My Lords, yes! I respect the Home Office research department and therefore I was surprised by that reply—all the more so because at paragraph 5 on page 24 of the report reference is made to government research which found —and other noble Lords have quoted this figure—that between 750 and 1,400 sentenced prisoners may currently require transfer to hospitals for psychiatric treatment. I realise that a proportion of those prisoners may not previously have been in mental hospitals, but I suggest that many of them would have been. I must point out that the Reed Report was commissioned by both the Department of Health and the Home Office. Therefore, the reply that I received to my Question was extraordinary.
The noble Lord, Lord Acton, referred to the homeless. How many of them have been discharged from mental hospitals and have no support within the community? Supporting, counselling and helping mental patients in the community is an incredibly difficult task. It is time-consuming and sometimes it is well nigh impossible. I know because I have done it. It is particularly difficult when dealing with schizophrenics. Some directors of mental hospitals were discharging patients because they said that they were not treatable. I should like to know from the Minister whether that still applies.
When I worked in Oxford, the Church Army and colleagues from the probation service worked hard to set up a hostel for the homeless. That hostel was built and we thought that perhaps we had contributed to diminishing the problem of homelessness in Oxford because we hoped that the hostel would be able to offer a rehabilitation service to the homeless. I now find that the hostel which was intended for the homeless is now full to the brim of men discharged from mental hospitals. Therefore, it is a mental hospital in the community; but it has no trained staff to administer medication or psychiatric help. Can that be right? It is surprising that the Charity Commission does not ask questions because the hostel is not being used for the purpose for which it was built and for which it is registered as a charity. We are not the only people who have found that to happen. It is happening all over the country. Of course there are also mental patients in prisons who should not be there.
Like the noble Earl, Lord Longford, I have visited many prisons. I know that the prison warders have great compassion, great patience and great understanding for men who have been sent to prison who they are quite sure should be in mental hospitals. Warders have complained to me that they do not have adequate training to give the men the help they should receive.
735 We have prisons, hostels for the homeless, the homeless themselves and the community care system. I support community care. However, before we attempt to implement the recommendations of the Reed Report, we should conduct a survey that covers all the methods of treating patients. We do not have a set of co-ordinated statistics from all the departments involved in this matter. However good the Reed Report is, its recommendations cannot be implemented successfully unless a survey of the type I have mentioned takes place.
I have become a little carried away and I have deviated from my script. The noble and learned Lord, Lord Mustill, spoke of fragmentation. I believe that is the thing that has held us back in this area more than anything else. I believe the Reed Report recommends that a committee should be established. I hope that if such a committee is established, it will first consider what is happening in this area—the comments of the noble Lord, Lord Acton, are relevant in this regard—before it attempts to implement the recommendations of the Reed Report. The Reed Report cannot and will not be successfully implemented unless a policy is established that covers all government departments. We should gain accurate statistics on this matter from the Salvation Army, hostels, prisons, social services and from psychiatric hospitals. I beg my noble friend the Minister to talk to everyone involved in this matter so that a good policy is adopted for the United Kingdom as a whole.
§ 9.16 p.m.
§ Lord Rix
My Lords, one of the reasons I retired from the Whitehall Theatre a few hundred yards up the road after 27 years and some 12,000 performances was that my social life had rather gone for a burton. I am delighted to note that noble Lords at this end of Whitehall, in Westminster, are also prepared to let their social lives go for a burton. There is no doubt that noble Lords' devotion to the cause we are discussing this evening, and to other causes, results in their being in this Chamber at unsocial hours and being away from their homes and loved ones. I pay tribute to all noble Lords who are taking part in this debate.
Last week the noble Earl, Lord Longford, paid me a gracious and generous compliment. I should like to return that compliment this evening. The noble Earl has made tonight's issue peculiarly his own. We all owe him a great debt, not only for the opportunities provided by this debate but also for the fact that the needs of mentally disordered offenders have got on to, and remained on, the public agenda.
I know that the noble Earl has over a very long period taken a personal interest not only in the theories but also in the welfare of individual offenders, so much so that it is rumoured that some patients believed that a visit by the noble Earl was a form of treatment prescribed under Section 58A of the 1983 Mental Health Act. Noble Lords may not be aware that Section 58 deals with treatments requiring a second opinion. The published statistics do not tell us 736 whether any detained patients have had recourse to a second opinion after the noble Earl's visits, but I think that extremely unlikely.
Perhaps it is a little late in the debate for me to offer my congratulations to my noble and learned friend Lord Mustill. It is good to know that we have at least one noble and learned Lord on our side—I believe there are others—and I particularly appreciated my noble and learned friend's remarks on care in the community for I know that some view that endeavour with profound and pessimistic gloom.
We also owe a debt of gratitude to Dr. John Reed of the Department of Health and his colleagues for the string of reports about services for mentally disordered offenders and those with similar needs. From my point of view the report —still at the consultative stage—on the needs of people with learning disabilities or autism is not the least important of that string of reports. It chimes in well with the recently published Mansell Report on the needs of people with learning disabilities and what the professionals call challenging behaviour, and those who have to cope with it sometimes describe with more colour and passion.
I want in this short intervention to make just four points. The first is a reminder that learning disability is not the same as mental illness. I am sure that noble Lords present are well aware of that fact, but I should like to record it for others who may read the debate. Crudely put, learning disability is a limitation with which one is either born or acquires very early in life. Mental illness is a disturbance of the mind which may affect anyone at any age, and, sooner or later, does affect many of us. Some people with learning disability have superimposed mental illness. Most do not. I am still surprised at the extent to which people, eminent in public life—some of them with medical qualifications and some of them with political ambitions—still confuse mental illness and mental handicap or learning disability. Perhaps an advantage of the new-speak "learning disability" is that there may be rather less confusion.
My second point is that since learning disability is distinct from mental illness, it is vitally important that there should be consultants, psychologists, psychotherapists, nurses, social workers, occupational therapists, speech therapists, physiotherapists, and teachers with expertise in learning disability and dedicated to working with those people with learning disabilities who fall into the offender and related categories. I am very much in favour of giving people with learning disabilities nice houses in which to live and a map showing the way to the nearest leisure centre, and asking the milkman to keep an eye open for their interests, but that does not constitute a service strategy for people with special needs.
The Department of Health has had time to consider the recommendations of the Reed Committee on extra places and additional qualified and specialist staff. I am glad to see that some extra funding for new places has been announced, and to know that new medium-secure units are in mind for Chase Farm and other places. I should like to know whether Ministers 737 accept the full implications of what the Reed Committee had to say about the need for places and staff.
Thirdly, I recognise that where people have a dual diagnosis —learning disability and mental illness—and especially where the learning disability is mild and the mental illness is the dominant factor the appropriate service may be a mental illness service; but where that happens, it is important that people with learning disability should be supported by staff who have some understanding of their extra needs. Those needs may be for a slower pace of treatment. I am apprehensive about what I suspect is a macho tendency in the health service to measure success in terms of turnover. If the door by which one came in is still spinning when one leaves, that is deemed success. Some detained patients in areas where beds are few and needs are many seem to be detained just long enough to send them on leave, so that bed occupancy can be not 100 per cent., but 120 per cent. People with learning disability need, in many cases, a slower and surer approach to rehabilitation.
It also needs saying, under this same heading, that the Ashworth Inquiry and wider experience show the vulnerability of patients with learning disability to situations in which they can be the victims both of staff and of other patients who trade on their vulnerability. If they are to be supported in "mixed" settings, alongside patients with personality disorder or mental illness, and by staff without special training in learning disability, general training has to take much more account of their needs than it does at present.
Fourthly, and finally, there are the mentally disordered offenders who happen to fall the wrong side of a line drawn by the law: it is a fairly arbitrary line. The same behaviour in other settings would not necessarily produce the same consequences.
We inflict on people with a mental handicap or learning disability a combination of deprivation. The least that we can do is to provide a first-class service for those who experience and cause problems as a result. I hope that we shall also improve our community services to spare our fellow citizens the problems in the first place. My noble friend Lord Acton referred to the "jargon" words, ring-fencing. Jargon they may be, but they simply will not go away.
§ 9.25 p.m.
§ Lord Dean of Beswick
My Lords, I express my appreciation to my noble friend and colleague Lord Longford for again introducing a debate in your Lordships' House on a difficult problem which does not always receive the mileage that it should. My noble friend has brought many issues before your Lordships for debate over the years. No case which is left to the efforts of my noble friend goes by default. He is to be congratulated again for giving us the opportunity to debate the problem.
I congratulate the noble and learned Lord, Lord Mustill, on his maiden speech. In the few moments that we have spoken I found that we have a tenuous connection. He came from Leeds and went to Manchester for a legal career; I went from Manchester to Leeds to start a political career. We have both 738 ended up in this Chamber. However, having heard his speech on this very human problem I am sure that I speak for all Members of your Lordships' House when I say that we are delighted to welcome him and his support on this subject. He is someone who has been mainly concerned with dispensing the law. His speech indicated great compassion from a person who wished to achieve the best for people, many of whom in some respects cannot help themselves.
One of the main themes underlying this subject is resources. I agree with the noble Baroness, Lady Macleod, who spoke of the efforts by the people with whom she is associated. I sensed a note of optimism in the figures that she quoted. Although I fully accept her point, that is not what I believe. From the figures produced there is undeniably an increase in the numbers of people, many of them young, who have been removed from institutional care and sent out into the community without adequate resources to start a new life. The figures published by non-political bodies show that in London, and to a lesser degree in other major cities, an increasing number of people are now sleeping rough and suffering the rigours of winter, sleeping on the Embankment, in the shop doorways of the Strand, and down Victoria Street. One passes them when walking in those areas. An increasing number of people who have been sent back into society from hospital find themselves in the same difficult situation of those unregistered homeless people.
My background has been in local government. I listened with great care to what the noble Baroness, Lady Faithfull, said regarding her former career as a director of social services. She hit the nail on the head. If the social service departments of local authorities are allowed adequate funding specifically to deal with the situation, I have no doubt that they will do that. When I first entered local government, the social service departments took care of many people who needed it, some of whom were not, in the strictest sense of the term, able to look after themselves.
What is worrying me is the great publicity being given at present to the Government's round of cuts and whether we are living above our means. We all know that although we have taken the trouble to be here tonight and most Members of your Lordships' House, wherever they sit, are sympathetic to the cause, it is not the most popular one with other people. The noble Earl, Lord Longford, referred to the difficult dividing line between the person who comes before the court because he is evil and the person who is sick. Where does the division lie?
People outside who have been the victim of an attack by someone who is a borderline case do not see it that way at all. We all know that when a risk is taken in favour of people doing a custodial sentence by allowing them back into the community on the recommendations of medical staff there is the possibility that they may commit another crime of enormous dimensions—perhaps murder or rape. In that case, the first question put by the victim or the public to the people involved with the wrongdoer is why it was allowed to happen. Someone is at fault and 739 the victims or the public do not wish to err on the side of the person with problems; their sympathy is with the victim and his or her family.
We must take all those calculations into account when we deal with the situation. I was delighted to hear the remarks of the noble Baroness, Lady Faithfull, on the subject because no one has been closer to it in the past than she has. It was also interesting to hear the noble Lord, Lord Rix, speak of the Whitehall farces in which he appeared for 27 years. He now graces a new stage in coming to this place, but he has already earned a reputation for being listened to and for speaking forcefully, powerfully and knowledgeably on behalf of people who need champions of his stature so that the case will not go by default.
The noble Earl, Lord Longford, referred to the staff who have to deal with the problems. Just before Christmas, he introduced a debate on another facet of the prison service and its problems. Very often the prison officers and staff do an excellent job but they are always at the sharp end if something goes wrong. Prison officers know, more than anyone, that the resources they are given to carry out their job are less than adequate. If the job is not done, they are blamed.
The disgraceful scenes at Strangeways Prison were mentioned. I happen to be a Mancunian and I think that very little of the riot was to do with people who were mentally ill. Possibly the most brutal section of the prison community was involved. I could say that I have a feeling of déjà vu, I have said this previously in your Lordships' House. Had the prison officers themselves been allowed to get on with the job, that disgraceful event would have ended after 48 hours and would not have gone on; but they were prevented from acting by people from the Home Department in London who thought that they knew better how to deal with the problem. I understand that the eventual bill for what took place was between £60 million and £80 million in a service which we know is short of money because of its lack of appeal to the public. I am worried, as are a lot of other people, that if massive and swingeing cuts in public expenditure are on the way, we may well be talking tonight of a door that has already closed. I hope I am wrong.
I should like to say a few words regarding prison officers and the staff who deal with these offenders. They are not prison officers, although they are members of the prison officers' union. People ask: should they not have a union of their own? But there is nothing new in an association or a union having divisions which cater for people doing a special job. The transport and general workers, the agricultural workers, the building section and the transport sector are autonomous under one umbrella. The Prison Officers' Association members in those particular types of institution are, in fact, not prison officers. They are highly qualified, highly trained and highly dedicated nurses who have been trained in that specific profession and trained to deal with such problems. From the reports I am given, their talents and ability are considered to be amongst the finest, if not the finest, in Europe.
740 The Prison Officers' Association itself is on record as being critical of the Government. It is always easy to be critical of the Government. But everybody is saying—and I believe that Members of your Lordships' House would say—that the situation we are dealing with is grossly under-funded. In an ideal world it would not be under-funded, but we do not live in an ideal world. The Prison Officers' Association has been in the forefront of the identification of problems, which of course are many and varied—problems which are created in the main by the mentally disturbed offender and those with personality disorders who have to be contained within the prison system.
The association also recognises the need for change and calls for the resources to be made available in order to administer the correct level of psychiatric intervention and diversion to the mental health care areas, be this at court, police custody, remand or sentenced prisons. So it covers the full spectrum of places where people have to be incarcerated, very often for the protection of the public and very often for their own protection. The association continues to call for a full public inquiry into the management of special hospitals and sees a need, following correct and proper assessment, to examine the way forward for these very valuable assets, and their use, that currently exist.
The POA was also the first to call for the closure of the disgustingly inadequate psychiatric provision at Brixton Prison. In calling for the closure of F Wing it was noted that neither the prison service management nor other pressure groups of any kind had seen fit to call for this closure. The Prison Officers' Association and its members concerned in that particular service did so.
To conclude, the noble Earl, Lord Longford, has opened a tremendous discussion on a difficult subject that will never go away. There are ways of dealing with it and Reed has suggested some of them. But it is an ongoing problem. Other proposals will come forward. The people in the service who are specially trained in dealing with the situation have a dedication as high as any. But they do not have the privilege of coming to this House to put their case. I stress that they must be given the resources to match the job given to them in the discharge of people into the community. I tremble at what is going on, because I cannot for the life of me see the present policy succeeding, though I wish it well. As the noble Lord, Lord Acton, said when he spoke about ringfencing, unless more adequate resources than the Government even dream of at present are released to local authorities and other bodies charged with looking after this section of the community, I can only see it being a tragic failure. I put the following question: if it does fail—I hope it does not, but I think it will—where do we go from there? What do we do if we have tens of thousands of people living out in the open? That is not a stupid exaggeration. The situation is moving that way. What do we do with them when the institutions have all gone? How shall we cater for them? As far as I can see Dr. Reed has not been able to give an opinion on that point.
741 Within the next few years we shall be debating the situation again. With the Government's present policy on housing and the discharging of people into the community, I can only see the number of people requiring special training, special medical treatment and special care increasing. However, on behalf of the members of the Prison Officers' Association I can say that whatever can be humanly done, they will do it. But they will do it a lot better, and for more people, if they are given adequate resources to get on with the job.
Some people criticise the members of the Prison Officers' Association in an almost run-of-the-mill way without being aware of the problems. But the POA will do the job. Sadly, however, with the present round of cuts that the Government are to announce, we are already talking to a closed door.
We have heard some wonderful speeches this evening. The number of noble Lords who put down their names to speak in the debate is an indication of the feeling on the subject in your Lordships' House. Once again I thank my noble friend Lord Longford for giving us an opportunity to debate the problem.
§ 9.42 p.m.
§ Lord Henderson of Brompton
My Lords, I refuse to be left out of those in the House who have expressed their admiration, and I add my own affection, to the noble Earl, Lord Longford, for all that he has done for us over many years in bringing penal affairs and the affairs of those whom we are addressing tonight before the House. He cajoled me to speak on this subject when I did not feel like doing so and thus inflicted a few extra minutes on the House before the speech of the Minister, to which we are all looking forward.
I say straightaway that I have nothing but praise for Dr. Reed and his colleagues for the final and interim reports. Of course I give credit to the Government for appointing him. It was an imaginative act and I am sure that we shall all benefit from it over the years.
My noble friend Lord Acton mentioned money and ring-fencing. I have great sympathy with him. However, I must say—I may be anticipating the Minister—that the recommendations of the Reed Committee are so many, so vast and so expensive that we can only hope for them to be implemented over a long period of years.
I am particularly glad that Dr. Reed and some of his colleagues are being kept in commission and I hope that he will give us some indication of his priorities. There are almost 300 recommendations and they are not prioritised. I hope that his continuance on the committee will enable him to indicate which recommendations he feels are the most important. In that regard I would expect him to highlight those which are the least expensive. Later I shall raise one point—perhaps my major point—which I should like to press on the Government. It may improve the situation overall and yet it should cost next to nothing.
In the first instance we look forward to the recommendations which cost least. Foremost among them will be the recommendation which the noble Lord, Lord Ennals, mentioned. Mentally disordered 742 offenders who are kept in prison rather than in hospital and those who are in maximum security conditions who could be kept in less secure conditions should be looked at straight away. I very much hope that that will be done because it has the blessing, I believe, of the Parliamentary Secretary for Health. He has said that in public. I should hope that the recommendations of the Reed Committee would have the wholly admirable consequence of depleting the prison population by the provision of alternative extra custodial care or other local authority provision. The prison population is already going down and this should give a boost to that decline. I strongly welcome that.
My next point has hardly been mentioned by other speakers. I am very pleased with the guiding principles for service provision, which again have been endorsed by Ministers. That is welcome progress. I very much hope that these guiding principles or something very like them will also be promulgated and endorsed by Ministers for the prison service. It would do that service a world of good and would help to improve the atmosphere in the ways recommended by Lord Justice Woolf and the Inspector of Prisons. Young offenders, as well as the offenders whom we are discussing today —the mentally disordered offenders—should be able to benefit. If we cannot make progress in keeping young people out of custody we shall make very little progress in the criminal justice system.
The noble and learned Lord, Lord Mustill, who made a most sensitive speech which we all appreciated, mentioned the paragraphs in the report about the interface between the professions. I want to concentrate on that. The report says that a study of the interface between the professions is of the utmost importance and should lead to,growing commonality of interests",which is a pregnant phrase. That includes training needs and in particular,contact between general psychiatry and the criminal justice system",which is generously characterised in the report as widespread though patchy. We hope to make good use of that recommendation which should, incidentally, cost either nothing or very little.
That leads me to my main interest arising out of the recommendation that there should be a study of the interface between the professions. It is perhaps not mentioned in Reed because it is outside his terms of reference but it is quite definitely relevant and also, I would hope, cheap and therefore capable of being introduced soon if there is the will. I refer to the amalgamation of the prison medical service and the National Health Service. That is indeed a breaking down of interface between two professions. I am convinced—the noble Earl, Lord Longford, mentioned this but he had so many other things to say that he did not pursue this line—that nothing but good could come from such a step. There might even be financial savings as a result of that integration. There certainly would be better delivery of health services for those in custody, especially for mentally disordered offenders, as recommended in paragraph 11. But I very much doubt if anything substantial will come of these recommendations unless and until the National 743 Health Service extends its service to embrace the work now done behind the walls of the prisons by the prison medical service.
I wish to refer to one particular instance. Members of the House may be aware that in a certain weekly periodical there is an article every week by someone who purports to be a prison doctor. He writes on happenings in custody and therefore one must presume that he belongs, or is attached, to the prison medical service. His sentiments are light-years away from those of Dr. Reed and his committee. One can hardly believe that they belong to the same profession.
He clearly has no use—indeed he has open contempt—for what he calls the "mentally subnormal and chronically hallucinated" prisoners who come before him. Fortunately, I realise that he is not exactly typical of the prison medical service, but he gives it a bad name. I question whether any doctor in his right mind would regard it as ethically correct to write anecdotally of his patients, as he does or, as he likes to term them, "clients". But they might as well be his victims.
I wonder whether the prison medical service is content that it retains in the service a man who regularly mocks his patients in a sick, mordant and sardonic way and holds them up to contempt, ridicule and hatred. A service which retains a man of that kind should be looked at. Indeed, I very much hope that it will be and that as a result the National Health Service will extend its bailiwick, as it should do in any case, to cover those who are in custody in the prison service.
§ 9.53 p.m.
§ Baroness Robson of Kiddington
My Lords, may I also add my grateful thanks to the noble Earl, Lord Longford, for having introduced our debate tonight. As we all know, it is a subject to which he has devoted his life. We are privileged to have him in this House to remind us of what our responsibilities are in relation to the problems raised in the Reed Report.
I welcome its publication and the comprehensive analysis of what needs to be done. As has been said by many noble Lords, the report has produced 276 proposals which it states need early implementation if we are to solve the problem of inadequate treatment of mentally disordered offenders. It is an enormous task. I wish to take up the idea of the noble Lord, Lord Henderson. There are certain matters in the report that I would like to see implemented before others. There is no doubt that too many prisoners are detained in prison who should be receiving care and treatment from NHS specialist psychiatric services. The figure mentioned by many noble Lords is between 750 and 1,700 prisoners.
The noble Baroness, Lady Faithfull, raised a question that I also should like to mention. The policy of emptying psychiatric hospitals in this country and moving the patients into the community is altogether an admirable aim so long as the services in the community are there to take care of them. I should like to know—if the noble Baroness the Minister can answer—how many of these 1,700 prisoners are former inmates of psychiatric hospitals who have only 744 become criminals because they were released into a community where there was no one to look after them. It would be interesting to have that figure.
The report states that there are too many patients detained in high security hospitals for longer than their treatment requires because of a lack of development of medium secure units and a lack of community services. The treatment of a mentally disordered offender should have an aim in the sense that you move from the highly secure unit to the medium secure unit, and in the end, when the treatment has been successful, you are allowed to live in the community again. Those are essential elements of hope for people—not the feeling that they are never going to be released because there are not the services for them to be passed on to.
The noble Baroness, Lady Macleod, gave a marvellous example of what has happened in the psychiatric hospital in Hertfordshire with which she is involved. That is a wonderful example. But I must say to the noble Baroness that it is not a common experience in my view. Too many psychiatric hospitals have been emptied without there being the community services to look after the patients when they have been released. Therefore, I believe that that figure would be of great interest. It is essential that we have a system that gives hope to people. The report clearly states the three stages that are necessary.
If you are going to start from the beginning—and we must do that—one of the most important recommendations that the report makes is that we should have psychiatric assessment and diversion schemes to serve every magistrates' court in the country. There are only 40 such schemes in operation at present. It has been mentioned that fewer than half of district health authorities have a plan for the introduction of such diversion schemes. Those schemes, properly implemented, are probably the best means of preventing inappropriate prison sentences for mentally disordered offenders, so that we would not be starting at the prison but at the psychiatric or regional hospital secure unit.
The report puts great emphasis on the fact that regional health authorities will have to take on the responsibility for ensuring that adequate services, both secure and medium secure hospital places, are purchased by district health authorities in their regions. We had a wonderful speech by the noble Lord, Lord Acton, about the provision of community services and how they are to be funded. We heard from the noble Baroness, Lady Faithfull, about the enormous extra effort that the community services have to make to deal with and give adequate support to the people coming out of secure units.
I agree very much with the recommendation in the report that there should be a move towards mental health care being provided by NHS staff in all prisons. However, I agree also with the noble Lord, Lord Henderson of Brompton, that there should be an amalgamation of the medical service that is at present provided in the prisons with that provided by the NHS. All this needs monitoring. I am pleased that a 745 new advisory committee will be set up to monitor the implementation, and that Dr. Reed is likely to be the chairman of that committee.
However, I believe that the biggest stumbling block of all is the question of funding. Various Members of your Lordships' House have indicated that perhaps not all of the recommendations are financially demanding. But a lot of them are. I believe that it was the noble Lord, Lord Mottistone, who said that Mr. Tim Yeo, the junior health Minister, had announced that the Government have boosted their support for secure units from £3 million to 18 million but, as the 746 noble Lord also said, another £18 million will be necessary the following year. What worries me much more is that in that same announcement Mr. Yeo said thatprogress in the care and treatment of mentally disordered offenders can be achieved by better use of existing services and resources and by improved co-ordination of the responsible agencies".I am not saying that that cannot happen, but I should like to emphasise that that in itself will not be enough; the problem is much too great. We need improved funding, particularly for community services.
§ 10.2 p.m.
§ Lord Desai
My Lords, at this late hour let me first thank my noble friend Lord Longford. As on the previous occasion on 18th November when we debated the Ashworth Hospital, he has once again drawn our attention to a very important problem which he has spent a lot of time studying. We are grateful to him for giving us the opportunity of this debate and the benefit of his thoughts.
As I have said on previous occasions, I rise to speak with probably the least knowledge and experience of all noble Lords who have spoken this evening. I shall therefore fall back on trying to do what an academic can do, which is to give a little pedagogic lecture on the problem and to hope that I say something of use.
As the noble and learned Lord, Lord Mustill, said in his most excellent maiden speech—which I hope will be one of many that he will make to us—we are faced with a difficult problem. Because of the very nature of people who are mentally disordered and who are likely to become offenders, the public are not likely to feel sympathy for them but, as my noble friend Lord Dean has said, for their victims. When local authorities decide to apportion money for various uses, these people are not likely to be at the top of the list because they will not be able to lobby for the money and they may not have friends who can do so.
Faced with this difficult problem, let us also acknowledge that there are many dedicated people in the prison service, in hospitals and among social workers who do a most difficult job excellently. We only hear of them when something goes wrong, which is a great pity; but from day to day they do an excellent job in adverse circumstances.
The spirit of this excellent report by Dr. Reed is captured by what I might call two displacements, which are at the heart of this problem. One problem which has not been mentioned so far, if my memory is correct, is a horizontal displacement. It is the problem of people who are in prison but who are not properly identified as being mentally disordered. In that respect, the numbers that we hear of are understated regarding the number of mentally disturbed offenders.
Some interesting research by Professor Gunn, which is mentioned in the report, showed that over 20 per cent. of male prisoners had acute or chronic mental disorder which had not been diagnosed as such. On the one hand, we have fewer people who are correctly identified as having a mental disorder. The report would like us to go for a vertical displacement, by which I mean they would like people to be classified further down the list of acuteness or seriousness. The report would like us to use what is called divergent and discontinuance mechanisms as a means of ensuring that offenders do not get caught up needlessly in the criminal justice system.
Here I must acknowledge that I was somewhat perturbed by what the noble and learned Lord, Lord Mustill, seemed to say: that perhaps in looking for ways of avoiding the possibility of these people going into the criminal justice system we should be consistent as regards those who are classified as mentally disordered and those who are not. However, 748 I presume that as long as we are careful, that is not likely to happen. However, down the line we want people to be in milder and milder forms of incarceration, if I may call it that: from high to medium security and from medium to low security, and so on.
As is pointed out in paragraph 4.3, the problem is,the range of hospital provision, in particular that in conditions of low to medium security, is inadequate overall to meet existing and projected need.At the same time, it is not all that good to send these people out into the community, diverting people away from where they should be. The report says in paragraph 4.4:There is little point in 'diverting' someone if he or she has nowhere to go or if the placement is unsuitable or inadequate. This may simply lead to a deterioration, with the risk of further offending or resort to crisis intervention: the so-called 'revolving door' syndrome. It may also be a poor use of resources.We should like people to be diverted from the most serious imprisonment; but at the same time one has to be careful about where they go and about the costs imposed upon society if they are prematurely released, badly classified or put into a low security facility before the right time. In this respect, I draw your Lordships' attention to the problem of resources and costs, especially for the National Health Service. Paragraph 8.8 of the report says that underlying these issues are two important principles. It reads:planning decisions about services for mentally disordered offenders should take account of the cost to all agencies"—and they italicise "all agencies"—including the future cost of deterioration in a person's condition if needs are not met properly".I think that is a very important principle. When we talk about resources and about how much we are spending on national health or how much we have achieved, there is a tendency to think in terms of money or in simple terms of bed space, and so on.
As the noble Lord, Lord Rix, pointed out, it is tempting to exaggerate output or performance. We should like the throughput (if I may call it that) to be smaller; but each person will cost more money if one is going to do the job properly. What is important is not the quantity of health, but the quality of health, as we are witnessing in the case of the elderly. As we learn more we should like to do a better job for those people than we have done so far; but to do a proper job costs a great deal of money. There is nothing we can do about that. We must face up to the fact that such provisions cost a lot of money.
One of my responses to reading the excellent report was almost of despair. MIND summarised the recommendations by stating:The report recognises the importance of introducing new mechanisms which will accurately assess unmet needs, ensure effective diversion from inappropriate custody, guarantee constructive joint working between agencies and authorities, remove legal and financial disincentives and guarantee equal opportunities and freedom from discrimination on grounds of race and gender in allocation or operational services".My noble friend Lord Ennals also referred to that statement. That is a tall order given the kind of facilities which are likely to be available. All the same, one should like to see those recommendations put into 749 effect; one should like to see all the proper things happen for these people. The fact that they will cost resources is taken as read.
Many noble Lords have pointed out various aspects of the problem and therefore I wish to point out only two which have not yet been mentioned. The first is the problem of racial discrimination. The British Association of Social Workers has in its briefing summarised the various NACRO reports on the problem. In that respect, the problem is the opposite of that which I described as horizontal displacement. It is that many more black people are classified as being mentally disordered than is strictly warranted. That is partly due to cultural barriers, prejudice or whatever. We must watch that matter carefully. As regards issues of race and culture, the Reed Report states at page 8:funding should be made available to establish an action research project on the diversion from custody of people from ethnic minority communities".It further states:Health and local authorities should enable agencies from black and ethnic minority communities to develop and provide services for mentally disordered offenders".There is serious and concrete action to be taken in terms of research liaison with ethnic minority active groups and in re-examining the procedures under which people are classified as mentally disordered.
The second problem is that of gender discrimination, which has not been mentioned tonight. We should take note of what was said by the British Association of Social Workers. In addition, the report points out the extreme disproportionality in sending women to special treatment hospitals once they are in prison. The numbers are so striking that it must be something more than an accident or randomness which causes it. The problem of gender discrimination also points to the need for monitoring as well as extra research.
Finally, I share the strong feelings expressed by the noble Lord, Lord Acton. Given that the total numbers involved are rather small, that it is not possible to assign some of those people to a particular local authority, and that those people will not win their proper share of resources in any battle for local authority money, we may need to think about what the noble Lord called a centrally-administered specific grant scheme. That is a more elevated version of ring-fencing. It is ring-fencing at a national rather than a local level.
The entitlements which those people require to ensure adequate provision and attention to their problems will not come to them by them fighting for it because they are not capable of doing so. It will not come to them through the generosity of local authorities because they no longer have the funds to be generous. Logically, it must come by following the recommendations in the reports of enlightened people in this field like Dr. John Reed. Logic points to the fact that those people are entitled to funds and those funds can only be centrally guaranteed.
§ 10.17 p.m.
§ Baroness Cumberlege
My Lords, I am aware that the hour is late and that everybody wants to go home. I shall be as brief as I possibly can but it has been such an interesting and wide-ranging debate that I should like to try to do justice to it. I should like to associate myself with other noble Lords in expressing my gratitude to the noble Earl, Lord Longford, for initiating this debate. It is the second time in less than three months that the noble Earl has given us the opportunity to consider the complex needs of mentally disordered offenders. That says much for his interest in and knowledge of the subject and his determination, which the Government share, to see improvements in the provision of health and social care in this area.
I also add my congratulations to the noble and learned Lord, Lord Mustill, on his maiden speech. I thought that it was a remarkable speech which was perceptive, knowledgeable and challenging and no doubt in the tradition of the Duke of Wellington. We look forward to hearing more from the noble and learned Lord on this and other subjects.
In November your Lordships looked specifically at the relatively small number of patients who need psychiatric care in conditions of high security. Today we have been considering a much broader group, the majority of whom have much less severe mental health problems, but who nevertheless need the right kind of assessment, care and support. If they do not receive that support, there is a danger that they will become part of the criminal justice system, or fall victim in the community to what has become known as the "revolving door" syndrome.
The joint Department of Health and Home Office review—the Reed review as it has become widely known—was the most thorough examination of services for mentally disordered offenders since the late Lord Butler reported in the mid-1970s. Like my noble friend Lady Macleod of Borve, I found the report not only interesting but gripping. I share the view of the noble Lord, Lord Henderson of Brompton, that the quality of the report was outstanding. The Government have already expressed their thanks to Dr. John Reed and his colleagues for their painstaking work. I am happy to do so again today. Their output in the space of 18 months was quite prodigious. In addition to their final summary report, published on 27th November, they produced 10 consultative reports which covered: services in the community, in hospital and in prison; staffing; training and financial issues; academic development; research; mentally disordered offenders with special needs; offenders with learning disabilities or autism; and racial and cultural issues. As the noble Earl has said, this work represents an immense fund of knowledge likely to be referred to for some years to come. For that reason we recently arranged for the formal publication by HMSO of those earlier reports to which I have referred. These are now available for public sale in four volumes.
The noble Earl, Lord Longford, referred to the large number of recommendations made by the various advisory and working groups—276 in all. The 751 Government said, when the final report was published, that they would be making decisions in due course about which of the recommendations they could accept, and the pace at which these recommendations could be implemented. Available resources will obviously be a factor, although many of the recommendations are mainly to do with better practice and closer working between the various agencies. In a formal sense that is still the Government's position, but I can give your Lordships a flavour of how we are approaching some of the main issues and describe the action that is already being taken nationally and at local level.
As the committee said in its final report, each recommendation represents a piece of a very large jigsaw. It may be helpful if I draw attention specifically to Chapter 10 of the final report, as this was evidently intended to summarise the review findings as a whole and to identify what the committee saw as the fundamental issues.
The noble Lord, Lord Henderson of Brompton, has drawn to the attention of your Lordships the guiding principles set out in that chapter. The Government have already accepted that those principles should be adopted. I have sympathy with the noble Lord's view that those principles may well have a wider application. They are fivefold. They state that patients should be cared for and treated with regard being given to the quality of care and proper attention being given to the needs of individuals. That is important. Patients should be treated as far as possible in the community rather than in institutional settings. They should also be treated under conditions of no greater security than is justified by the degree of danger they present to themselves or others and in such a way as to maximise rehabilitation and their chances of sustaining an independent life. Finally, they should be treated as near as possible to their own homes or families, if they have them.
The committee then went on to identify a number of fundamental issues. These are: a positive approach to individual needs, including those of women and people from ethnic minorities—the noble Lord, Lord Desai, mentioned that; a multi-agency and multi-professional approach at all levels—this was mentioned by many speakers including my noble friend Lady Faithfull; the complementary role of mainstream and specialised services, the majority of patients being seen by the former, but needing access where necessary to the latter; and closer working at the court and pre-court stages between criminal justice agencies, the NHS and local authorities to divert people where necessary to health and social services. The identified issues also included an improved range of secure and non-secure health and social services, including those to meet the needs of homeless people; better mental health care services for prisoners; and, finally, a broader training, academic and research base to underpin all this activity.
Giving effect to these aspirations will be no easy task, and, as the report itself makes clear, where major deficiencies exist, significant progress is unlikely to be 752 made overnight. That point was also made today by many speakers. However, there are, I believe, grounds for optimism on a number of counts.
One of the distinguishing features of the review was the inter-active and relatively public way in which it was conducted. I have referred already to the range of consultative reports, the broad direction of which were overwhelmingly supported by the 200 or more bodies and individuals who responded to them. In addition, officials working with the review from both departments undertook an intensive programme of visits which included meeting people from a range of agencies, including the criminal justice system and the voluntary sector, in each of the 14 health regions. On the local authority side there was a series of seminars to which representatives of virtually all social services departments contributed, together with a major Home Office circular highlighting the opportunities for diverting offenders, which was issued shortly before the review began. This whole process has stimulated considerable practical interest in the subject. It is already beginning to bear fruit on the ground through a range of local initiatives.
The noble Lord, Lord Desai, and other noble Lords expressed concern that people may be sent to prison when that is not appropriate. I believe he used the term "horizontal displacement". I am sure that those noble Lords will be pleased to learn of the growth of court assessment and diversion schemes now taking place. When the review began there was only a handful of them. There are now over 40 operating in England and the number continues to increase. We want to see still wider coverage, and so funding is now available from the Home Office to meet the sessional costs or fees of psychiatrists or community psychiatric nurses who attend magistrates' courts to provide professional advice. Agencies have been invited to submit bids for such support.
Another area to which we are contributing directly is the medium—or regional—secure unit programme, to which the noble Earl, Lord Longford, devoted part of his speech, as did the noble Lord, Lord Ennals, who expressed his impatience at the rate of development. We agree with noble Lords and the Reed committee that the number of beds in those units needs to be increased. Accordingly, we have made available in the current financial year £17 million for the capital development of new places. That represents nearly a six-fold increase on last year. In the next financial year, the sum available will be £22 million, a further increase of about 30 per cent., which I hope will reassure some noble Lords, not least the noble Baroness, Lady Robson of Kiddington, and the noble Lords, Lord Desai and Lord Dean of Beswick. That will enable speedy progress to achieve the existing target of 1,000 medium secure beds. As the noble Earl said, the Reed Committee envisaged further progress to a national minimum of 1,500 beds. It also wanted to see, as we do, greater diversity in the type of places to include better provision for, among others, those with longer-term needs and people with learning disabilities, a point made so cogently by the noble Lords, Lord Ennals and Lord Rix. We shall obviously be looking at those recommendations very carefully, 753 but, in the meantime, I emphasise our commitment to the growth of the programme, matched as it is by substantial increases in funding.
The noble Earl, Lord Longford, the noble and learned Lord, Lord Mustill, and the noble Lord, Lord Dean of Beswick, all mentioned prison care. The Reed review supported the intention that the Health Care Service for Prisoners, as the former Prison Medical Service is now known, should become a purchaser rather than a provider of services. In particular, it welcomed the proposed contracting-in to prisons of a full mental health care service and the closer alignment with the NHS that that would entail. That would be valuable, not least for effective discharge and care programme planning. I am conscious that that proposition raises other issues which go far beyond the scope of our debate today. Indeed, the noble Earl raised some of them during the Committee stage of the Criminal Justice Bill. Suffice to say that we want to see prisoners with mental health care needs receiving effective treatment—where necessary outside prison altogether. I am pleased to say that there has been a steady growth in recent years of transfers from prison to hospital under Sections 47 and 48 of the Mental Health Act 1983. In 1990 there were 325 transfers; in 1991, 450; and last year the figure rose to 611. We hope to continue that trend in 1993 and beyond.
The noble Lord, Lord Ennals, raised the subject of compliance with Department of Health guidance on maximum waiting times (one year) for the move from special hospitals to other services. That is being monitored by the NHS Management Executive and details of patients waiting and moved from special hospitals are being made available for that purpose. The projected growth of the medium secure programme—only part of the picture, of course—will help that process. These, as I say, are transfers under existing provisions. The review made various suggestions for legal changes which might assist both hospital transfers and more suitable disposals by the courts. However, it recognises also that any changes would need to go hand in hand with service development, and any amendments to the Mental Health Act, in particular, would need to be approached with great care, given the careful balance struck by Parliament when it formulated the legislation 10 years ago. We shall be looking carefully at the various possibilities and will need to involve other bodies which may have an interest.
I should perhaps mention the recent initiative of my right honourable friend the Secretary of State for Health in asking officials of the Department of Health to consider urgently whether new legal powers are needed to ensure that mentally ill people in the community receive the care they need and whether the present powers in the Mental Health Act are being used effectively. The timescale for that work is about six months and I know that many noble Lords are keenly awaiting the outcome.
My noble friend Lady Macleod of Borve spoke movingly of the success of community care schemes. Should the view be taken that there is scope for further 754 powers in terms of a new community supervision order, it might be possible for more people to live in happiness in the community.
On a broader front, the Health of the Nation White Paper identifies mental illness as one of five priority areas. What happens with general mental health services is crucially important to the majority of mentally disordered offenders. That includes applying the new care programme arrangements to which the review report made frequent reference. I wish to emphasise in particular that those apply specifically to patients in special hospitals and hence to those transferring to other places. We also wish to see more effective arrangements for discharge prisoners with mental health needs. To that end, we are hoping to fund a pilot project in Wessex region to which a number of agencies are also contributing.
Within the Health of the Nation there is a specific task for mentally disordered offender services. We shall be requiring that the strategic and purchasing plans of all health authorities include the necessary range of health and social services, both secure and non-secure, to enable them to respond to the special needs of this group. The message is set out also in the Key Area Handbook on Mental Illness that we published last month.
I hope that the noble Lord, Lord Rix, will take comfort from our determination not to forget those offenders with learning disabilities. He will be aware that the review report issued for consultation in November was specific on the subject. We have already received constructive comments from MENCAP and other bodies. We recognise that there needs to be better access to secure services other than in special hospitals and action to identify the needs of the majority of learning disabled offenders who have mild to moderate disabilities.
It is important that service developments based on needs assessment take full account of the staffing and training implications. I listened with deep concern, and indeed anger, to the incident—I hope that it is an isolated one —concerning a particular psychiatrist, referred to by the noble Lord, Lord Henderson. It is important that we have good training. I have referred also this evening to the need for a better academic base in an area which in many respects is under developed.
The noble Earl, Lord Longford, referred to the projected increase in forensic psychiatrist numbers. It may be worth noting, as Reed does, that 30 years ago there were just two forensic consultants. Today there are 70. We are in touch with the Royal College of Psychiatrists and others about the proposed further increases to which the noble Earl referred. However, I wish to emphasise that those projections are based on major service changes which, on the most optimistic plans, will necessarily take several years to effect. They do not represent a level of medical staffing that is required for services in place here and now.
The noble Lord, Lord Acton, expressed concern for those whose place of residence is unclear. It is a very complex area and because of that the department is about to give guidance to local authorities on the general issue of determination of financial responsibility for social services provided under the National 755 Assistance Act 1948 in circumstances where local authorities are unclear about where that responsibility lies.
The noble Lord also returned to the arguments for ring-fencing. He was quite correct in saying that the Government have included the whole of the social security transfer within a ring-fenced special transitional grant to local authorities next year. We do not believe that it would be helpful to ring-fence sums within that for particular groups or services. To do so would restrict authorities' ability to match resources to need. Therefore it is up to local authorities to decide how much to spend on those services, using not only the special grant and the specific grant, but also money from their mainstream funds. I should love to go into the issue but at present there is a case pending and it would be unwise for me to go further, I understand.
§ Lord Acton
My Lords, with the greatest respect to the noble Baroness, the case pending is on the matter of alcohol. That is not what we are discussing this evening.
§ Baroness Cumberlege
My Lords, I am prepared to go on. The noble Lord is quite right. The burden of the argument up to now has been borne by the drug and alcohol services. But the suggestion being made tonight is that the services for the mentally disordered offenders should now also have money ring fenced for their services. This illustrates the problem very clearly. If we are to ring-fence for these groups, why do we not ring-fence for people with learning disabilities, the elderly, children, and so on. There are a number of needy groups. In the end, what takes place is that the Government make the local decisions which, in my experience, is not in the interests of local people.
My noble friend Lady Faithfull drew your Lordships' attention to the difficulties of supporting people in the community. In no way do I underestimate the challenges, but I believe that the new care programme approach applied explicitly to special hospital patients will go a long way to meeting some of those needs. No patient should be discharged without proper arrangements being made for him or her, including a place to live. That is an intrinsic part of the care programme approach.
The noble Earl, Lord Longford, referred to the groups under Dr. Reed's chairmanship that are currently looking at high security and related provision and at services for people with psychopathic or personality disorders. These will report in the spring. I hope that the noble Earl will understand if I resist his invitation to comment at present on Dr. Reed's work. Like him, I have not been a fly on the wall.
However, as I indicated to your Lordships last November, the guiding principles of the review have obvious implications for the current centralised pattern of special hospital provision. Indeed, as the noble Earl said, the special hospitals service authority 756 is not wedded to the status quo. That was clear from the presentation made by the authority at last autumn's ministerial review. I am sure that the working group will be looking closely at all the various options and we await with interest their conclusions.
I should like to turn to the issue of homelessness, so sensitively raised by the noble Lord, Lord Dean of Beswick. I know that he will be encouraged by the £20 million programme for the 150 short-term hostel places that we are putting into place, as well as a lot of other provisions. My noble friend Lady Faithfull and the noble Lord, Lord Henderson of Brompton, were concerned about the fragmentation of services. It is a picture some of us will recognise. But the Reed Committee was a fine example of inter-departmental working. It was an outstanding example of co-operation between departments and I think will lead the way for further developments. The noble Earl mentioned the national advisory committee which will provide a continuing forum and will also link with other departments which have interests and responsibilities in this area.
The noble Baroness, Lady Robson of Kiddington, asked a specific question as to how many people in prison had formerly been in mental institutions. I regret to say that we do not have that information. The total figures quoted —750 to 1,400—are extrapolated from a very small sample survey. Not all will have previously been patients in hospital. So that is further work that we clearly need to do.
In conclusion, the profile of mentally disordered offenders is now much higher than it has been for many years. The interest shown by your Lordships in this debate and our debate in November on the Ashworth Hospital report is an illustration. We need to build on that interest and enthusiasm to ensure that this vulnerable group of people receives the right kind of help when they need it. I believe that the Reed review has provided a strong lead which we must do our best to follow.