§ 3.32 p.m.
§ The Parliamentary Undersecretary of State, Department of Health (Baroness Cumberlege)
s: My Lords, I beg to move that this Bill be now read a second time. The Bill makes important changes to mental health legislation in England, Wales, and Scotland. It underlines the Government's commitment to care in the community by introducing key measures to strengthen it. Though the community care principles continue to enjoy widespread support a number of recent cases have served to heighten public concern. The Government recognise those concerns and this Bill addresses them. It deserves the support of all those who want the policy to work and who recognise that the safety and protection for the public are important—indeed are inseparable— from the interests of mentally ill people. Since a major part of the part of the Bill refers to Scottish law my noble and learned friend Lord Fraser of Carmyllie will respond to the debate and deal with any issues that refer to the Scottish provisions in the Bill.
I should like to start by setting the Bill in context. The public have become conscious of the needs of severely mentally ill people through a handful of well-publicised cases which have gone tragically wrong. But the full story is far from being one of tragedy and failure. We have made great strides in moving people out of large 934 and often forbidding asylums, into towns, cities and villages where the rest of us live. We have seen people become de-institutionalised; leave the isolated institutions where they existed out of sight out of mind, and go into houses, flats and bungalows. People who had been denied a normal social life can now carry out the day-to-day activities that the rest of us take for granted, such as shopping, attending church, spending an evening down the pub.
Some severely ill people who prior to the introduction of new treatments and therapeutic drug regimes would have spent years in hospital can now hold down responsible jobs. People with a mental illness can, and do, become part of the community in which they live; and a recent survey showed that the majority of people in the country (75 per cent.) agree that opportunities should be given to those who can be supported.
The gains have been enormous. We do, however, recognise the dangers. There is a very small minority of severely mentally ill people who on discharge from hospital fail to take their medication or comply with agreements reached in terms of their continuing care. Then they can become a risk to themselves, their families and the public. That risk is not acceptable and policy and practice have to work to minimise it. The Government have brought forward this Bill to address this important issue.
So far as concerns England and Wales the Bill does three things: first, it introduces the new power of supervised discharge, referred to in the Bill as after-care supervision for mentally ill patients leaving hospital; secondly, it extends the period of leave of absence which detained patients may be granted before their final discharge; and, thirdly, it closes a loophole in the present Act by which a patient who goes absent without leave can no longer be detained if he or she has been away for 28 days. These provisions are covered in three clauses amending the 1983 Mental Health Act. The Scottish provisions follow the same broad structure.
Clause 1 deals with supervised discharge, and is the most important element in the English part of the Bill. It meets the 1993 commitment made by my right honourable friend the Secretary of State for Health to ensure that the most vulnerable people do not slip through the net after they leave hospital.
My right honourable friend had made clear her view that stronger legal powers were needed to back up care in the community well before the subject started to hit the headlines. Others shared this concern. The Royal College of Psychiatrists published its own proposals for community supervision orders in January 1993. They provided the starting point for my right honourable friend's review of legal powers from which came the proposals for supervised discharge. Subsequent consultation showed widespread support for our view that a new legal provision was needed.
Supervised discharge is the most important part, but only a part, of a comprehensive strategy announced by my right honourable friend in August 1993 to strengthen care in the community. Other effective measures include supervision registers, introduced last April for patients considered to be at risk to themselves and/or to others. Those registers are designed to ensure that contact is 935 maintained with patients after they are discharged. We also issued comprehensive guidance last May. That guidance is clear and firm. Patients must not be discharged unless and until the clinicians responsible for their care are satisfied that it is safe to do so, and that the patient poses no significant risks to himself or herself, or to others in the community. The guidance is to be supplemented soon by our detailed guide to co-operative working, on which we have also consulted widely. Wales has its own comprehensive arrangements for dealing with mental health. My right honourable friend the Secretary of State for Wales is considering issuing further guidance on assessment and care management, including discharge and after-care arrangements, to strengthen co-ordination of care for severely mentally ill people.
Supervised discharge will provide a new power to ensure that patients keep to the care arrangements which are considered necessary to enable them to live safely in the community. If arrangements are broken, then the patient's case will be reviewed and that could lead to readmission to hospital under the 1983 Mental Health Act. Patients subject to supervised discharge are those who have been detained in hospital under the 1983 Act and who need special support in the community. These are patients who present a significant risk of substantial danger to themselves or others but are not in the category of restricted patients who have committed serious offences and are subject to the Home Secretary's special powers defined in the Act.
The application for supervised after-care will be made by the consultant who has been responsible for the patient's care in hospital. That consultant is referred to in the Bill as the "responsible medical officer". The application will be made to the health authority, which will be responsible (with the local authority) for providing the after-care services the patient requires. In making the application the responsible medical officer must consult the patient, and others professionally concerned with his or her care. He or she must also consult any informal carers. The application must be supported by a further medical opinion and a recommendation from an approved social worker. A statement of the after-care services to be provided must be submitted with the application.
On accepting the application the health authority must tell the patient and his or her professional and informal carers. Unless the patient objects, the health authority will also consult the nearest relative as defined in the 1983 Act.
Once the patient has left hospital, the Bill provides for a supervisor—normally the patient's key worker— to supervise and monitor the after-care services. Under the powers in the Bill, the patient may be required to reside at a specified place or to attend for medical treatment, occupation, education or training. The supervisor, or a person authorised by him or her, may take the patient to a place where he or she is required to reside or attend. There will, however, be no power to administer medication or any other form of medical treatment against the patient's will.
936 The responsible health and local authorities have a duty to keep the after-care services under review. There would be an immediate review if the patient ceased to accept the after-care services. In this case, the professional care team would consider whether supervision was still appropriate. It may consider that the patient should be readmitted to hospital under the existing provisions of the Mental Health Act. It is clearly important that when patients are not prepared to comply with the terms of their supervision the option of taking them back into hospital is considered. Otherwise there is a real risk that they will lose contact with the care they need and go on to pose a danger to themselves or to others.
A patient will be subject to supervision for an initial period of six months. If the original conditions are still satisfied that may be extended for a further six months and then for periods of a year at a time, but only after consultation with others concerned in the patient's care. The patient may also be discharged from supervision at any time, but again only after consultation.
Patients subject to supervision, and their nearest relatives, will have the right to appeal to a mental health review tribunal when supervised discharge is first imposed or is subsequently renewed. These rights are specified in Schedule 1.
Supervised discharge will underpin the principles of the care programme approach, which we introduced in 1991 and upon which the after-care of all psychiatric patients should be based. We do not believe that it will impose extra cost because it does not introduce new requirements. Rather, it gives legal backing to what is already recognised as good practice.
NHS spending on services for mentally ill people has increased by 40 per cent, in real terms since 1979. The corresponding figure for local authority services is 171 per cent. Local authority spending is strongly supported by the mental illness specific grant, which we introduced in 1991. That stands at £36 million in the current year and we are increasing it to £47.5 million next year, which is a rise of one-third. The benefits of this growth in spending can be plainly seen; for example, a fourfold increase in the past 12 years in the number of community mental health nurses. These are expanding and developing services. Supervised discharge, with our related initiatives such as supervision registers, will help to ensure that extra spending is targeted at the most vulnerable mentally ill people who need it most
Local authority guardianship under the 1983 Act will remain available for those patients for whom it is considered more suitable. There is a clear difference in the character of the two powers. Supervised discharge, as I have said, embodies the principles of the care programme approach and gives a specific role to healthcare professionals. We do not believe that its purpose could have been achieved by simply extending guardianship.
I now move on to Clauses 2 and 3. Clause 2 closes the loophole in the 1983 Mental Health Act by which patients who are absent without leave may not be taken into custody more than 28 days after the day on which they absconded. That is a strange anachronism which 937 dates back at least to the 1890 Lunacy Act. The new provision will allow a patient to be taken into custody at any time up to six months from the date on which he or she absconded or, if later, the end of his or her existing authority for detention in hospital or guardianship. Where a patient is taken into custody or returned after more than 28 days the responsible medical officer must reassess him or her within seven days of the patient's return. The patient will remain liable to be detained only if the responsible medical officer so recommends.
The clause also provides for the return of patients who have absconded to the Republic of Ireland. Apart from the provision relating to the Republic of Ireland, none of this applies to restricted patients. The Act already allows them to be returned at any time and we are not changing this.
The return of absconding patients appears to be a straightforward matter. It is, nevertheless, important to take account of all the relevant factors, which include our international obligations under the European Convention on Human Rights. We have consulted widely about these provisions and we are confident that we have got the balance right.
Finally, as regards England and Wales, Clause 3 extends the period for which a patient may be given leave of absence from hospital. That is currently a maximum of six months. Clause 3 increases that to a year. A patient on leave of absence remains in the care of the responsible medical officer and it can be an important first step towards rehabilitation in the community. The extension to 12 months was also proposed in my right honourable friend's review and has been widely supported.
I now turn to the Scottish provisions. My noble and learned friend Lord Fraser has kept in close touch with our policy development in England and Wales and our officials have worked together on our respective legislative frameworks and practices. Your Lordships will be well aware of our different legal systems, so different but equivalent approaches have been adopted to our respective provisions and, accordingly, I will address what is proposed for Scotland in a slightly different way. First, I turn to leave of absence. Unlike the equivalent provision in England and Wales—where there was a limit of six months and is now to be one of a year—leave of absence is open-ended in Scotland. In light of the judgment of Sheriff Younger in 1987, my noble and learned friend has concluded that the use of leave of absence on a long-term basis carried a risk of legal challenge. It was also based on an apparently illogical premise; that if the patient is well enough to stay in the community on a long-term, almost indefinite basis, then why is he still liable to be detained in a hospital?
That said, leave of absence is a valuable and effective community rehabilitation and treatment option and there is no desire to lose it altogether. So, as proposed for patients south of the Border, Clause 5 of the Bill introduces a limit of one year to its duration. The need to reduce the legal difficulties associated with leave of absence has been the main impetus for change in 938 Scotland. To that extent, my noble and learned friend has come to the issue from a different angle to ours, but we have arrived at similar conclusions.
However, introducing this new limit on leave of absence in Scotland does leave a gap in the legal framework for the care and treatment of mentally ill people in the community. Following consultation, my noble and learned friend has decided to develop a new community care order to fill the gap. Clause 4 of the Bill introduces this order. It has been tailored to fit the separate and different Scottish Mental Health Act and different legal system.
The community care order will provide a broadly similar safeguard to the supervised discharge proposals for England and Wales. The different terminology and the more formal approach of the Scottish proposals reflect the principles of the 1984' Act and Scottish practice. That acknowledges the key role of the sheriff and the Mental Welfare Commission for Scotland in that system. Community care orders are intended for the same categories of mentally disordered people as will be covered by the proposals for supervised discharge. The process will be triggered when the patient's responsible medical officer and another medical practitioner are satisfied that the patient's medical condition justifies a community care order, that an order is needed to ensure that the patient receives treatment and support services and that it is necessary in the interests of the patient's own health or safety or for the protection of others.
An application for the order may then be made to the sheriff by the responsible medical officer, supported by the second doctor and a recommendation from a social worker.
If the sheriff makes the order it will specify the conditions with which the patient should comply and give the names of his special medical officer and the after-care officer. Any variation in the conditions will have to be discussed with those concerned with the patient's care and treatment and requires the sheriffs approval. If the patient objects to any variation, there has to be a hearing. As with supervised discharge in England and Wales, the initial order will apply for six months, after which it may be renewed by the special medical officer for six months and, if appropriate, yearly thereafter.
Patients will have a right to a hearing when the order is made and may appeal to the sheriff on its renewal. The protective functions of the Mental Welfare Commission for Scotland will be extended to include patients subject to an order, and the commission will have the power of revocation in appropriate cases. The Mental Health Act Commission, which looks after the interests of detained patients in England and Wales, has a different remit which will not be extended to cover those subject to after-care under supervision. This reflects its much more specific role under the Mental Health Act 1983. However, we have consulted it over our proposals.
A new feature proposed for Scottish legislation is the inclusion of a provision for reassessment in hospital for any patient subject to an order whose condition has deteriorated and is, or is likely to become, such as to 939 give grounds for serious concern regarding his health or safety or the protection of other persons. Such a reassessment—for a period of up to seven days—would have to be justified by two doctors on objective mental health criteria. Following this, the order may be continued or revoked; or an application for detention in hospital be made. As with after-care under supervision, there will be no provision for compulsory medication in the community.
Finally for Scotland, Clause 6 makes a provision equivalent to that proposed for detained patients who abscond from hospitals in England and Wales, or those subject to guardianship; that is, a period of six months, or the current period of detention or guardianship, within which he may be taken into custody and returned.
In the main text of the Bill this only leaves Clause 7 covering the formal provisions for the short title, commencement and extent. Other detailed matters are covered in the two schedules. For England and Wales these confirm, among other things, the appeal rights of patients subject to supervised discharge, and for Scotland, the role of the Mental Welfare Commission.
We are confident that the new supervision arrangements in England and Wales, the equivalent provisions in Scotland, and the other measures with which they are linked, add up to a coherent and consistent approach. They preserve the vital principles of care in the community for vulnerable people. They also provide the safeguards which are essential for patients and the public alike. The Bill will strengthen care in the community and reinforce public confidence in it. Care in the community is a long-standing policy which has enjoyed the support of all parties and a high proportion of the public. It deserves that support. This Bill displays the Government's continuing commitment to this policy which is right and which is working. I commend the Bill to your Lordships' House.
§ Moved, That the Bill be now read a second time.— (Baroness Cumberlege).
§ 3.53 p.m.
§ Baroness Jay of Paddington
My Lords, I thank the Minister for introducing this, her second piece of important legislation in the same number of weeks, and for outlining the proposals very precisely. I am glad that before Committee stage we are to have an opportunity to consider the details with the Minister at a special meeting. My noble friend Lord Carmichael of Kelvingrove will speak later this afternoon and will take forward the special issues in relation to Scotland as the Bill proceeds.
Although the Bill is relatively short, it is, as we will have gathered from the Minister's clear explanation, relatively complicated. Its provisions embrace difficult areas of jurisprudence and ethics way beyond the practical concerns of health care. We shall wish to consider carefully the issues of civil rights and the relative rights and duties of both patients and professionals as the Bill makes its way forward.
On these Benches, we believe it is a serious indictment of government policy that this complex Bill is needed at all. It represents the admission that an 940 important part of care in the community has failed. As the Minister said, community care for the mentally ill has been widely supported for more than a decade. There has been general clinical and political agreement about closing the old-style long-stay hospitals and developing services to help patients lead their lives outside institutions in what we hoped would be a normal environment.
That is the vision of community care. Sadly the vision has never been properly achieved because it has never been properly resourced and supported. Today we have the shameful spectacle of mentally ill people wandering the streets, often homeless and apparently totally uncared for. Many health authorities, particularly in the big cities, talk of service provisions being dangerously inadequate.
In September 1994, just six months ago, the Mental Health Task Force, a national body set up by the Department of Health, published its findings on Inner London and reported a serious problem of access to appropriate care. The task force stated:Patients with severe and chronic mental disabilities are being discharged without adequate supervision, or the provision necessary to meet their housing, social and health needs. This could incur risks not only to public safety but also to the safety of the individuals concerned".
At the same time, specialist voluntary organisations, like the Matthew Trust, have experienced an enormous increase in demand for their charitable grants and services. In the three years to 1994 applications to the Matthew Trust from mentally ill people who had exhausted official channels of support, rose by 300 per cent. Just last month the trust produced a commentary called Victims of Care. That is a powerful document which, through individual stories, highlights the failure of the new care system to help vulnerable people, people whose daily lives are dominated by a struggle against mental illness and poverty.
It is worth reminding your Lordships of the overall financial context of mental health care. NHS spending on mental hospitals and community services has remained at roughly 11 per cent, of the total budget for a number of years. The Mental Health Foundation now suggests that spending on community services may be actually falling. Savings from the proceeds of the closure of long stay hospitals have often "leaked" into other services. In the health market, it would be realistic to assume that competing trusts have little enthusiasm for expanding the expensive and unglamorous services for the mentally ill. And yet we were told this afternoon by the Minister that this Bill will make services more effective but will not give rise to any additional costs. There will be no need for extra staff. Instead, apparently, a dreadful situation will be improved solely by a new statutory supervising system. There will be no additional resources for health authorities or social services departments.
The central proposal that we are considering for supervised aftercare is, as the Minister said, obviously the result of some high profile tragedies which created legitimate public anxiety. But I hope that I will not offend when I say that in some ways the Bill reminds me of the Dangerous Dogs Act—a few very serious 941 incidents leading to a reactive measure which seeks more to reassure tabloid opinion than to solve the problem.
However, in the field of mental illness, there seems to be a reluctant acceptance by most of those involved in therapeutic relations with patients that, for a very small minority, some form of additionally supervised care in the community may be necessary, not so much to deal with the rare cases of random aggressive violence, as with the severely ill who find compliance with any care programme very difficult. As MIND has pointed out, 90 per cent, of those who are diagnosed as mentally ill and living in the community are not violent. The Royal College of Nursing has said thatA mentally ill person is more likely to harm himself than others and the rate of homicides by mentally ill people reflects the rate amongst the population as a whole".
The RCN thinks that the Bill before us offers false reassurance to patients and the public about violent incidents.
The central question is, given the present appalling state of community services, some form of extra supervision may be needed: how is that best achieved? Your Lordships will recall the Ritchie Report in 1994 on the case of the schizophrenic Christopher Clunis, who murdered Jonathan Zito on the London Underground. The report laid great emphasis on the failure to co-ordinate services, and included the pathetic statements of Clunis himself, who described himself being passed from one person to another, and not knowing who was in charge.
The Ritchie Report concluded:The aftercare which is provided must be properly co-ordinated and supervised; it is severely to the patient's detriment if each member of the team acts in isolation. The consultant psychiatrist and care manager from social services must together be responsible for supervising aftercare".
That recommendation seems quite clear. But, in the present proposals, lines of responsibility for supervision are imprecisely developed. The Zito Trust which, as your Lordships will remember, has been courageously established by Mrs. Jane Zito following the report on her husband's death, has commented on this part of the Bill:Lack of clarity and clear lines of accountability in this context are not only unhelpful but may be potentially fatal".
In the trust's response to the Bill itasks that the Bill is more explicit in its definitions regarding the role and responsibilities of the supervisor under its provisions".
As stated at present, it seems that supervised care will be the personal responsibility of a nominated supervisor, working with a community GP, trying to co-ordinate services from different agencies. It is not obvious who is likely to be named as the supervisor. Although the initial application for supervision will be made to a health authority, it is generally supposed—and I would be grateful if the Ministers would correct me if I am wrong—that the responsible supervisor will in fact be a nominated social worker.
There are already professional concerns that, if the supervision breaks down, the unfortunate social worker would become very exposed—a scapegoat—and the centre, no doubt, of widespread unpleasant publicity. No 942 wonder managers are already doubting their ability to get colleagues to take those obviously very difficult roles, if they are expected to act without sufficient support and additional resources. The precise nature of the responsibility for continuing care under supervision, and who will be accountable if there is a failure or breakdown, must be clearly stated and spelt out.
It has also been suggested that there is nothing in the Bill to prevent either a health authority or, for that matter, a social service department refusing a supervision application. What then happens to the miserable patient? Does he have to stay in hospital?
Other specific concerns have been raised about the nature of consultation on supervised aftercare, both with supervising agencies and, most importantly, with the patients. Many professionals are worried that the so-called "therapeutic alliance" with patients may be seriously threatened if the heavy hand of potential coercion is emphasised in supervised discharge plans. Many of the community-based voluntary service organisations agree that they only want to work with patients on the basis that the service users themselves want to use the service. We will need to examine in detail the issues of whether there will be genuine consultation, and free consent to treatment plans in supervised aftercare, at a later stage. It will be particularly important to see how a patient's relatives, friends and informal carers will be properly involved and not just "informed" as the Bill suggests in several places.
Those are significant details about the present Bill, but we should return to the central question of whether the new powers are really needed at all. Although the Minister said that that was not the case, it still seems to me to be possible to achieve all that is important under the existing guardianship orders—orders which, after all, have been in existence under the Mental Health Act since 1959. The concept of guardianship was reasserted in the 1983 Act and —this is most important—the code of practice says:The purpose is to enable patients to receive community care where it cannot be provided without the use of compulsory powers. It enables the establishment of an authoritative framework for working with a patient with the minimum of constraint to achieve as independent a life as possible within the community. Where it is used"—
and this was something that the Minister said was not possible; but it is explicit in the guidelines—it must be part of the patient's overall care and treatment plan".
Surely that code contains the basic aim of the new proposals.
Therefore, why not use the guardianship laws, combined with the existing discharge planning requirements under Section 117 of the 1983 Act, and the care programme approach adopted in the past few years? In that way, it seems that a care agency can already achieve what the Bill sets out to achieve. That approach was underlined by the report of the Law Commission on Mental Incapacity published on 28th February this year, two weeks after the Bill was published. The report supports and seeks to extend the powers of guardianship. For example, the commission suggests amending the 1993 Act to give a guardian 943 additional power to convey a patient to a residence specified by the guardian. The power to convey, as the Minister mentioned, is regarded by the Government as one of the essential new provisions of the new Bill.
However, the Law Commission report shows that that could have been achieved by amending the 1983 Act. The commission also recommended that the powers of the Mental Health Act Commission should be extended to include people in guardianship, a provision which, as the Minister mentioned, is rather surprisingly not included in the new Bill for the new type of supervision. In addition, the commission also creates a new emergency protection scheme which, to quote Mr. Justice Brooke, the chairman of the Law Commission,is designed to enable local authorities to act effectively to protect vulnerable people who may be at risk of harm, without interfering with their autonomy".
I hope that the Minister will indicate precisely why, given the existence of guardianship and the new proposals from the Law Commission, the Government now think it necessary to introduce this new, complicated statutory procedure. One is tempted to think that it is simply so that they are seen to be doing something. We will want to pursue the detail of the similarities and distinctions between the proposal for supervised aftercare and guardianship at a later stage.
I am told that guardianship has sometimes not been very widely used partly because responsible care workers have judged that they have insufficient resources to make it work effectively. Presumably, that must also be true of the new proposed arrangement. The lesson must surely be that if supervised aftercare is to succeed, it should be accompanied by statutory provision for a minimum set of services in the community for everyone who is receiving that type of aftercare. It is the services which are crucial: they are what is needed.
Indeed, many doctors and healthcare managers see the introduction of a new statute as simply adding another administrative layer to their already existing burdens. We should be under no illusions about how heavy such burdens already are. Since the Bill was published, I have talked to a large number of people who work in all different capacities directly with the mentally ill, both in hospital and in the community. During those meetings my admiration for their dedication and commitment has grown even stronger than it was before. They feel that they, and their patients and clients, are struggling at the moment against almost overwhelming odds. When asked what could improve their situation, their priorities include: better training and limited caseloads for community psychiatric nurses; more intensively staffed crisis homes where severely ill people can be looked after on a temporary basis; crisis cards so that there can be easy admission to such places; and a wider network of support staff to help people at home. They are not agitating for additional, legal powers. I am glad that some of those front-line workers will be able to be involved in our informal meeting before the Committee stage of the Bill.
944 The overall problem is clearly inadequate services, not inadequate laws. The chairman of the Law Commission recently said that the law in this area has grown up piecemeal and is,now out of date and full of gaps".
But the solution must be to conduct a thorough review and reform of the Mental Health Act 1983 and to make our legislation, which was originally designed for hospital services, more relevant to community care. The Bill before us today is trying to patch up a crisis; but that crisis needs different long-term solutions.
The Zito Trust has kindly shown me the case studies of many of the people whom they are trying to help in their victim support programme. The story of Mary Collins is typical. In October 1994, Mrs. Collins' son, a diagnosed schizophrenic, stabbed her husband to death and attempted to kill his mother. This man had been sectioned to hospital care on several occasions but, most recently, had been a voluntary patient and was discharged, against his will, on the pretext that he was better. One suspects that this may have been because pressured medical staff needed his bed. Following discharge he was provided with a flat, but with no furniture and he was given little support. His mental health deteriorated and Mary's attempts to remain in contact with her son, to improve his care, led to the fatal attack. Even after this new Bill, Mrs. Collins's son would not have been subject to the supervised after-care arrangements. He would have fallen through the legal net. He, like many others, needed structured and intense support. We must find foolproof ways to provide it.
§ Baroness Robson of Kiddington
My Lords, I, too, wish to thank the Minister for the clear way in which she introduced the Bill. I also wish to announce at this point that my noble friend Lord Mar and Kellie will deal with the Scottish part of the Bill.
We on these Benches very much welcome the aims of the present Bill. We are pleased that the Government have recognised the need for reform of the current Mental Health Act. But that does not by any means mean that we approve of every detail of the Bill. We have deep reservations about many of its details. However, it gives us the opportunity to discuss the problem in detail and we hope to improve the Bill by introducing amendments at a later stage.
First, I wish to look at the Bill from the point of view of its implications under the European Convention on Human Rights. Article 5 of that convention provides that everyone has the right to liberty and security of the person. However, that right can be limited in relation to persons of unsound mind. The Bill before us states that a patient may be detained if he represents a danger to himself or others. The court has held that this constitutes a deprivation of liberty. However, the present Bill goes further. New Section 25A(4) (b) states that after-care supervision can be sought for a patient who is at risk of being seriously exploited. The proposed infringement of liberty contained in the Bill is not warranted in relation to those who are at risk of being seriously exploited. 945 They should be supported in the community and protected in the community without the threat of being taken away and conveyed to a place of safety.
New Section 25D(4) gives the power to take away and convey the patient to a place where the patient is required to attend for the purpose of medical treatment. It implies that the Bill will also allow medication to be administered without the patient's consent, even though he is not, in the true sense, a detained patient. There is nothing in the Bill, apart from the explanatory memorandum, to confirm that a patient cannot be required to take medication against his will. This freedom must be safeguarded in the Bill itself.
The three amendments to the current Act contained in the Bill are particularly welcome. First, the right of a patient to apply to a mental health tribunal for supervision to be terminated; secondly, the extension of the limit on the period for which patients may be given leave of absence; and, thirdly, the extension of the period during which patients who are absent without leave may be taken into custody and returned.
The patient's right of appeal to the mental health review tribunal to be discharged from supervision is in itself welcome, but the procedure envisaged in the Bill is not. The fact that the burden of proof that the supervision is not necessary rests on the patient will heavily militate against a discharge being granted. Further, hearings before the mental health review tribunals are subject to considerable delays during which time the conditions of the supervision order will have to be complied with. The right to apply to the mental health review tribunal will only be safeguarded if the burden of proof is reversed and if patients can be guaranteed a speedy hearing.
The Bill assumes that the new powers will enable more resources to be concentrated on those patients subject to supervised discharge, but makes no provision for an overall increase in the level of resources. Concentrating resources on one client group will inevitably lead to fewer resources being available to the vast majority of mentally ill people who already receive inadequate support in the community, and consequently may lead to an increase in the need for supervised discharge powers.
We are also concerned about the limited number of hospital beds now available for those patients who are considered to require hospital treatment. With a shortage of beds patients run the risk of being discharged into the community before they are ready to accept the responsibility of life in the community, resulting in frequent, short-term re-admissions to hospital. If the Bill is to be effective, immediate hospital admission when needed must be safeguarded. Incidents like that of the patient who telephoned for help on a Monday and was told that a community psychiatric nurse would see him the following Thursday simply are not good enough. That is like ringing the fire service on Monday and that service telling you it will arrive on Thursday. It is desperately important that people who ask for assistance should be given it immediately.
946 According to the Royal College of Nursing, only one in five people diagnosed as having schizophrenia has access to a community psychiatric nurse. The number of community psychiatric nurses must obviously be increased if patients are to receive adequate support. Perhaps the most disturbing aspect of the Bill is that the only extra costs envisaged by the Government are the costs for mental health review tribunals. But even those costs do not include the cost of the extra time spent by psychiatrists and social workers on preparing reports. If this Bill is to improve the position of the mentally inadequate people in our society there will be many other additional costs involved in providing the right background. For example, I cannot see how the Bill's provisions can possibly work without a 24-hour emergency service provided by a multi-disciplinary team.
I do not know whether the Minister is aware of the West Birmingham home treatment service which covers an inner city population of 200,000 people. It is open 24 hours a day, seven days a week, and has reduced hospital admissions by 50 per cent, and produced a saving of 25 per cent, in the cost of the service. One of the most important matters is to make certain that people who are out in the community are given the right conditions in which to live. It can never be acceptable that some of these people are put into bed and breakfast accommodation.
I believe, therefore, that if there is to be any possibility that the Bill will improve the services available to patients, the Government must withdraw the statement in the financial memorandum that it should give rise to no additional costs for the health authority or local authority. That cannot be true. The scheme will not work unless we fund it.
§ 4.19 p.m.
§ Lord Thurlow
My Lords, I welcome the Bill. I support its broad objectives. I thank the noble Baroness for her very clear exposition.
While I welcome the Bill, like previous speakers I have strong reservations. The new legal framework can be very helpful in improving the level of care in the community, but the question is how it will work in practice. As the noble Baroness, Lady Robson, said, there are considerable doubts as to whether the resources will be available to make it work properly.
I shall not go into the question of whether guardianship could be a sufficient means of dealing with this difficult problem. The fact remains that for a considerable number of years guardianship has not proved to be sufficient. Therefore, from the point of view of the lay public the introduction of this new legal framework is welcome.
All the experts, professionals, agree that there is a critical issue: that of the trust between the responsible professionals and the patients. There is a real danger that unless the provisions of the Bill are handled with great sensitivity that trust, not only between the individual patient and those seeking to help him or her but also 947 more widely among those suffering from mental ill health, may be undermined as a result of the prevailing impression.
I recognise, as will your Lordships, that there is sensitive and effective handling by the responsible authorities of difficult cases requiring sectioning. However, the mentally ill who will be the subject of supervision are very difficult people. Suspicion is one of the basic symptoms of schizophrenia. Suspicion is easily translated into violence, and when that escalates and becomes a matter for constraint the situation becomes very painful and difficult.
As the noble Baroness, Lady Robson, indicated, a factor to be considered is the pressure on CPNs and social workers. We were glad to hear from the noble Baroness that the number of CPNs has increased considerably; but from what a small base. When community care was introduced, the army of CPNs was pathetic. Therefore, as Griffiths observed in his great report, the need is very much greater than can be met by the present resources.
Community care has proved satisfactory in some areas. West Birmingham has been mentioned. However, all responsible people concerned agree that it has been patchy. That is inevitable in the development of a new system which has been running for only a limited period of time. However, Griffiths indicated that the closure of the big hospitals would inevitably lead to greater requirements for resources because care in the community is more expensive. It requires more resources. Although resources have been increased—the noble Baroness quoted the figure of 49 per cent, in real terms—and that is welcome, the need runs ahead of provision. Therefore, we look forward to a progressive increase as the years go by. Public perception is that in relative terms the amount allocated within the health service to the mental health sector has fallen.
The noble Baroness mentioned the leakage of funds saved in the closure of mental hospitals into other budgets within local authorities. That is a statistical quagmire. It is probably impossible for anyone to sort out what goes on in that way, but there is a general impression that, in view of the great constraints under which so many local authorities are operating, that leakage has been at the expense of mental health funds.
I should like to mention one point that the Law Society has emphasised. That is the crisis in inner city mental health services, particularly the high throughput and rapid discharge of detained patients. That creates a serious problem of high bed-occupancy, leaving no space in many cases for informal admissions. That is a very serious matter because we all prefer patients to go into hospital informally rather than under section.
I echo the appeals made by the noble Baronesses who have spoken from this side of the House for a continued increase in resources while admitting and' acknowledging that an increase has already taken place.
§ 4.28 p.m.
Lord Campbell of Croy
My Lords, I should like to thank my noble friend Lady Cumberlege for outlining so clearly the purpose and the proposals in the Bill.
948 Last November I was pleased to see included in the Queen's Speech a measure to provide for people with a serious mental disorder to be cared for under supervision when not in hospital. That seemed a quick response to disturbing incidents, including murders by schizophrenics in particular. In the Clunis case the subsequent inquiry produced recommendations for sensible action and changes.
While I applaud the intention, therefore, there are disadvantages in instant legislation. First, one cannot avoid disturbing the present law and procedures without having had a general review. Secondly, the time for consultation with the medical professions and organisations involved and concerned has been very short. The Bill has been given an early place in our parliamentary programme; and I welcome that. But it must have been in draft, and possibly in print, over a month ago and that is only a short time after the announcement in the middle of November. Some of the objections and reservations voiced by interested organisations may well have arisen because of the short time between the announcement in mid-November and the presentation of the Bill. The present law to be changed and supplemented is contained in the 1983 Act for England and Wales, and the equivalent 1984 Act for Scotland. The Bill is sensibly divided neatly into two for that reason.
The Bill's proposals are before us at a critical time— previous speakers have already referred to this—in the new system of care in the community which has not yet settled down, with differing results so far in various parts of the country.
As some noble Lords will know, for nearly 30 years I have been advocating in both Houses of Parliament that there should be more care in the community for disabled people, (both physically and mentally disabled) in suitable conditions rather than keeping them in institutions as long-term patients. I welcomed the Griffiths Report and the decision to launch the system in the 1990 Act. However, adopting the system has not been simple or straightforward. Where the mentally ill are concerned, the intention has been clear and admirable. No one should be discharged from hospital until full and proper arrangements have been made for that individual in the community. In practice I am sure that many of us know of cases where that simply has not happened. We are in the early stages, and one hopes that the situation will improve.
Furthermore, with mental illness, hospital beds will be needed at short notice for patients who have had relapses or failed to take their prescribed medication. We must remember that care in the community has been made possible largely because of the advances in medicine and in knowledge over the past 40 years, and in the drugs and treatment possible. Sufferers from mental illness can now live fairly normal lives in the community provided that they are not too bad and that there are arrangements for them to be returned quickly to hospital when necessary. However, if sufferers from mental illness cease to take assistance—medication and treatment—then the situation can change dramatically and in some cases their ability to cope with ordinary life recedes.
949 The cases which have had great publicity in the past three years involved schizophrenics, violence, danger to the public, and danger to the sufferer himself in the case of the London Zoo incident. The schizophrenics who are violent form a small proportion of the whole. They can usually be identified by the medical profession and I suggest that they must be the people for whom this Bill is primarily designed. There is a delicate balance to be achieved between protecting the public and patients themselves on the one hand, and preserving civil liberties on the other. Depriving a person of freedom by detaining in hospital, or forcing treatment against someone's apparent will, are controversial matters which will doubtless be raised later in the debate.
I speak with no medical qualifications, but from experience. As some noble Lords know, and I remind them, a close member of my family has been suffering from schizophrenia for the past 30 years. Also for part of that period I was for four years (when in another place) Secretary of State responsible for health. I have been closely associated with the National Schizophrenia Fellowship since it was established 25 years ago; and I am the patron of the National Schizophrenia Fellowship (Scotland). Therefore I am close to the problems and have been for some time.
I strongly support the principle that the consent and co-operation of a sufferer from mental illness should be sought and obtained if possible. At the same time, the minimum powers of compulsion necessary should be available in the patients' best interests. A characteristic of schizophrenics is that they hear voices. Often those voices seem commanding, and to be obeyed. The voices usually propose unpredictable actions, or foolish ones such as, "Stop taking the medication", or "Disappear into the blue without telling anyone and go missing for days". In those circumstances the schizophrenics are probably not violent, but they need special care and supervision.
Of course, compulsion must be used only on suitable occasions and with care. We are all well aware of the gross misuse of psychiatric diagnoses and detentions by totalitarian regimes, especially in the former Soviet Union, to keep political opponents, or as they thought dissidents, in custody or out of the way. In a democracy, however, that should not be possible and the safety of the public and of the individual require some powers of restraint.
Perhaps I may make some comments regarding Scotland. Because the law and system are different, the Bill proposes community care orders—an alternative arrangement for Scotland. I must tell your Lordships that those proposals have met with some disappointment among the organisations concerned north of the Border. The present indefinite leave of absence from the hospital which has worked extremely well is now to be reduced to one year. Some of us have known that leave of absence from hospital without time limit might be challenged legally. That has not happened so far. As it is an accepted system, operating well in Scotland, we had hoped that the Bill might make a simple change in the legislation and remove the possibility of a legal challenge.
950 In Scotland the mental illness system includes arrangements for guardianship but that has been very little used. I understand that it is considerably used for mental handicap—for people with learning disabilities—north and south of the Border. That disability is not a subject for this Bill. However, I believe that the guardianship arrangements have special application in that field.
Two weeks ago I wrote to my noble and learned friend, who will reply, about the points which have arisen among the organisations concerned in Scotland. He has already sent me a full reply. I quickly add that I shall not dilate on any of the points now. However, as my noble friend Lady Cumberlege stated, unlimited leave of absence seems illogical. Sheriff Younger pointed that out. Its great merit is that it works and has been accepted in Scotland by almost everyone concerned. I think that in other walks of life there are similar situations.
The intentions behind the Bill are sound, in my opinion. The difficulties arise from the details of the changes and the new procedures proposed. I hope that the Government will continue their discussions, especially north of the Border, with the organisations most concerned and first, explain more fully what they propose and how the procedures suggested will operate in practice; secondly, listen and be prepared, if necessary, to make amendments.
§ 4.40 p.m.
§ Lord Carmichael of Kelvingrove
My Lords, first, I wish to congratulate my noble friend Lady Jay on the competent way in which she spoke about the Bill and her attitude to it. There is a long list of speakers today not just for the Bill but for the other measures and I shall endeavour to outline some of the points on the Bill which relate to Scotland and which have been raised with me by outside organisations. I hope that I shall be able to spend more time on the Bill when we reach the Committee stage, proposing well-documented amendments after receiving information. I apologise to the Minister and the House; I have never before left a debate halfway through, but unfortunately I must leave early. It is quite unavoidable, I must be in Scotland at a reasonable time this evening and I hope that the House will forgive me. I shall, of course, carefully read the speeches when Hansard is published.
We must all thank the Scottish Office for its efforts to involve the many statutory and non-statutory bodies in Scotland in consultations before the Bill was published. However, that does not mean that the views of the statutory and non-statutory bodies have been met to anything like the extent that we would have liked. I read with care the consultation document issued by St. Andrew's House last December and must admit that I found it pretty hard going. Perhaps that had less to do with the paper and much more to do with my learning curve. As I read on, I began to understand a little more and with the help of many agencies I am just beginning to grasp some of the Bill's proposals.
951 It is a pity that the clauses relating to Scotland could not have been incorporated into a revised Mental Health (Scotland) Bill rather than the way we have had them presented to us in a UK Bill. I am pleased that the noble Lord, Lord Campbell of Croy, took exactly the same attitude to the Bill. I have no desire and I am sure he has none to make a narrow nationalist point, but I feel that the Bill is a clumsy way of legislating for Scotland and the rest of the United Kingdom in a measure which is so mixed and difficult to access for the layman. There are two Bills dealing with two separate spheres all in one volume and I do not believe that that makes for good legislation.
It is generally accepted, and has been accepted in all the speeches that we have heard so far that, where possible and where beneficial to the patient, as many people as the services can cope with should be treated in the community. However, there are problems, many of which have been mentioned today, to which we must find solutions. I hope that some of the amendments which I intend to put down at Committee stage will elicit information from the Minister.
I am informed by professionals that there is not always easy or indeed any proper co-operation between all the agencies which should or need to be involved in dealing with individuals who have mental difficulties. A specific staff member should always be responsible for regular contact with the patient and have full awareness of and liaise with all the other professional agencies involved.
Another point which I wish to emphasise is that I am told there is no easy method of co-ordinating information across the agencies which deal with the patient in the community. Sufficient weight is not always given to the experience of families and friends of the patient. After all, they see him much more often than anyone in the hospital and they also see the patient in different moods. They should be consulted much more widely than they seem to be. It is even difficult for the professionals—whether it be the nurse, social worker or the psychiatrist—to judge, because they only see the patient for short periods. Relatives and friends, however, live with the patient for long periods.
I am indebted to numerous agencies in Scotland and to individuals for their help in briefing me for this debate. It would probably be helpful if I outlined some areas of unease on which I shall try to put down amendments at Committee stage in order to obtain clarification. I hope that the Government will take the opportunity to consider the amendments and go halfway or even further towards meeting the desires and views of most of the professionals in Scotland.
We will need definitions of those to whom the Bill will apply. Obviously, it includes patients with serious mental health problems, but what about those with serious learning disabilities which affect their performance? Sometimes they are treated as though they have a mental problem, whereas it is a specific type of mental disability. That causes anxiety in Scotland.
Then there is the question of leave of absence with which I shall deal at some length at the Committee stage. Is this a serious problem in Scotland? We do not really know whether it is. I do not know that any serious 952 research has been done on it and, if it is not a serious problem, why should we change the legislation? Again, the Minister will be able to tell us about that in winding up.
I return to a question on which I was trying to obtain elucidation earlier. Is the psychiatrist the best person to take the leading role? Obviously, he will play an important part, but should he take a leading role in the long-term supervision of a patient? He will have a vital input, but surely the social work department will be in much closer and more continuous contact with the patient and should have at least an equal voice in helping to make decisions, playing an important role in any assessment of the patient. I am not trying to reduce the role of the psychiatrist who, as well as being the senior professional, has a leading role. Knowing the medical profession, I believe that he will make the real decisions, but it would take a strong-willed psychiatric nurse to bypass him.
The other point raised concerns compulsory treatment of a patient who returns to hospital for assessment which is dealt with under Clause 35. The wording of the clause suggests that the patient who is re-admitted for assessment is "detained". We would like the wording clarified, because it may very well mean that a patient who has been detained may be given medication, whether or not he wants it. In other words, he could be given medication against his will. I should like to know whether the patient has any right to appeal against recall to hospital. What is the process by which he is recalled?
We on this side of the House and the Scottish people to whom I have spoken believe that the Government have genuinely tried to deal with the situation. Care in the community is something which we all feel is right in the proper circumstances. We believe that it is good, but the Minister will not be surprised that those professionals and specialists are asking for clarification on a large number of issues within the field of mental health. I hope that in Committee we shall be able to help by getting answers from the Minister on some of the points that I have very briefly tried to outline.
§ 4.50 p.m.
§ The Earl of Mar and Kellie
My Lords, I should like to thank the noble Baroness the Minister for introducing this Bill. I also apologise to the whole House. I sincerely hope to be present at the end of this debate, but I may need to leave early to return to Scotland.
We are discussing mental health. This is a forgotten area and, regrettably, one that is probably still taboo. I suspect that most families would prefer that their relatives were bad rather than mad. We are considering compulsory measures of care for those who have been labelled as psychotic or schizophrenic, or as having aggravated learning difficulties. Here I must declare an interest. During my social work career I was, in England, a duly authorised officer and, in Scotland, a mental health officer. That was some time ago, but I speak as a former practitioner.
953 Mental health patients often do not realise that they are ill, and therefore they sometimes do not take their medication. That prevents them from functioning normally in the community. I regard this as a very important point and I shall return to it. I thank my noble friend Lady Robson of Kiddington for introducing the Bill from our side and for mentioning that I shall be dealing only with Part II, relating to Scotland. This Bill amends and alters the Mental Health (Scotland) Act 1984, and, like other noble Lords, I wish that this were the "Mental Health (Community Care Order) (Scotland) Bill", so that we could be discussing that on its own.
Clause 4 extends the range of compulsory measures in the treatment of people who are either mentally ill or suffer from aggravated learning disabilities. The range of these measures is: Section 18 hospital orders; Section 37 guardianship orders; and restriction orders where the Secretary of State determines when a patient will be released, rather than the consultant. There are also fairly extensive leave of absence arrangements. Among this range of measures are two new mental health orders; namely, the supervision and treatment order, coming in through the Criminal Justice (Scotland) Bill that is currently in another place, and the community care orders that we are discussing at the moment.
Clause 5 deals with those who are absent without leave. It lengthens the period before they cease to be detained from 28 days to six months. That is probably too long. Clause 6 deals with the leave of absence arrangements and restricts the period to one year, which is probably too limited.
Most patients in Scotland are informal patients. We have 30,000 admissions, of whom 3,000 are normally on compulsory measures. Significantly, there are approximately 100 patients in Scotland who have been on leave of absence for more than one year and are therefore prescribed candidates for community care orders.
The Bill lays down the criteria for the community care order patient—that is, that he or she should be mentally disordered, requiring treatment but not requiring detention, with some risk to his or her own health or safety; or someone who is likely to generate the need for the protection of other people. These are not the same criteria as for a Section 18 hospital order, as there is no requirement for detention and no power of treatment. Obviously, acute psychiatric patients will remain in hospital, which is an unnatural environment. Mental health implies the ability to live in the community.
There is some logic in this statutory halfway house provision. The expected route to getting onto a community care order would be that the patient would be admitted to hospital under either a Section 18 compulsory admission or possibly a Section 24 emergency admission, and would come into hospital for assessment and treatment. The consultant psychiatrist would apply to the sheriff for a community care order after consulting the social work department, a community mental nurse, some voluntary agencies, the carer and the patient. The consultant psychiatrist is 954 required to draw up a community care plan which will distinctly need a care worker, as was mentioned by the noble Lord, Lord Carmichael.
What exactly will these people do? I suggest that the social workers will not only produce a social circumstance report but will also make arrangements for accommodation for an occupational programme, probably in daycare or in a sheltered workshop. They will make travel arrangements; arrange an income with the Department of Social Security; provide counselling; and may do things such as advising the school to which the patient's child goes as to what is happening. The community mental nurse would be dealing with medication and monitoring the patient's mental health, and of course providing counselling.
The carer is perhaps the most critical person in this whole sphere. This person may be a parent, a spouse, a relative or even a neighbour. The carer is the person who, frankly, has the burden of care. Then, of course, the patient must also consent to being placed on the order. The sheriff will make the community care order but cannot make such an order unless there is a satisfactory community care plan that is ready to implement. It seems to me that the quality of the community care plan ends up being a burden on the sheriff to decide. Ironically, the patient may be on leave of absence from hospital while the community care plan is being prepared.
So the patient is released to the community care team. I suggest that a busy community care team might be able to handle up to 15 patients, and probably fewer in a very rural area. The team must be able to respond today, usually on a call from the carer, and not just make routine visits. We are dealing with people who would otherwise be revolving door patients. If the patient deteriorates, then readmission can follow, and the consultant psychiatrist will arrange for the person to be brought back into the hospital for a new period of reassessment at seven days, whereas normally emergency admissions are only 72 hours.
If, as a result of the reassessment period, the person is found to be rapidly restabilised, then the patient will go back out into the community and the community care order will continue. Otherwise, a new Section 18 admission will be taken from the sheriff court. The community care order will last six months. It can be renewed by the consultant psychiatrist, first for six months and then subsequently for 12 months. But I note that renewals are not subject to judicial scrutiny by the sheriff. They are, however, notified to the Mental Welfare Commission for Scotland. A community care patient will take his or her medication voluntarily, whereas patients on leave of absence will be liable to compulsory treatment because they are still subject to a Section 18 hospital order.
While the legislative arrangements are properly ordered in the Bill, there is more to a community care order than passing a Bill about it. Community care plans require the co-operation of social work departments, housing, health board staff, voluntary agencies and carers—and the use of their funds. The House will be well aware that Scottish local authorities are to be reorganised in 1996 when we move from 12 social work 955 reorganised in 1996 when we move from 12 social work authorities to 32. So I fear that this Bill may be introduced into an atmosphere of organisational chaos.
I also wonder whether the consultant psychiatrist should be making the community care application, as he will be committing other agencies' funds and personnel. Also, in Schedule 2 (page 39, line 27) dealing with offences, I am a little worried by the part which reads:(2A) It shall be an offence for any individual to ill-treat or wilfully neglect a patient in respect of whom a community care order is for the time being in force.
Does this failure to provide after-care services, which may occur, come under this Bill? If so, who is going to end up in the dock? As it is, Section 8 of the Mental Health (Scotland) Act, dealing with after-care services, is already regarded as being underfunded. Community care orders will cost more than the community-based budget but, of course, less than the hospital budget. As the community care team seems liable to prosecution for failing to provide after-care services in extremis, it seems to me that they should be making a joint community care application rather than the more hospital-based consultant psychiatrist. These resource implications are, of course, the crux of any community care proposals. Hospital care is expensive but all the patients are together and easily administered. Care in the community is cheaper but more difficult to carry out effectively, especially on a shoestring budget.
I am also worried by the wording of new Section 35A (on page 17) in Part II, which says that the responsible medical officer may make application to the sheriff for an order,providing that the patient shall, instead of continuing to be liable to be so detained, be subject to the conditions specified in the order, being conditions imposed with a view to ensuring that he receives—
I am worried about the possible implications of that. If community care order patients are given statutory access to health and social work services, it seems to me this would lead to a rescheduling of priorities and a denial of services to others, unless the budget can be expanded.
- (a) medical treatment; and
- (b) after-care services provided for him under section 8 of this Act."
To conclude, provisions of a community care order are in fact weaker than the provisions in respect of leave of absence. There are no powers of treatment in a community care order and of course leave of absence is to be restricted to one year. I wonder whether psychiatrists will rush to use them in view of that. I think we shall see the psychiatrists holding on for a full year before implementing them. However, community care orders may bring compulsory measures and after-care services to the most vulnerable among the currently informal patients, and this may be a bonus.
Finally, Scotland needs an overhaul of all mental health provisions, in the light of increasing community care provision, not just additions and amendments. I look forward to a new mental health Bill for Scotland being introduced.
§ 5.3 p.m.
§ Baroness Seccombe?
My Lords, I thank my noble friend Lady Cumberlege for, as always, spelling out so 956 clearly the proposed legislation. I welcome this Bill. I feel that the proposals provide for the care of people in the best sense of the word. The Bill proposes extra care for the patient who is in need of medical care, and care for the general public who can suffer if the proper supervision is not present.
When my children were small and I was thankful for my good fortune that they had both good mental and physical health, I went with many others on a regular basis on a Saturday afternoon to a nearby hospital, where long-term patients lived. My job was to help in the hospital shop and canteen, providing refreshments to the families who came every week to spend three or four hours with their relatives. I found it a very humbling and worthwhile experience. The dedication and love of these people was demonstrated; some making long and difficult journeys to visit their relatives on a weekly basis. Without any medical knowledge, it appeared to me that marry of the patients were responsible and capable people who could have lived a normal life outside. It was therefore very heartwarming when I heard that more suitable accommodation had been found. The hospital was an old Victorian institution and care in the community, if organised properly, seemed to be a much happier and more sensible answer.
Many of those patients are now living useful lives in independent accommodation but of course there will always be a need for more structured and constant supervision for the few suffering from severe mental illness. We have all read the tragic circumstances of certain recent cases. Although care in the community is working well in the majority of cases, it is essential that for that minority the provisions are strengthened where people have been detained under the Mental Health Act 1983. This minority of people are those who need special and extra support on discharge from hospital.
So I welcome the proposals for supervised discharge. Patients should agree with their carer to a treatment plan. It should be detailed and should specify requirements, if necessary, such as residence and attendances for medical treatment. As everyone who has been ill appreciates, even with general medication the need to continue a course of treatment may still be there after the initial symptoms have been relieved. In the case of mental illness this may be even more vital. Failure to make use of the facilities available can cause many problems, and it is this issue and not only the alleged lack of facilities for mentally ill people which has needed addressing.
In a compassionate society such as ours, it is essential that those suffering from mental illness have access to all the services that they need. For some, that may mean a period as an inpatient in hospital or in receipt of continuing care in the community. Financing the right treatment has been a priority for the NHS, with a 40 per cent, increase in funding. The number of consultant psychiatrists and community health nurses has risen dramatically. Local authorities are also providing places for people with mental illness, to help meet the social rather than the health needs involved. This is very important in the care of an ageing population. There is a perception that the number of beds has decreased over the last decade, but in fact it has been fairly constant at 957 around 80,000. It is the closure of the large institutions, such as the one where I worked, which leads us to that belief. But of course there is now a whole range of options, from the more highly supervised larger units to the smaller homes. I should like to pay tribute to the thousands of volunteers who, with pump priming from the Government, participate in the care of mentally ill people. I refer to the Samaritans and SANE in particular, who have put forward many initiatives in this field.
Finally, I should like to pay tribute to the families of mentally ill people, often suffering themselves from the stress of caring for their sick relatives. I believe that we should all welcome this Bill as it strives to improve the quality of life for the patient while maintaining the confidence of the public that the safety of us all is paramount.
§ 5.8 p.m.
§ The Earl of Longford
My Lords, I am an unrepentant feminist even though I am not always politically correct. I assume that women possess certain qualities not possessed by men, and of course there is the other aspect of that—that men may possess qualities not possessed by women. At any rate, today we have a debate in which the first three speakers, all highly qualified and eloquent, were women and now I find myself speaking between two ladies who are also eloquent and highly qualified; and so I will offer a rather diffident contribution.
I am encouraged by my noble leader in this matter, Lady Jay, who referred to the Matthew Trust report, Victims of Care. I remember that during the war, Mr. Duff Cooper, then Minister of Information, suggested that when people talked in a rather defeatist way, they should be asked: are you a paid or unpaid agent of Hitler? I suppose I might be asked whether I am a paid or unpaid agent for the Matthew Trust in these days when everybody has to declare an interest. I am not a paid or unpaid agent of the Matthew Trust but I am a great admirer of its work and of Peter Thompson, its founder and inspirer, who, as I have said before now, has done more for mental health than anyone I know of in our time.
Perhaps I may dwell for a moment on the report, Victims of Care. No one could read it without realising that there are great deficiencies in our arrangements for the most difficult cases. I do not know whether it is possible to enumerate these cases statistically, but there are a number of our fellow human beings who present difficult problems. I am glad to find that one of the Ministers in the Department of Health has written to Mr. Thompson saying that he found the report thought provoking. I hope that the noble Baroness, Lady Cumberlege, has also found it thought provoking. Reading the report one realises that there are great deficiencies. The question then arises: what do we propose to do about it? People in their different ways, many of them highly expert, have tried to cope with the problem, but it will always remain one of the most difficult in the world with which politicians will have to cope.
958 These people are problems. They are problems for society. The press regard some of them as dangerous. They are problems for those who love them and they are problems for themselves. They must be supervised and helped. Those two problems are at the centre of what the Government are trying to do. When we come to the Committee stage we shall no doubt have a lot of detailed proposals to consider. I am looking at the broad issue in my few remarks today.
On a previous occasion I mentioned someone who was referred to me by the Matthew Trust. He is a young man, now aged 28, who when he was 16 was diagnosed as schizophrenic. Now, 12 years later, he has been in and out of trouble—not very bad trouble but in and out of trouble. He is going to provide a very great problem for all concerned, not least himself.
How do we propose to tackle such problems? Resources are an important part of the solution. I hope that the Government are not committing themselves to the idea that they cannot or will not provide any more resources. The idea that a new and better service can be provided without more resources is absurd.
Perhaps I may offer an analogy from the prison area. I am in touch with someone who, I was told by the Minister with responsibility for prisons, was to be treated in a certain prison. However, he has not yet received any treatment. The excellent governor concerned pointed out that when the prisoner arrived there were 14 other prisoners in the same category arriving on the same day and there was one psychologist to make the initial assessment. Without more resources, nothing of any consequence will happen in this area.
But resources are not everything. With so many experts present I hardly need to say that most of the public do not realise quite how shortsighted it is to say that these mentally ill people ought to make use of the existing services. It is all very well to talk like that. There must be a few noble Lords present—I cannot see any of them today—who have pensioner bus passes.
§ The Earl of Longford
My Lords, there are apparently one or two present. Perhaps some of them— I am sure only one or two—lose their bus passes occasionally, as I am inclined to. In that case I hope that they do not go to the local post office. At my post office, which is a few hundred yards from where I live, one is put through a very awkward cross-examination if one loses one's bus pass. I was told, "We must be sure that you live here where you say, just a few yards down the road. Do you have your passport on you?" I said, "I'm sorry. I don't carry it with me". I was then asked, "What about your birth certificate?" I said, "I don't have that either". The next question was, "Your driving licence, perhaps?" I replied, "I'm sorry. I don't drive". I was told, "Go away and come back when you are better equipped", or words to that effect. Luckily, one can outsmart those people because we have a lovely post office here. Any Peer who knows his way about this building can get a new bus pass by presenting himself at the post office. That is the privilege of Members of the House and of the House of Commons. However, the ordinary mentally ill person, confronted with that kind 959 of treatment, as he is likely to be, will not go near a post office again. Therefore, there must be a lot of extra help—beyond what appears to be duty—if those people are to benefit.
Resources are not everything. Even good intentions are not everything. There must be skill and understanding in those who seek to serve mentally ill people. The Matthew Trust makes a big point of more training. I do not say that there should be more training for all local government officers but social services workers should have more training—perhaps a year's more training—and there should be a much greater number of psychiatric community nurses. Without that kind of provision, throwing money at the problem will not make as much difference as one would wish.
Many other points will be raised by subsequent speakers in the debate. I just want to back up what has been said from our own Front Bench, and said much better than I could wish to say it.
§ 5.16 p.m.
§ Baroness Macleod of Borve
My Lords, we are discussing the lives of the most vulnerable members of our society and a Bill which we hope will be of help to them. I thank the Minister for the way in which she so cogently presented the Bill. To me, it is very complicated. I had looked upon it as going repeatedly over the same point but probably to those who drafted the Bill it was done with expert knowledge. The Minister has helped us on our way.
I thank also the noble Earl, Lord Mar and Kellie, who gave us an insight into what it is to help the people for whom he has been responsible. The noble Earl's name always appears before mine on the list of speakers. Perhaps the typewriter has become stuck. I have followed the noble Earl on the last three occasions I have made speeches on the welfare of other people. Very few people have done more than the noble Earl for the welfare of other people.
Many people, both inside and outside the Chamber, have knowledge of those who have left psychiatric hospitals. We know that it is the after-care which will shape their lives. Today, we are dealing with men and women who have suffered from mental disorders which include schizophrenia, severe mental impairment, psychopathic disorder or mental impairment. I sincerely wish that we could offer much more help to those who suffer from depression. There are far too many people who are homeless and deeply lonely. Such people are often unemployed. They rarely get offers of the care which the Bill envisages for those who have been in hospital. It is estimated that there are 2,000 mentally ill patients in London alone without accommodation. I have the honour of being president of the Cherry Tree Housing Association which helps those who are in Napsbury hospital in Hertfordshire.
We started the association some time ago because we were worried about the welfare of the patients going out into the community. We began a plan which, unfortunately, is very rarely used in the rest of the country. The plan consists of medical and nursing staff who get together and choose six men and women who 960 are expected to like living together. Through our auspices those people are put into a flat within the hospital boundaries. They are able to see their doctor, nursing staff or whoever they want. They are put there for six months to see if they can live together.
People have to be on the verge of going out into the community. After they have spent six months in one of the two flats—there are 12 people at a time involved— we have borrowed, begged and perhaps stolen and had homes built for the same group in some of the 12 boroughs in which we have a catchment area. We now have 18 homes administered by the Cherry Tree Association. The ex-patients who are still on licence live in the homes and go out to work as normal people. They are paid for their work and are therefore able to pay rent for the homes in which they live. Usually one person in the home acts as housekeeper and cook while the others go out to work. It is a home for people who have had no key of their own for very many years.
The scheme has worked amazingly well. I am very proud that the most recent home, built from knocking down two very old houses, was named after me. That is how we have dealt with the matter at Napsbury. Beds are being closed in that area. It is vitally important that beds should be available when needed by any of the people in the homes or those who have gone out into the community. They may have to return at almost a moment's notice. Some of the illnesses from which they suffer can take control again very rapidly and the patient has to be restored to hospital.
Not enough people care for ex-patients. There are not enough people in the community to care. Although we have been told by the Minister that no more money will be needed, I say that it will. We need more people like the noble Earl, Lord Mar and Kellie, who will undertake to look after people who are on the verge of being totally cured of a very serious illness.
Those who go out from the hospital arc lucky if they have relatives to go to. If they have not—we have been told by the noble Baroness, Lady Jay, about the guardians who came into existence after the 1983 Act— I wish that the guardians were more fully used. I have also heard of foster homes where perhaps one ex-nurse will take in, and look after, one patient, very often for the rest of their lives. I know of one case of a schizophrenic who is so much better because she is being looked after by an ex-nurse who sees to her medication.
Two billion pounds is spent on services for the mentally ill —a vast budget. One would have thought that it covered people who work in this field both inside and outside the hospitals. But money is always very difficult to come by. We look to the Minister to help us to come by more for the working of the Bill.
As I have tried to say, it is people in the community who are vital in looking after these ex-patients whether in the voluntary sector, as the noble Baroness, Lady Seccombe, said, or as carers who are very often part of the local authority. They are the people who will care for these patients. We owe them our thanks for all that they do.
961 To my knowledge, which is fairly extensive, but perhaps not as great as that of other noble Lords, voluntary helpers will come forward and help to look after people either inside or outside hospital. I say to the Minister that to my knowledge it is young people between 16 and 22 years of age who will help to look after the psychiatric and mentally disordered patients, more so perhaps than middle-aged people who may believe, "There but for the grace of God go I". I hope that the Bill will do more than has been done in the past for people who have psychiatric disorders.
§ 5.27 p.m.
§ Lord Ennals
My Lords, I believe that the noble Baroness, Lady Macleod, has every reason to be proud that the most recent of these homes has been named after her. The long period of work which she has done in this field is admired by all. It is typical of the tremendous amount of voluntary work that is going on throughout the country in one way or another.
I was ruminating as I heard the noble Baroness, Lady Cumberlege, presenting the Bill and the speech of my noble friend Lady Jay of Paddington. I thought how privileged we are in this House to have two women of such ability to lead us in our debates. But I then had another thought which is not against my former thought. Many noble Lords begin by saying something like, "Ladies and gentlemen"—as one does when making a speech—"I welcome this Bill". I cannot welcome this Bill at all. I would like to do so. If a penny farthing is added to it I would welcome it to the extent of the penny farthing. I believe it is a difficult Bill which will create more problems than it resolves.
I had the honour to be president of the mental health charity MIND. I have been associated with its work for 25 years including four years working on its staff and another four years as its chairman. I have watched its work. MIND is the National Association for Mental Health. I have seen its campaigns and its work for a better life for those diagnosed as being mentally ill. I have seen a great deal of the work of its 240 local associations. It is a major provider of services and, through its information, legal and campaigning work, it promotes respect for the rights and dignity of those who are diagnosed as mentally ill.
When I was Secretary of State for Social Services, having concluded that the 1959 Act was too old and that it needed to be revised, I had the privilege of starting the long process of consultation which, as far as I was concerned, would end in a White Paper putting forward new ideas for a new Mental Health Act. When I then found myself sitting on the wrong side of the House—I am not expecting to sit on the wrong side of the House for very much longer—I later had the privilege of serving on the Special Select Committee which considered the 1983 Mental Health Act. We benefited greatly from the meetings that were held in advance to clear away some of the misunderstandings and to ensure that the committee was more aware of some of the complications of such a Bill than might otherwise have been the case.
962 I believe that experience has shown that those who, in earlier times, might have spent long periods of their lives incarcerated in long-term hospitals can, and do, live full and valuable lives in the community. To that extent, I very much agree with the Minister that the situation has improved. Parts of the country have good community care services, which provide essentials such as crisis services, long-term support and a choice of treatments and where people with mental health difficulties are listened to and are fully involved in the decisions that are taken about their care and treatment. I should like to repeat that because I believe that we simply cannot act on behalf of other people. We should act only following proper consultation with those whose lives are as real as ours and whose views need to be listened to carefully.
It is clear that short-term hospital admission can be avoided, freeing resources to end what the Audit Commission characterised as a "vicious circle" of inadequate community care services, leading to hospital admission. The commission's report shows that, despite the rhetoric of community care, over two-thirds of the spending on mental health is still on hospitals. Community services are inadequately funded—and under the Bill not a penny is provided to help with that.
Together with most organisations that are involved with mental health care, MIND believes that the problem is that there are not enough good community care services of the type that people need and want. In my view, crisis services come at the top of the list. When people are stuck and they do not know where to go or where they will sleep, and when all of a sudden things are crushing them, they need some help. MIND has argued that the Government should set national minimum standards for community care which would prevent the provision of such services being the geographical lottery that it is at the moment. The Government should promote the entitlement of psychiatric patients to the services that they need. I repeat that such patients have an "entitlement".
The Bill does not offer any new resources. It does not place any new duties on authorities to provide essential community care services—nor does it lay down standards of service provision. Instead, it proposes that patients who are discharged into the community can be forced to accept the services that they are offered through health and social services authorities imposing requirements of residence, attendance for medical treatment, work or training, and by giving "supervisors" the power to "take and convey" a patient to their residence, treatment, work or training place. I find the power to "take and convey" a patient from one place to another (when that may well be against his will) to be very intimidating.
MIND fears that the framework proposed in the Bill will undermine the very things that are required for good community care: good therapeutic relationships, trust between patients and carers and, as I have already said, patient involvement in decision-making, and that the coercive measures undermine fundamental human rights. MIND's concerns are shared by organisations such as the Royal College of Nursing, the Community Psychiatric Nurses Association, the Mental After Care 963 Association, the Mental Health Foundation, the Law Society, Liberty, the UK Advocacy Network and Survivors Speak Out.
I have had letters from many psychiatrists—in fact, I have had more letters from psychiatrists than from any other group in the period leading up to this debate— who are now running successful community services and who are worried that the Bill will undermine, if not destroy, the services that they are providing. Perhaps I may give one example. I refer to a letter that I have received from Dr. E. V. Edmunds, who is a consultant psychiatrist in Rugby. The letter states:Over the past five years or so we have developed for Rugby District, which has a population of about 90,000, a mental health service which is community based and involves different disciplines working together. We actively involve both the service users themselves and their carers in planning their treatment and management, and have tried to focus on building a therapeutic and trusting relationship with our service users, some of whom have had a long history of contact with the psychiatric services which have not always been to their satisfaction.I believe this approach has had good results. Some of my patients who have suffered from very severe mental disorders have made good recoveries and have been able to return to full time work and education. A number have returned to complete degree courses and one has completed teacher training and has gained employment".
The letter continues:I am … very concerned that the additional compulsory powers will have the opposite effect from that which is intended"—I stress the use of the word "intended" because I am sure that the Minister does not intend to do otherwise. The letter concludes:and I think that it would be very difficult for me to continue with the style of working that I feel is most effective. It is difficult to build up trusting relationships when the patient/user perceives that all of the power rests with the psychiatrist. I would instead prefer that greater attention should be paid to the provision of community care services which are suited to individual needs and the communities that are served".
I was also interested in the comments made by the Royal College of Nursing, which refers to the Bill as offering,false reassurance to patients and the public".
Those are the words of an organisation which all of us in this House respect including, I am sure, the Minister. It points out that the Bill fails to provide mentally ill people with the full range of services that they need; threatens to offer little more than a method of compelling patients to take harmful neuroleptic medication; fails to provide sufficient resources and training, particularly for community psychiatric nurses, to implement the proposals; and will reinforce existing discrimination in mental health services against patients from minority ethnic communities. We must watch that point carefully.
Indeed, the RCN developed that point later, stating that it,fears that far from addressing discrimination in mental health services against patients from black and minority ethnic communities, the Bill will only serve to reinforce it. Patients from black and minority ethnic groups are already over-represented in the use of Dowers under existing mental health legislation. They are more likely to be treated with neuroleptic drugs and to be given higher doses than white patients. It is likely that 80 per cent, of the new supervision orders will apply to this group of patients and the discrimination will therefore continue".
964 I have another useful quotation from the Mental Health and Disability Sub-Committee of the Law Society for which I have great respect. I spoke at one of its conferences a year or so ago. It says that the Law Society:considers that the case has not been made for more extensive powers of compulsion over people with mental health problems, whether they are being treated in hospital or in the community. In the Committee's view, the existing powers and provisions of the 1983 Act have never been properly used because of insufficient understanding of the extent of those powers, nor fully implemented because of the lack of adequate resources devoted to the care of mentally ill people".
My last quotation comes from the BMA which I know does not always command the Minister's respect. It deals, as did the noble Baroness, Lady Macleod, with guardianship. We must look at that carefully as the Bill proceeds. The BMA said:The Government recognises that there may be scope for extending the use of guardianship and amendments could be made to the provisions on guardianship in the Mental Health Act 1983 to meet the need to tighten up and improve the care provided in the community for severely disordered people".
I shall say no more except to ask the Minister a question. Bearing in mind all the organisations to which I have referred and which have such sharp criticisms of the Bill's contents, when she replies will she tell me with some precision what organisations the Government consulted before they brought the Bill to the House?
§ 5.41 p.m.
§ Lord Mottistone
My Lords, it is always a pleasure to follow the noble Lord, Lord Ennals, although on one point alone I disagree with him, and that is his keen support for MIND. I have found the members of MIND useful and easy to work with out in the country, but the enthusiasm for civil liberties at the centre of MIND does nothing but harm, rather than good, to the cause of mentally ill people. It is sad that that should be so. He made an admirable speech with quotations from all sorts of other people. It is a pity therefore that I find it difficult always to pay the respect that I should to the noble Lord's speeches when he is doing one of his "MIND jobs".
I thank my noble friend the Minister for so clearly introducing what I believe to be a most welcome Bill. It is supported in principle by the National Schizophrenia Fellowship which advises me on these matters, as I expect your Lordships know, and by SANE of which I am chairman. With the excessively rapid reduction in the number of hospital beds for the mentally ill over recent years—I emphasise excessively rapid—there have been several well-publicised cases of persons with schizophrenia who have not had sufficient care in the community—some with disastrous results. We all know of them, and indeed some noble Lords have given examples.
However there have been several cases, not so very different, which have come to my notice from time to time where the people most affected were the sufferer and his or her family. I had a friend in the Navy. He was a close friend in the early days, and I am talking about 55 years ago or more. He was invalided out of the Navy in the late 1950s or early 1960s. He was mentally 965 ill. He lived a satisfactory life during the 1960s, cared for by his family and his GP. In the late 1960s, by which time I had moved away, he had to go to a mental hospital because of something that he did. I really cannot remember what it was. He spent a bit of time there, and was discharged in due course. None of the procedures about which we are talking today was around. To cut a long story short, before long he murdered his second wife. He is now in a mental hospital again. If something like the proposed system had been in existence 30 years ago, it is possible that the lady would have survived. I do not believe, as I think my noble friend Lord Campbell implied, that the legislation is being rushed through. I believe that the legislation is overdue.
Lord Campbell of Croy
My Lords, perhaps my noble friend will give way, because I think he has misunderstood me. I was saying that I was delighted when the Government announced last November that they were going to produce the Bill in this Session. I said that there were disadvantages when preparations had to be made quickly. There was just a short period for consultation. I certainly welcomed the fact that the Bill was coming. Some of the problems that have been raised about organisations outside Parliament have arisen because of the short time in which the Bill has been brought forward. I am certainly not suggesting that it is being rushed.
§ Lord Mottistone
My Lords, I understand what my noble friend is saying. However, it is not something that should be dismissed, because of the difficulties that will unquestionably arise. The National Schizophrenia Fellowship estimates from its long experience that sufferers from schizophrenia will always need a great deal of help if they are to have reasonable lives in the community. About 30 per cent, will need support between lapses, in hospital it is hoped. An additional 50 per cent, will need varying degrees of care indefinitely from their families and statutory bodies. Within that 80 per cent, of schizophrenia sufferers, there will be a small minority—estimated at about 3,000 people —which will reject care or which will never be offered it.
The Bill should be especially helpful to that minority which so often causes most anguish to the public. I hope, however, that the Bill will also provide some better care for the larger number of sufferers.
Although I accept that there might be legal difficulties in adding compulsory medication for mentally ill persons in the community where that is needed, the Bill would be much more useful for the sufferers and the public if a measure of compulsory medication had been included within it. It would also be more helpful and give a clear understanding to health and local authorities of the probable commitments required by the Bill if the explanatory note admitted that, properly implemented, it is bound to cost more and to need more manpower, as most noble Lords have already said.
One other criticism that must be made is that the Bill's wording seems to take particular care to limit the involvement of the nearest relatives. It is true that some schizophrenia sufferers feel passionately, some of the 966 time, that they want their nearest relatives kept off the scene. That can be understood. Relationships may not be good or the resistance may be a symptom of the illness. However, close adoption of the procedures which keep the nearest relatives at bay may mean that some nearest relatives will be kept completely in the dark about what is happening when it would be helpful, if not essential, for them to know more. There is certainly room for amendments to deal with that problem.
With the aid of the National Schizophrenia Fellowship, I shall be spelling out my doubts about the Bill when we have our preliminary discussions on its detail next Wednesday. In that connection, having heard our noble friends from Scotland, I believe that there are significant differences between Parts I and II and, more importantly, between the types of amendment relating to Scotland and those relating to England and Wales. Will my noble and learned friend Lord Fraser consider having two separate preliminary meetings next Wednesday in order to discuss Parts I and II independently? That will allow more time for each subject. I understand that we shall have approximately two hours for discussion. It could be the case that, from the point of view of the Scots, that time could be absorbed by the English and Welsh or vice versa. That would be unfortunate if, in the event, the detail is different. Perhaps my noble and learned friend will consider that proposal and give an indication in his reply tonight.
In the meantime, I hope that your Lordships will give this useful Bill a Second Reading.
§ 5.51 p.m.
§ Lord Desai
My Lords, my noble friend Lady Jay gave the analogy of the Dangerous Dogs Act in respect of which a small number of well publicised problems led to reaction in terms of legislation. I wish to use the analogy of car pollution. We know that only approximately 10 per cent, of cars cause most of the pollution but we feel obliged to legislate for all cars.
My belief about the problem, on which I am not a specialist, is that a few mentally ill patients have been discharged from hospital, perhaps too soon, and pushed from pillar to post—as Mr. Clunis claimed—from one person to another in an unco-ordinated fashion. The problem requires not legislation but a rethinking of the treatment.
It may be, for example, that the problem within the NHS is that since the introduction of care in the community and the purchase of provider arrangements there has been a fragmentation of treatment. I direct the Minister to an article in the latest issue of the Health Services Journal about incentives and mental illness. It points out that among the three main purchasers in the mental illness field —the health authorities, the local authorities and the funded GPs—there are conflicting incentives about what to recommend and what to opt for.
Therefore, it is not surprising that, while health authorities wish to minimise long stay care in hospitals local authorities, when they are landed with the care of someone, must find the resources for it. And not only 967 resources for social workers but for housing and so forth. When someone is put into the care of the community they need not only a social worker but housing. If there is one thing that local authorities are short of it is housing. Therefore, we have not thought through the problem. Only a small number of patients are involved—not more than 10 per cent., as was pointed out by the noble Baroness, Lady Robson. Each person has a unique problem and one must devise a package of treatment for him or her. That package must be co-ordinated and as I look through the Bill I do not see a reference to anyone who will do that. That worries me. It may be the case not that we need more resources but that we need to deploy the existing resources more intelligently and carefully in a more directed fashion in order to produce a package of treatment for those people who require special attention. If there is scope for such amendments to be made, we may increase the effectiveness of the Bill.
Many noble Lords mentioned human rights. Perhaps I may re-emphasise what was said by my noble friend Lord Ennals. Many patients from ethnic minorities, in particular the Afro-Caribbean, are disproportionately represented among the mentally ill. There is a problem and it may be that classification in a certain category is thought by the patient to be not a medical judgment but a judgment biased by racism. That may not be the case but conflict might arise.
In such a case, the person has a right to refuse medication. It may be said that the person is right and the doctor is wrong, but there has been a great deal of controversy in this area. A great deal of literature has been published about schizophrenia and people disagree about its nature, symptoms, causes and cures. There is no single philosophy and no single belief about the medication that should be used. It is likely that the patient, or someone related to the patient, may object to medication and may have good grounds to do so. In that case, we must look most carefully at the problem of forced medication.
In that respect, I wish to comment about the problem of language. Many people of ethnic minorities may not know English sufficiently well to be able to articulate their objections or desires, let alone the fact that they have religious objections to certain kinds of medication. All those problems must be considered carefully when we deal with the issue of civil liberties.
There is a problem but I am not sure that this Bill is the solution. However, if we identify the problem we might, with a great deal of goodwill and consultation, be able to find a solution which is similar to these proposals but not exactly these.
§ 5.57 p.m.
My Lords, I too thank my noble friend Lady Cumberlege for introducing the Bill so clearly. The debate has been most interesting and the noble Lord, Lord Desai, made some valuable and interesting points. Ideas have moved on since we debated these matters in 1989. Those debates took place in a non-party-political atmosphere. All noble Lords on all 968 sides of the House want the Bill to set out as clear a programme as possible to enable authorities to carry out the provisions.
The Bill addresses the difficult issue of discharge from hospital and, where necessary, the return to hospital. I support the Bill because it will increase the possibility of the mentally ill leading a reasonably normal life in the world outside. Many people will continue to suffer for the rest of their lives but, given supervised after-care and proper medical treatment, there will be less chance of their having to return to hospital and having to endure appalling suffering in loneliness and squalor.
I feel diffident about entering into discussions about the advantages and disadvantages of the detailed proposals. I do so, perhaps, having a relative who suffered from schizophrenia but who has been successfully treated. I know that many people in the medical world, supported by people such as the noble Lord, Lord Ennals, who know what they are talking about, are lukewarm about the Bill.
The serious need for after-care supervision concerns a relatively small number of vulnerable patients, many of whom have bad home lives and many of whom are so ill that they cannot cope with the smallest problem. It is in those situations, where patients are being released into the community, that there is a special requirement for social workers, and in such situations more psychiatric care and medical help is needed to administer medicines and offer counselling.
It is among that section of the community that there are patients who may be a danger either to themselves or to others. Those cases present grave anxieties to relatives and friends. Their difficulties can be overcome only by generous spending and good co-operation between the Departments of Health and the Environment and local authorities, in particular as regards the provision of accommodation.
A recent report commissioned by the Department of Health stated that there are an estimated 2,000 mentally ill people in London alone without any accommodation. In the words of a member of the City and Hackney Community Services:There are large numbers of people with high care needs who cannot just be put in flats or bed and breakfasts—they need someone to drop in or be around all the time".
To keep down the costs of looking after the mentally ill in the community would be counter-productive. If the authorities are starved of funds, there will be a danger of regression and rehospitalisation. I ask the Minister who is to reply whether the statement in the Explanatory and Financial Memorandum that the Bill will mean no additional costs for health or local authorities is made in the context of financial savings made through the closure of hospitals.
There is a danger that with inadequate community care resources, the money will be targeted on the individuals who have previously been detained in hospital. That course may be at the expense of other severely ill people who have been voluntary patients who do not need orders, but who need community support.
969 The Bill will give health authorities, medical practitioners and psychiatric nurses greater control over patients. I speak with a little experience of those matters and I believe that much depends on the trust which a patient has in the doctor. Only gradually do patients grow to accept and come to terms with their illness. Where there is greater insight, surely there will be a greater keenness to take medicine. I do not mean to imply that on some occasions it may be necessary to enforce the taking of medication.
Concern has been expressed about the powers given to supervisors south of the Border. Those powers are not given to their Scottish equivalent—the after-care officers—as regards taking and conveying a patient. In Scotland a special medical officer may, with the consent of the patient's after-care officer, direct the patient to attend. In either case, there is an element of compulsion and I believe that there are occasions when that may be needed.
Much will depend on close co-operation and consultation between the patient and the psychiatrist concerned. There must be a system to enable a patient to go back to hospital for short periods when necessary. A flexible approach is vital. In many cases, a successful improvement will depend on the quality of the home where members of a family are involved in congenial surroundings.
I support what my noble friend Lord Mottistone said about the need for family involvement. I support also what he said on the subject of medication.
Some of your Lordships are concerned about the lack of powers to treat. The Bill should spell out that the psychiatric nurse or other professional should have the right to say to the patient that he must take the medicine prescribed. There is a hollow ring in the words that he cannot be required to take medication. Those words remove the main purpose of the Bill. Should recall to a hospital be necessary, there will be a need for swift action. In Scotland there is a question as to how long the process of reassessment will take. There is uncertainty as to who initiates the reassessment. On that point, the Bill is far from definite. It contains only a somewhat vague mention of those who are concerned with the patient's medical treatment.
My noble friend Lord Campbell of Croy and the noble Earl, Lord Mar and Kellie, have referred to Scotland. In many ways community care orders fall into line with current Scottish regulations, but under the new proposals the present Scottish system of discharge on a more or less permanent basis monitored by the Mental Health Commission will be changed.
The Bill restricts the period of leave of absence so that there will now be an indefinite threat of return to hospital. That is not in the interests of the morale of patients who, until now, have been given the freedom to continue their treatments under minimum duress. As my noble friend said, the National Schizophrenia Fellowship (Scotland) has expressed opposition to that part of the Bill because it curtails a valuable long-term option that has been widely used in Scotland and which has allowed patients to live successfully in the community.
970 The community care orders should be backed up by a greater awareness of psychiatry among GPs and the local police who may be required to face dangerous situations. Much depends on the availability of expertise in local communities to meet emergencies. Doctor Finlay was no doubt adequate in his day, but in these complex times, a quick, expert response may be needed.
The Bill may not do all that is needed but it points in the right direction. With proper funding, I believe that it will help to resolve some of the difficulties which have arisen in relation to care of the mentally ill.
§ 6.6 p.m.
§ Lord Milverton
My Lords, this has been a very interesting debate. I am grateful to the Minister for her clear explanation of the Bill. In this Bill, the Government are being practical in a very good and sensible way, as they have been with other legislation concerned with health. They have realised the weaknesses which have emerged since the introduction of that very worthwhile principle of community care. They have seen the missing pieces and the breaks that there have been, which have meant that the high hopes for community care have not been realised.
I realise that it is important to have mental patients brought back into the community. When I was at theological college, the principal thought that it would be a good idea to take us students to a hospital where there were mental patients. I can well remember how it really shocked me. It made me think. Other students told me that I turned pale and they thought that I was going to pass out.
In my first living, I remember visiting a parishioner who had to go to a mental hospital as a patient. That made me realise the need for improved care and how many ordinary lay people needed help in order to help them. Even a priest needs that help.
As my noble friend Lady Macleod said—and I firmly believe this—people in the community need to be helped so that they can help the professionals, the carers and the wonderful voluntary workers who have the necessary experience and understanding. I know that I need help to help those people. That may sound odd coming from a priest who is trying to help all the time. However, those people need specific help. Indeed, because one is a priest it does not mean—Hey presto!— one has the ability to help in the way that one would like in all situations. I believe that to be important.
As I am sure is the case with most noble Lords, I can remember being in the community and seeing mental patients who had been sent back into the community. I refer to people who are, somehow or other, ill in that way. One notices that some people seem afraid and shy about having to be in their presence. Yes, we need help to assist professionals and others.
In fact, I can remember my father-in-law who, bless him, died some years ago. He was not at all well during his last years. I can recall when my wife Mary and myself took him out and when he came to see us at the rectory. However, I remember especially taking him to a tea place in Corsham which was near my parishes. It stuck in our minds—and indeed, it still does—how the 971 manager of that place rather frowned upon us and my father-in-law because, well, one could see that he was ill. That is quite wrong.
There are people in the community who need to be helped in that respect. Of course, there are those to whom helping comes naturally, but there are also others who find it awkward and who are rather shy about such matters and need to be helped. As one speaker said, invariably it is the young who can lead; indeed, they are marvellous in every way and in all things. They can, perhaps, give the lead to others. I remember asking some young people in one parish whether they would visit some old people. Those people were not mentally ill, but they were old and more or less housebound. The response was, "Yes".
I cannot agree with the noble Lord, Lord Ennals. Like my noble friend Lord Mottistone, if it is decided that a mental patient should be returned to hospital for some further treatment, I cannot see how the Bill in any way infringes that person's liberty. I believe that we are really going mad about the word "liberty" in every way. The Bill is aimed at trying to help such people. If one is trying to help someone, does that mean that you are taking away that person's liberty? Indeed, that is crazy because one could more or less say that about anything being done for someone. One can always say that his or her liberty is being taken away. I do not understand that point of view. If we have the welfare and care of such people in mind, as, I believe, the Bill has, one is not taking such liberty away. One is simply trying to help. If it means that such people need to go back to hospital, how can one say that their liberty is lost?
The noble Lord, Lord Desai, spoke about discrimination. I also find that argument difficult to understand. If some ethnic person cannot understand English very well, can it be said that the Bill is in some way discriminatory? I still find that hard to believe. In the practical sense, I believe that the Government have been bold enough to realise that there were some deficiencies in the community care programme and that such deficiencies needed to be put right. Is that wrong? No, of course it is not. Too many people in this world are afraid to acknowledge that, in their great principles and theories, which were put into effect, were some things that they did not foresee. One of the weaknesses in the present world is not being able to face such facts.
On the whole, I believe that the Bill is good groundwork for great improvement. I do not believe that the proposals have been irrationally thought through; indeed, I believe that great care and attention has been given to the legislation. I hope that the Bill will have a blessed way and that it will be accepted. No doubt some people will want to make amendments to it; but let those amendments be good, and good enough to improve the legislation and be part of the Bill.
I believe that Her Majesty's Government can be praised. I do not believe that they have brought the legislation forward in any hurried or ill thought out way. Indeed, perhaps I should try to make amends in that respect. I do not believe that the Government have acted in that way. They wanted to improve and make even better what basically has been, was, and is very good in the whole field of the National Health Service. As a 972 priest who visited hospitals and so on, one saw just that. But that does not mean that one did not think that there could be improvements. I hope that the Bill has a good passage through the House.
§ 6.16 p.m.
§ Lord Rea
My Lords, the role of a "winder-up" should be to gather up and emphasise the points in the debate which back up his case and, perhaps, to counter those which detract from it. There has hardly been a speech this afternoon which has not made a valid point on one side or the other. My overall impression is that the majority of noble Lords agree with our view that the Bill is only really a stopgap or, rather more crudely, a rather sluggish response to several recent tragic occurrences. At best, it is of marginal value and at worst it is a backward step which may be counter-productive or discriminatory. Above all, many speakers have said that other measures need to be taken to improve the care of the mentally ill in the community to diminish the likelihood of further tragic cases, that the current mental Health Act 1983, if properly used, could well serve the purposes of the present Bill and that the latter is probably unnecessary.
The other improvements which are required in community care will have financial cost implications which, according to the face of the Bill, this legislation will not have. Like my noble friend, I find that most extraordinary. If the Bill works, it surely must have cost implications. Alternatively, if it does not have cost implications and is much used, then other patients will suffer as the noble Earl, Lord Mar and Kellie, said.
I believe that all of us in this House accept—indeed, even the National Schizophrenia Fellowship does so— that, if properly resourced and administered, community care of all but the most acutely disturbed and mentally-ill patients is a humane and constructive policy. But, as so many speakers have said, the system is not working well—certainly not in inner-cities in England and Wales. I am not so sure about Scotland. In fact, I am not even sure whether the Bill is necessary in Scotland because I believe things are working better there.
In inner cities community care has been getting worse, not better, since the National Health Service and Community Care Act of 1991. Pressure on resources in the community in the inner cities, whether run by social services or community health providers, has been greatly increased recently. A contribution to this has been the diminishing number of acute psychiatric in-patient beds and also lack of emergency centres which now hardly exist at all, as my noble friend Lord Ennals pointed out. So great is the shortage that in some mental hospitals bed occupancy has reached 200 per cent. That does not mean to say that there is double the proper number of patients in those wards but, with a full ward, doctors have had to refuse admission to the equivalent of another "wardfull" of acutely ill patients and have directed them elsewhere. One result is that there is a growth industry in private psychiatric hospitals on the periphery of London and, I imagine, other cities too.
973 If there is great pressure on beds, then, as so many psychiatrist colleagues have told me—including Professor Anthony Clare—the mental health threshold for deciding when a patient is fit to be discharged is lowered, and unstable people are sent into the community often before adequate arrangements for follow-up have been made. Theoretically the supervision orders created by this Bill should ensure that these arrangements will be made, but I am concerned that the procedure may be too bureaucratic to be used often and that the resources in the community required to fulfil the supervision orders will not be strengthened at all by the Bill.
My noble friend and other noble Lords have pointed out that guardianship orders are similar in effect to the proposed orders in the Bill. They are available under the current Act, but have not been used very often for mentally disturbed patients. Social services play a central role in guardianship orders but they have often been reluctant to use them partly because of lack of resources but also, it should be added, because of a lack of power in guardianship orders to require treatment. That is also a feature of the current order in this Bill.
Compulsory medical treatment is a sensitive area. Ideally medical treatment should not imply medication alone but a whole programme of rehabilitation, occupational therapy, housing and financial assistance, in the way that MIND calls for, as has been described by my noble friend Lord Ennals. As he has also pointed out, those measures have been called for by a whole range of other organisations in the community.
I return to guardianship. Sir Louis Blom-Cooper and his fellow committee of inquiry members in The Falling Shadow—that title is taken from T.S. Eliot's poem "The Hollow Men"—describe the background of the Robinson case in Torbay where an occupational therapist, Georgina Robinson (no relation) was murdered. This report describes a period when Andrew Robinson—the schizophrenic in the case—was under a guardianship order. Although a guardianship order cannot compel treatment against a patient's will, any more than the current Bill can, Andrew Robinson agreed to medication during the period of the guardianship, even though there was no compulsion to do so. After the guardianship order, and the containment it offered, was lifted, his medical treatment became less adequate and eventually lapsed with a severe deterioration in his condition. His father wrote a letter to the nurse involved in the case, asking for him to come. That was four months after the guardianship order had finished. On 8th March 1993 the Reverend Peter Robinson wrote to John Camus, the nurse, stating,I am sure you are aware that, since ceasing to take medication last November, Andrew has become very unwell, and, as always when he refuses medication, we know (from 16 yean experience!) that it can only end in some disaster. We feel as though we are sitting waiting for a time-bomb to go off!
It was three months before Andrew was admitted to hospital and it was three months after that that he deteriorated so much that he did not respond to treatment and the murder occurred.
974 In summary, we think that Clause 1 of the Bill adds a bureaucratic procedure to the 1983 Act whose effect could have been achieved very much more simply by strengthening the existing provisions for guardianship. This has the advantage that a guardianship order can be made while the patient is still in the community and is not restricted to those about to be discharged from hospital, as this Bill requires. We have no great quarrels with Clauses 2 and 3 which tighten the provisions for absence without leave and prolong leave of absence. But, again, I believe that there are resource implications there which are not addressed.
In a well informed brief the Scottish Association for Mental Health stated its concerns. These are not too different from those of many English bodies and point to deficiencies in mental health services which are not being addressed by the present Bill, in particular the lack of co-operation and communication between different agencies and the,need for a known member of staff to keep contact with the patient".
Like 'Sir Louis Blom-Cooper in The Falling Shadow, the association suggests that in Scotland, as well as in England and Wales, the time may have come to consider whether the current Mental Health Act, which sees hospitals as the main centres for treatment of seriously ill people, should be replaced by a new Act which recognises that more and more people are, and will continue to be, treated in the community. The current 1983 Act was seven years in gestation. The next Act may not take so long to develop but I suggest that the time is now overdue for the Government to initiate moves towards a new community-based mental health Act so that in a year or so, when we are sitting on the other side of the House, some groundwork will already have been done.
While I am full of admiration for the quality of the two recent reports based on inquiries into particular tragic cases, they are really a form of worst case analysis. What is needed before the legislation is changed is soundly and widely based research on the working of the present Act. The Government should initiate such a research programme as a matter of urgency.
We have, however, got this Bill in front of us. The noble Lord, Lord Milverton, has said that undoubtedly there will be amendments. There will be amendments, and they will be good amendments for a not very good Bill. We hope that they will make it better.
§ 6.28 p.m.
The Minister of State, Scottish Office (Lord Eraser of Carmyllie)
My Lords, I am indebted to all those who have contributed to this important debate on this Bill this afternoon. Some of those who have spoken have revealed that they have, possibly, rather unfortunate circumstances and intimate personal knowledge of some of the problems that can arise with the mentally ill. Others, such as my noble friends Lady Macleod and Lady Seccombe, have revealed their intense effort in the voluntary organisations supporting those who are mentally ill. There have also been valuable contributions by those who have spoken for a 975 number of highly respected organisations dealing with the mentally ill, not only this side of the Border but also in Scotland.
I believe that it would be fair, with one honourable exception, to characterise the views expressed today as welcoming the Bill although clearly a number of detailed reservations were expressed which will undoubtedly be explored as we move to the Committee stage of the Bill. However, I say to the noble Baroness, Lady Jay, that to characterise the introduction of the Bill as a reaction to tabloid opinion was unfair, particularly as my noble friend who opened the debate indicated that the report of the Royal College of Psychiatrists in 1993, with its suggestion of community supervision orders, was an important precursor to what we have introduced.
There were some questions about whether the Bill was welcomed beyond your Lordships' House. It has been broadly welcomed and the public believe it to be appropriate. A number of professional organisations, not least the British Medical Association, have written to the Secretary of State welcoming the Bill while, I accept, at the same time adding the reservations expressed by the noble Lord, Lord Rea, and others that it may be desirable to have a broader review of the mental health legislation.
§ Lord Ennals
My Lords, I am grateful to the Minister for giving way. I asked specifically that the Government should tell us, in view of the number of organisations that I listed which I know have strong and fundamental criticisms of the legislation, which organisations were consulted in the preparation of the Bill.
§ Lord Fraser of Carmyllie
My Lords, there was an extensive list. I have just given an example. I am reluctant to try to pick out one organisation and say that it offered wholesale or fulsome support. As I said, the BMA welcomed the Bill but qualified that welcome by saying that it would like to see a further review of mental health legislation. It is difficult to separate those organisations as he would like me to, but a full range of professional bodies and voluntary organisations concerned with mental health issues and patient organisations were consulted.
§ Lord Ennals
My Lords, will the noble and learned Lord write to me and place a copy in the Library?
§ Lord Fraser of Carmyllie
My Lords, if the noble Lord wishes I shall try to draw together a list of those who were consulted. However, one cannot assume that their reactions to what is provided for in the Bill fall clearly into categories of either black or white.
One area of reservation was whether there were sufficient resources for the care of those who are mentally ill. Health authority spending on mental illness services has increased by some 40 per cent, since 1979. Local authority spending has increased by some 171 per cent., and the mental illness specific grant supporting local authority expenditure will be £66 million in the year 1995–96, with the Government committed to continuing that grant through to the end of 1997–98. That funding has supported something like 1,000 new projects helping about 100,000 mentally ill people. Without wishing to appear boastful, in Scotland in the 976 next year we shall spend approximately £18 million in the same grant form on 300 projects supporting something like 30,000 mentally ill people. Furthermore, an important feature is that community psychiatric nurses have increased in number approximately fourfold in the past 12 years.
There are undoubtedly pressures and costs in the care of the mentally ill. However, with the exception of what I shall have to say about tribunals in answer to a question from the noble Baroness, Lady Robson, we do not believe that there will be a significant extra cost. There should not be. One of the important features of the legislation which possibly has not come out as clearly as it might, is that psychiatrists have indicated that they would like to see what is done already in an informal way given a legal framework. One of the features of the Bill is to provide just that.
The noble Earl, Lord Longford, was concerned that there might be a gap in care. I acknowledge that services do not reach all those who need them. That is not entirely' a failure of the services because, as has been indicated in the course of the debate, a number of those who are mentally ill are very reluctant to accept help. We believe and hope that the new supervision arrangements will go some way to help them because it will be more difficult for them to lose touch with the services that are being provided.
As regards the training of key workers, in firmly standing by a care programme approach we have included a commitment to improve the training of key workers in their duties under that approach in the 10-point plan. A number of specific initiatives aimed at both NHS and social services staff are already under way.
In the same area of resources I was asked by the noble Lord, Lord Thurlow, whether there were enough acute beds. Leaving aside London, there is no evidence to suggest that there is a general shortage of acute beds. The pressures in London are acknowledged. However, the recent report to which the noble Lord referred found that those could often be alleviated by increasing community provision or improved bed management strategies. The task force identified the need for more acute beds in a few inner London districts. Those district health authorities have agreed action plans to bring about the required increase in provision.
Similarly, in answer to my noble friend Lady Macleod, it is fully accepted that it is important to have in-patient beds readily available in a crisis. It is important that there should be proper integration between hospital and community services. That again was emphasised in the report which I have just mentioned. Action plans are now in force to increase the number of acute beds.
I can tell my noble friend Lord Haig that the importance of suitable housing is emphasised in that report. At present the Department of Health is considering with the Department of the Environment the action that is needed to ensure that local authorities fulfil their responsibilities for housing the mentally ill and others with special needs.
977 More generally, the noble Lord, Lord Desai, asked whether we really need this legislation. The short answer to that question is yes. Fundamental and identifiable action is needed to allay a degree of public concern and to provide the proper legal framework to support patients and to guide professionals.
However,—and I was interested that the noble Baroness, Lady Jay, focused on this point—we would not wish to introduce a set of arrangements which, because they necessarily contained within them a degree of coercion or compulsion would thereby damage therapeutic relationships. That would clearly be very unsatisfactory. Ultimately, the effectiveness of the treatment and care given under the provisions of the Bill will depend on the co-operation of the patient. That is why the principle of consulting the patient is so firmly enshrined. We believe that with the patients whose needs the Bill addresses a measure of legal backing is nevertheless justified, but we do not see that as undermining the principle that treatment relies primarily on co-operation. We would certainly not wish to damage that relationship.
Nor, I can tell my noble friend Lord Mottistone, would we wish to see relationships with patients' nearest relatives harmed. We would certainly wish to see them involved, but my noble friend will appreciate that if we are to deal with individuals appropriately their agreement should be secured before their relatives are informed unless the nearest relative is also recognised as the patient's informal carer on a day-to-day basis.
The noble Baroness, Lady Jay, asked whether the supervisor would normally be a social worker. The answer is that that supervisor may well be a social worker. But we think it more likely in fact that he or she will be a community mental health nurse. Most key workers in the care programme approach are such nurses. We anticipate that that would be the position.
§ Baroness Jay of Paddington
My Lords, I thank the Minister for giving way. I am grateful to him for expanding on that point. I am grateful, too, that he mentioned earlier that there would be extra training for such people. Obviously if community psychiatric nurses are to take that responsibility, they may well need that training. But how will that be achieved within the provisions of the Bill which state that there will be no further expenditure?
§ Lord Fraser of Carmyllie
My Lords, in the 10 point plan approach that we have already undertaken I indicated that emphasis has been given to that factor. I hope that I used the present and past tenses. A number of initiatives have been or are already being taken notwithstanding the fact that the Bill has not yet reached the statute book.
The noble Baroness was also concerned that the supervisor should not be a scapegoat for any errors. An important factor is that there is a well-established principle that the delivery of the patient's care plan may be the responsibility of a named individual, but that individual works as part of a team. The individual should know the limits within which the authority is to 978 be operated. There should be agreed procedures for consulting other members of the team where any specific difficulties arise.
In contrast to a number of the observations made about England and Wales, some concern was expressed about existing arrangements in Scotland. I refer to an arrangement of leave of absence from hospital without end. It was believed that we should simply leave that arrangement in place because it was working well. It would be fair to say that, generally speaking, the arrangement has worked well. However, proper concern has been expressed that we should ensure that what is undertaken in relation to the mentally ill should be beyond legal challenge. As I recall, in opening my noble friend indicated that we have been made aware from a decision in the Scottish courts that to allow leave of absence without end is ultimately illogical and threatens to be opened up to legal challenge.
So far as concerns Scotland, we have restricted the provision to 12 months. By the same token, to ensure that we. march in step in England the period has been extended from six months to 12 months. That would seem about right so far as we can best judge.
A theme that also ran through the contributions—my noble friends Lord Mottistone and Lord Haig raised the issue—related to compulsory medication. It is a matter which raises real issues. Civil liberty arguments have to be addressed. Difficult practical issues on administering compulsory medication in the community to an unco-operative patient have to be addressed. The issue is unlikely to command widespread support in your Lordships' House or in another place, or among professionals. Within Scotland there will be some opportunity for compulsory medication, not in the community but in circumstances where the condition of the individual has so deteriorated that it is considered appropriate to take that individual back to hospital for reassessment. Within the clinical context of the hospital reassessment, such compulsory medication would be permitted. We may return to that matter during later stages of the Bill. But beyond that we do not consider that we can go any further, nor indeed that we should.
The noble Baroness, Lady Robson, raised the issue of the pressure on mental health review tribunals. It is anticipated that there would indeed be additional costs, not only in respect of the tribunals but also in respect of legal aid for those patients, and those extra legal costs would indeed be met.
It has been difficult to attempt to strike a balance. My noble friend Lord Campbell properly emphasised that we have to weigh up the issues regarding human rights and civil liberties of the individual with a mental disorder. At the same time, we cannot lose sight of the rights and liberties of the members of the public to whom we also have a duty. So far as possible, we should seek to keep any danger to the public at large to an absolute minimum. But we wish to maintain the civil liberties of the patients with mental illnesses as best we can. We trust that what we have allowed for in the Bill strikes an appropriate balance. I am grateful to those who have indicated that they believe that we have achieved that balance, although they may have individual points of concern.
979 We were asked whether we could not simply rely instead on the existing arrangements of guardianship which are to be found on both sides of the Border. As has been rightly pointed out, recently the Law Commission on this side of the Border has reported. We do not consider it appropriate to approach individuals with mental illnesses simply on the basis of guardianship. Guardianship is essentially an arrangement which is oriented towards social care. I believe that these sets of provisions, whether they apply in England, Wales or Scotland, are based separately: they are centred upon the health service; they are rooted in a care programme approach. A separate identifiable, health-led provision is made. I believe that that is the right way to approach the matter. We are not persuaded that simply by adding a power to convey—I believe that it is accepted that it would be necessary in any event if guardianship were relied upon—would be an acceptable way forward.
Beyond the specific contributions made, there was a further and wider debate; namely, whether we should be undertaking a fundamental review of our mental health legislation, applying whichever jurisdiction. I wish to conclude by acknowledging the case for considering whether the Acts still reflect current practice. But there is no clear evidence at present, I believe, to conclude that they fail to meet present day needs or that there is as yet any emerging consensus about how the position might be changed. Our view is that we wish to take stock of the new powers that we propose should be introduced in the Bill before considering any further fundamental changes. However, as has been pointed out more than once, it is recognised that there are, and will continue to be, changes with more and more people appropriately being treated within the community.
If I have failed to answer all the detailed points, I hope that I may be forgiven. This seems to me to be a Bill which is particularly suited to the consideration that your Lordships will undoubtedly give it. There is a great deal of detail to be carefully considered. I have no doubt that we shall be able to do so at later stages.
I was asked whether I was prepared to consider having an additional informal meeting along the lines of that which my noble friend will conduct next week. While I certainly do not rule it out, I suggest that we might take the issue forward at that meeting. If at the end of the meeting there are specific Scottish issues of interest only to Scots, we might consider doing that as a separate exercise.
I thank noble Lords for all the contributions made at this Second Reading debate. I look forward to participating with your Lordships at Committee stage.
§ On Question, Bill read a second time, and committed to a Committee of the Whole House.