HL Deb 20 February 1996 vol 569 cc991-1004

4.9 p.m.

The Parliamentary Under-Secretary of State, Department of Health (Baroness Cumberlege)

My Lords, with permission I wish to repeat a Statement on mental health services.

"With permission, Madam Speaker, I wish to make a Statement about the future of mental health services.

"On 24th August last year, my honourable friend the Minister for Health wrote to health authority chairmen informing them that I had asked the regional directors of the NHS to review the progress being made in their regions, towards the delivery of modern and effective mental health services. I am today publishing the conclusions of that process, and I am announcing the further steps which the Government intend to take to deliver their commitment to a comprehensive, high quality mental health service.

"The background to these developments is familiar to the House. Over the last 40 years, in this and every other developed country, health and social service authorities have been replacing asylum based care with a broad spectrum of facilities which are better able to meet the needs of the individual person suffering from a mental illness. At its best, a modern mental health service represents a dramatic improvement in the quality of care available to its patients.

"Too often however the reality has not matched up to the potential. That is why we decided last June to make the improvement of mental health services a key medium-term priority for the NHS and it is why I initiated the review process last August.

"Today's report of that review confirms that every health authority now has in place plans which commit it to deliver a comprehensive mental health service. Sixty-eight health authorities have demonstrated that this objective will be achieved during the next financial year; the remaining 33 authorities have plans to deliver a comprehensive service which will take longer to complete. The review shows that health authorities are planning to increase the resources committed to mental health services next year by £53 million. Regional directors will continue to monitor the delivery of these plans at local level.

"It is important to be clear about the objective. The phrase "care in the community" has too often been taken to mean the abandonment of residential care for mentally ill people. That is not, and never has been, our policy. That is why I am today publishing a document entitled The Spectrum of Care which sets out in clear language the range of services which constitute a modern mental health service.

"It restates our commitment to provide treatment at home for those patients for whom that is the right answer. For this group there needs to be a range of services provided by the NHS and local authority social services departments, very often in partnership with local authority housing departments.

"The document also sets out the range of other facilities that are needed to complete the required spectrum of care: day hospitals and day centres: to provide for those who need care during the day; access to out of hours specialist services and crisis accommodation: to meet short-term crisis need; acute hospital beds: to meet the needs of those with acute mental health problems; 24-hour nursed residential places: to meet the long-term residential needs of those with severe and enduring mental illness.

"All of these facilities are needed together with a range of secure units for those who need treatment in a secure environment. Today's document makes clear the Government's commitment to deliver not simply care in the community, but the full spectrum of care required for a comprehensive modern mental health service.

"Along with this overview of the full spectrum of care, I am also publishing a report commissioned by my department on 24-hour nursed care. The report states that there is accumulating evidence of a need for residential nursing care, for a relatively small group of so-called new long-stay clients. The Government accept that facilities of this kind do have a valuable role to play in the spectrum of care, and it will look to health authorities to ensure that their plans for the future provide for this need to be met.

"Although it is understandable that much of the comment about the state of mental health services concentrates on the pattern of service provision, a crucial requirement is that there is effective collaboration between the wide range of agencies that contribute to an individual's care. That is why the Government are committed to the full implementation from 1st April of this year of the Care Programme Approach. This requires the preparation for each patient under the specialist services of a plan of care based on an assessment of their needs, which names a key worker to be responsible for ensuring that this care is delivered.

"The NHS is under an obligation from next year to audit the successful delivery of this approach. I am today publishing an audit pack designed to assist with this process. It has been developed by the NHS Executive with the Royal College of Psychiatrists and constitutes an important reinforcement of our commitment to quality in these services.

"A further reinforcement of quality is provided by the Government's decision to introduce a patient's charter on mental health. A charter does not, of course, by itself improve standards. It does, however, state clearly the standards which the individual patient can expect to receive from the statutory services, and it therefore constitutes a bench-mark by which the quality of the service can be judged.

"I am today publishing a draft charter and I am asking for comments by 26th April. The draft charter proposes standards for timely access to specialist services. It sets out the entitlement of a mentally ill person to have their illness explained; to have the effects of medication explained to them; and to be given information about advocacy and support groups, together with information about what to do in an emergency. It also establishes that a patient who needs continuing care outside hospital will not be discharged from hospital until appropriate arrangements, including a care programme, have been put in place.

"There has recently been disquiet about the arrangements which allow hospital managers to discharge patients from detention under the Mental Health Act, possibly against the advice of their responsible medical officer. It is clearly essential that a detained patient must have the right to have their case reviewed. The Mental Health Act provides for mental health review tribunals for this purpose. The powers of the managers operate in parallel with those of tribunals, to allow more informal consideration of individual cases. The operation of this system is currently being considered by the Royal College of Psychiatrists and the National Association of Health Authorities and Trusts with the Mental Health Act Commission. We expect to receive their advice in the spring of this year and the Government will reach a conclusion on the basis of that advice.

"Finally, I come to the question of money. This Government are firmly wedded to the provision of sufficient resources to allow the continued improvement of our mental health services. In December I announced the creation of a Mental Health Challenge Fund within the NHS, and I am today publishing the detailed criteria for applications to this fund. The fund will deliver £20 million worth of improvements and development in addition to the £53 million of growth money which health authorities already intend to spend on mental health next year.

"In December I also announced an increase of £11 million in the mental illness specific grant for 1996–97, and a further £9 million for 1997–98 subject to parliamentary approval. Of this £20 million, £4.5 million will provide for a 10 per cent. increase in the existing specific grant programme; £2 million will virtually double the provision for the homeless mentally ill initiative; and the remaining £13.5 million will be committed to a target fund to assist those local authorities working in areas where the strains on the mental health services are greatest. I have written today to the local authority associations inviting them to join us in drawing up the detailed criteria for the schemes.

"The combination of an extra £20 million through the mental illness specific grant; and extra £20 million through the NHS Challenge Fund; £53 million from health authorities' own plans; and a contribution of at least £2 million from local authorities' own resources will bring the total of growth money for the mental health services under this programme to over £95 million. Our National Health Service has made great strides in improving mental healthcare. I pay tribute to all those working in health and social services who have achieved so much for mentally ill people. We are committed to supporting them, to securing the best standards for users and carers, and to providing a service of which the public can be proud. The measures I have announced today constitute a substantial contribution to the progress we need to make. I commend them to the House".

My Lords, that concludes the Statement.

4.18 p.m.

Baroness Jay of Paddington

My Lords, I thank the Minister warmly for repeating the Statement made in another place. It is an important Statement, not least because the Government are acknowledging that community care for the mentally ill is failing, as we on these Benches have been saying for some time. There are growing numbers of mentally ill people in the country and their care is causing great anxiety to the professional and informal carers who try to look after them; anxiety to ordinary citizens who are disturbed and sometimes threatened by the presence of seriously ill people in their midst; and, above all, anxiety to the patients themselves, who often feel isolated and bereft of support and treatment.

Today it is sadly all too common to see mentally ill people apparently aimlessly wandering our streets. Their present plight arises from a failure to develop proper community care services to substitute for old-fashioned long-stay residential institutions. As the Statement rightly says, too often the reality has not matched up to the potential. Too many psychiatric beds in hospitals have been closed too quickly. Nearly half have been cut since 1980, and patients have been discharged to fend for themselves without adequate support. The modest package of proposals announced in the Statement does little to redress that central crisis—a crisis that has been often demonstrated by many reports that this House has considered. I remind the House of the tragic cases of people such as Christopher Clunis, Alan Boland and Andrew Robinson.

The Government's review of health authority performance has found the mental health services wanting. Will the Government now call a halt to further closures of psychiatric beds at least until these new measures have been given a chance to develop? Will appropriate residential care play an important part in the new spectrum of care programme to which the Secretary of State now lends his support? At the same time, and very importantly, will the Government insist as part of their apparently new, tough line with health authorities, that all those authorities have in place proper care programme policies? The Statement says that they expect full implementation from 1st April. The care programme approach, which is supposed to ensure that all mentally ill patients have a care programme in place before they are discharged into the community, was originally intended to be implemented by 1991. In 1996, it is still not universal. That is disgraceful. Perhaps the care programme approach should be included in the new Patient's Charter when the draft is finalised—which, as the Minister explained, will also be in April.

We welcome the new Patient's Charter, which, as the Minister said, sets out what services patients will have a right to expect. However, I add a note of caution about the value of such a charter in this special area of care. Many mentally ill people are confused, isolated and without personal support. Some will undoubtedly have willing families and friends who will be able to act as their advocates. But others will be literally unable to understand or to pursue their care entitlements. Many noble Lords will remember the evidence of Christopher Clunis, the schizophrenic who murdered Jonathan Zito on the London Underground. Clunis, although he realised he was in trouble, simply had no idea where he should look for help or what help was available. He continued to walk the streets. A new Patient's Charter will not solve that kind of situation, which I fear is very common. I hope that the Government will not have too much confidence in it as an instrument of policy.

Even in ideal circumstances, a Patient's Charter will work only if sufficient financial and staff resources are in place to deliver the services promised. Will the Minister explain whether any of the financial arrangements announced in the Statement today represent new money? Will she also tell the House how the Challenge Fund money and the mental illness grant can be used specifically to improve the numbers of healthcare professionals working in this very difficult area of care? The Royal College of Psychiatrists has complained that there are staff shortages at consultant, registrar and junior doctor levels. The Royal College of Nursing reported in January that there are fewer community psychiatric nurses working in England today than there were in 1990—although the past six years has been the time when more and more mental health patients have been discharged into the community. Today, only one in five people diagnosed as schizophrenic and living in the community has access to a community psychiatric nurse.

Staff shortages and low morale among those who are working under great stress make it very difficult indeed to deliver successful care. Perhaps the Minister will explain how the new measures will ease shortages and raise moral.

On these Benches, we welcome the Government's overall review of mental health services. However, we find it extremely disturbing. Despite the confidence expressed in the Statement about future plans and performance, it is disgraceful that, for example, the North Thames region reported that none of its health authorities presently has in place a comprehensive set of services for mentally ill adults. Two-thirds did not expect to be able to offer comprehensive services by the end of this next year, even with extra help. Community care is failing very badly, and this package of proposals is inadequate to deal with that failure.

Just over a year ago the Mental Health Task Force—a national body set up by the Department of Health—published its findings on London. It 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".—[Official Report, 16/3/95; col. 940.] Unless we have a far-reaching, much broader strategy than is represented by the Statement, one designed to address acute bed shortages and staff shortages as well as overall care and supervision in the community, it seems very likely that the alarming picture painted by the Mental Health Task Force will continue.

Earl Russell

My Lords, Whitehallspeak has a certain residual honesty about it which I rather like. We hear in the Statement that the measures, constitute a substantial contribution to the progress we need to make".

That, I think, is accurately translated as, "We believe this is a step in the right direction, but a very little one". We on these Benches would not dissent from that reading of the Statement.

I was glad to hear the Government say that the care in the community policy, as it relates to mental health—that is all that we are discussing at the moment—never meant the abandonment of a residential care policy. I remind the Minister of some figures that we discussed during the passage of the Mental Health (Patients in the Community) Bill from the Royal College of Physicians on the shortage of mental health beds in London, and from the noble and learned Lord the Lord Chief Justice about the number of occasions on which people in need of mental health treatment have to be sent to prison. In the light of those, will the noble Baroness tell the House how many more mental health beds, either acute or long-stay, will be provided as a result of the Statement? In assessing the needs, I hope that she will take account of other pressures on mental health beds which may result from increasing homelessness in a wide number of contexts. That is one factor that exposes weaknesses in people's mental health make-up. In fact, it accounts for quite a large amount of the pressure on mental health beds.

Will the noble Baroness also consult, first, the National Association of Citizens' Advice Bureaux, and secondly, her noble and right honourable friends in the Department of Social Security about the plans to remove the mobility component of the disability living allowance for patients in hospital? That will fall particularly severely on mental health patients whose state is perhaps not particularly acute and who are able at present to maintain a contact with friends, relatives and neighbours. For them, such contact will be very much harder in future.

We hear about every health authority having plans. There are plenty of plans. I recall listening to Mr. William Waldegrave, when he was still an undergraduate, referring to Her Majesty's Stationery Office. I believe he described it as, "the large intestine of the body politic producing excreta of national plans". I do wonder whether very much has really changed. What matters is not whether we have plans, but whether those plans are capable of being delivered.

We hear of £53 million being devoted to plans. From where will that money be taken? Is it new money? Or is it at the expense of some other programme that the health authorities might otherwise have undertaken—and if so, what?

I am glad to hear that there is concern about the care programme approach. I am also glad to hear the Government say that a charter by itself does not raise standards. I can recall Mr. Roger Freeman, when he was a junior Minister, in 1991, saying that the Citizen's Charter, by definition, could not be used to solve major problems. At the time Mr. Freeman was speaking about the London-Tilbury and Southend line. How right he was.

I want to know not only whether there is a charter but what it covers and what means there are to make it effective. I should like to know whether the charter will cover the discharge of mental health patients from prison and what arrangements are to be made for them. I want the noble Baroness to understand, as I am sure she does, just how irritating—I could use stronger language—it can be to public service workers who find themselves required to achieve targets under charters at precisely the moment when the means of achieving those targets are taken away. There is no procedure in our public service, and especially not in our public expenditure round, for matching the amount of funds given to various departments in the public services with the targets that they are meant to meet. So, if the targets go up and the funds go down, those who are trying to bridge the gap feel that they are being torn in two. It is not a particularly comfortable feeling.

In this context, we need to bear in mind the remarks of my noble friend Lady Hamwee about the competing demands on local authority resources. Especially we must remember the tendency of mental health sufferers to gravitate to a few particular areas of the country. They go not just to large towns. It is more specific than that. They gravitate in particular to places where there are large concentrations of cheap, privately rented property and in fact to certain corners of London. Those areas often face quite special burdens. I should like to think that there have been discussions between the Department of Health and the Department of the Environment about adjusting local authority revenue support grants accordingly. If that is not done, I do not believe that the Statement will succeed in delivering the changes that we all wish.

A total sum of £95 million has been mentioned. Can the noble Baroness confirm or deny that, of that £95 million, only £20 million is new money now allocated for the first time? Is she aware of and does she accept the figure offered by MIND, which suggests—to me rather more realistically—that something of the order of £300 million is needed? If that amount cannot be raised, we must return to Sir Keith Thomas's definition of magic: if magic be defined as the use of ineffective techniques to allay anxiety when perhaps no effective ones are available, then perhaps no society will ever be free of it. I understand that, but I should like some effective ones sometime.

Baroness Cumberlege

My Lords, I should like to respond now to the two members of the opposite parties who have had a very quick opportunity to see the Statement and to comment on it. Let me start with the comments of the noble Baroness, Lady Jay, who came in strongly to say that community care is failing. The purpose of the Statement today is to put community care into context. In the past, community care has not considered the whole spectrum of care. There was concentration on moving long-stay patients out of huge mental institutions and into the community. Perhaps there has not been enough concentration on those who are severely mentally ill and need a different kind of provision of acute care in hospitals and also with 24-hour staff nursing beds. That is one of the main planks of the Statement today in our policy for the future.

It would be a pity if community care were totally rubbished. I used to be responsible for four of the largest mental institutions that served London. They were built in the last century. When I became regional chairman, I looked through some of the reports. In all, we had 20 major inquiries into long-stay institutions. One has only to read those inquiries to realise what an utterly miserable and dejected life many of those people suffered. We had to do something about that. It is quite right that the majority of those people no longer live in long-stay institutions. Again, one only has to visit them in the community to see their quality of life, a quality which was denied them in the past.

However, there is the other end of the spectrum. That is the end on which my right honourable friend is concentrating today. We are going to put huge resources into mental health services but they are targeted at the severe end. Although the number of beds has been increased, it has been done over a relatively short time. We want to ensure that that momentum is maintained.

The noble Baroness mentioned Christopher Clunis and those very severe cases where homicide has been committed. She described them as quite common. That is not true. They involve a tiny percentage of people. Indeed, there is no evidence at all—

Baroness Jay of Paddington

My Lords, with the Minister's permission, perhaps I may intervene at this point. Perhaps she slightly misheard what I said. I did not say that cases involving homicide were common. Indeed, I should always be at pains to say that people who are severely mentally ill, as Christopher Clunis was severely mentally ill, are more likely, as the statistics always show, to do damage to themselves than to other people. I said that it was common for people who were supposedly under community care not apparently to be properly supervised.

Baroness Cumberlege

I apologise to the noble Baroness if I misunderstood her. Certainly, she will appreciate that the new programme approach that we are adopting will try to address that problem. Indeed, where it works well, we know that it is extremely effective.

Concern has been expressed about the increased numbers of psychiatrists and psychiatric nurses that are necessary. Growth in the past has been considerable. But we recognise that in future there will be an even greater demand. That is why we have put so much resource into this initiative. If we consider just the past five years, over 14,000 nurses have received training as mental health nurses. Again, there has been an increase in the number of psychiatrists. Indeed, medical schools will take an initial 10 per cent. more medical students from now until the year 2000. It is not a matter of funding in this case; it is a matter of ensuring that people want to enter those particular occupations and specialties. We are aware of the vacancy rate that exists at the moment among psychiatrists. The posts are funded; they are there and they are allocated. It is a matter now of ensuring that they are filled. A working party has been set up by the department with the Royal College of Psychiatrists to look at those specific issues.

We are anxious—my right honourable friend has given an undertaking in the past—to ensure that beds are not closed until there is adequate alternative facility made. It will not always be beds. Sometimes it will consist of emergency teams; there will be a strengthening of community services through GPs employing community psychiatric nurses or having them attached to their practices; and there is a demand for day centres. Above all, we know that we need to keep track of those people who leave intensive care—those who leave acute services—so that they do not get lost in the community. That is taken care of by the Bill which was passed by this House earlier this year and will come into force in April next year.

Perhaps I may now turn to the question of funding. The noble Earl, Lord Russell, asked whether this was new money. We are making available an extra £40 million over the next two years in addition to the £53 million from health authorities' own plans. They have already told us that that is the investment they want to make in mental health services next year. We know that every year the National Health Service receives an increase in funding. We expect the vast majority of that £53 million to come from the growth money that the National Health Service will be receiving through the PES round that was announced in November. We also expect local authorities to put in money from their allocations. They are also receiving additional money, but some of that money will be matched. We expect them to use the money they receive through the community care funds, the mental illness grant and other specific funds for this purpose.

The Patient's Charter in all its various forms—we now have a number of charters—has had an enormous impact, particularly on issues such as waiting times. We have seen waiting times plummet and we know that because we have set standards. Those standards are being met and they are being monitored. The noble Earl asked how we would ensure that the standards are met. There is specific monitoring of the care programme approach to ensure that the standards are met. We now have a system through the reformed National Health Service that enables that to happen through the regional offices.

I appreciate that noble Lords have not had a chance to look at the charter. I shall certainly place one in the Library if that is helpful. It takes into account the care programme approach so that relatives and carers can see whether that is being followed.

4.41 p.m.

Lord Campbell of Croy

My Lords, I welcome in general the proposals in the Statement. On one part of it, while the large majority of schizophrenics are not violent or dangerous, there are a few who are. Will the Government do all they can to ensure that the community care system identifies those very few and keeps them away from the public and under supervision for their own safety? Will the Government also resist attempts by civil liberties organisations to let such people freely into the community?

Baroness Cumberlege

My Lords, the care programme approach is intended to do just that—to ensure that when people leave hospital they have a key worker who makes sure they do not get lost in the labyrinth of different services supplied by the National Health Service and also by social services. One of the strategies in the policy is to ensure that social services and the health service work more closely together. We accept that some people will need secure accommodation probably for the rest of their lives. But I do not think we should underestimate the enormous progress that has been made, particularly through the new drugs that have become available. We see people now who in the past would have been kept in acute care. They are now holding down jobs, leading a normal life, and in many cases a very happy family life as well.

Lord Strabolgi

My Lords, arising out of what was said by the noble Lord, Lord Campbell of Croy, will the Government pay particular attention in future to the role of the so-called anonymous lay managers? There have been some cases where they have overruled the views of professional doctors and psychiatrists and have let out dangerous mental patients into the community against all advice. Who are they? Why are they allowed to remain anonymous? Why are they allowed to overrule the professionals? Will the Government pay particular attention to this point in future as there have been cases where dangerous mental patients have been allowed back into the community, without adequate supervision, to murder and rape?

Baroness Cumberlege

My Lords, mental health managers are not necessarily people in pinstriped suits who are employed by the health authority. Managers in these terms are often lay people who are brought onto a board. The National Association of Health Authorities and Trusts, the Mental Health Act Commission and the Royal College of Psychiatrists share the noble Lord's concern. They have set up a group specifically to review this role of mental health managers. They will be reporting very soon in the spring.

Baroness Faithfull

My Lords, does my noble friend agree that we have not got to the heart of the matter? We have talked about money; we have talked about beds; we have talked about homelessness; but we have not talked about the best way to treat a schizophrenic. I have had to do this work myself in the community and I have great sympathy with community psychiatric nurses and social workers. If a patient is discharged from hospital and he has to be supervised in the community it is impossible to be with that patient 24 hours a day. One problem—I am sure my noble friend will agree with me—is that some schizophrenics will not take their medication. If they take their medication there are not many problems. But how does a community psychiatric nurse, good though he or she may be, or a social worker, good though he or she may be, make a patient take his medication? The patient may have good accommodation at night but there is always that moment when he has not taken his medication.

We have closed down a number of centres where patients used to be able to go, morning, noon and night. At the centres a nurse would be on duty and food would be supplied. It is also to be regretted that we have closed down the occupation centres. They provided dignity for patients. They could be under supervision—we tried to make it not appear to be so—and they could do a job of work. In Oxford I used to be in touch with the Cowley works which would Send to us simple jobs which people could do. Cowley would pay the going rate to the patients. In that way patients were supervised throughout the whole day without it appearing that they were being policed. They were provided with dignity.

I do not think we have considered enough how we should deal with schizophrenic patients in the community who will not take their medication. We really should remember the families of schizophrenics. Schizophrenics are an agony to families. I have seen families destroyed because their schizophrenic son has disappeared. They wonder what has happened to him. They do not know. I know it is felt that it is wrong to supervise by laying down lines of supervision, but we have to do that with some patients. The only way to do it is to give them a dignified life. That means giving them somewhere to live where they are supervised, befriended and cared for, where they can work during the day and earn a living, but where they are in care and supervised.

I feel humble in speaking in front of noble Lords who are doctors, but I do not think the doctors have set out for social workers and community workers exactly how such patients should be treated. All the money in the world and all the community care in the world will not make a difference unless we give real thought to what these patients really need and how they can be cared for in a dignified but supervised way.

Baroness Cumberlege

My Lords, I agree with much of what my noble friend has said. Schizophrenia is a quite hard diagnosis to make. We know that it can vary enormously, from those who are extremely ill to those who have bouts of illness from time to time and are easier to manage. The supervision registers which we are putting into place in all health authorities identify those people who may be of particular risk to themselves and to others.

Our second initiative is the new power of supervised discharge under the Mental Health Act which, as I have said, noble Lords passed earlier this year. That enables the re-admission of a patient if they are not complying with the treatment. So there is a much greater grip on the situation. I agree so much with what my noble friend has said about ensuring that people are occupied during the day. One of the difficulties in the past has been when people have been discharged from hospital. Their basic routines, not only of where they sleep, how they eat, how they spend their weekends and whether there are employment opportunities, have been neglected in the past. That is why we want the care programme approach which will address these issues.

As regards families, I share my noble friend's sympathy for the families who take on these very difficult responsibilities. But through the Patient's Charter, which we are putting out in draft form for consultation today, we would involve families in the assessment of the patient and also in the discharge arrangements. That is very important because so often it is the family which is left to pick up the pieces.

Lord Archer of Sandwell

My Lords, if I understood the noble Baroness correctly, she said that her department would be reviewing the future of mental health review tribunals separately. Is she aware that that will come as tidings of great joy to those who have to operate the system? Will she ensure that the consideration which she indicated a few moments ago in answer to my noble friend as regards management meetings is undertaken jointly with consideration for the future of the mental health review tribunals? The relationship between the two procedures gives rise to a great deal of confusion.

Baroness Cumberlege

My Lords, at this moment we are not reviewing the tribunals but the mental health managers. We have some difficulty with the tribunals in that they are part of the Mental Health Act. It may be that the 1983 Act will need some sort of revision or review in time. I am very sorry to disappoint the noble and learned Lord, but that is the situation.

Lord Mottistone

My Lords, I very much support what my noble friends Lady Faithfull and Lord Campbell of Croy said. I also congratulate the Government on tackling the problem. Like other noble Lords, I have doubts whether they will be able to do so because I do not believe that there is enough money around in the country let alone in the Department of Health. But let us see how that goes.

When my noble friend was making the Statement she mentioned a number of reports, papers, plans and all kinds of other things. It seemed to me that some of them might be in print and some not. It would be helpful if everything that was mentioned by my noble friend, and not only the charter, was available for us to read as well as the Statement itself. There is a great deal there to be read because we have a great deal of studying to do. We are talking blind from this side of the House. Noble Lords opposite always get their papers in advance, and how lucky they are!

Lord Graham of Edmonton

How wrong you are!

Baroness Cumberlege

My Lords, I do not share my noble friend's pessimism. I believe that in time we shall get this matter right. I recall child abuse 20 years ago when it was a huge issue. By ensuring that we had key workers and a number of other procedures, we have managed now to make progress on that front. There are five documents. There is The Spectrum of Care; there is another document on 24-hour nursed beds, an audit pack on the care programme approach; the draft charter for mental health services; and the application criteria for the mental health Challenge Fund. I shall ensure that they are all in the Library.

Lord Hayhoe

My Lords, reference has been made to mental health managers. While I accept that on occasions mistakes have been made, in these exchanges it would be wrong if some reference were not made to the immense amount of work that they do in a voluntary capacity. That has been a duty laid on them by Parliament, who decided that this lay element should make the decisions. In those circumstances, I hope the Minister will agree that it is right that praise should be given to the great service that the vast majority of these managers give to the community. I have a little knowledge of it myself. I believe that the individuals concerned deserve praise rather than condemnation and criticism.

Baroness Cumberlege

My Lords, I am very grateful to my noble friend. He is right in that we owe a huge debt in this country to the number of people who serve as mental health managers. Sometimes they have not only a difficult but an impossible task to carry out. They are expected to make some very difficult judgments. I would like to be associated with my noble friend's comments.

Lord Finsberg

My Lords, is my noble friend aware that there is one point that worries me very much? I first became associated with mental health when I went over Friern Barnet hospital with Richard Crossman and another Jay, Mrs. Peggy Jay—a much underrated person. I saw those enormous buildings and it was a ghastly sight.

As a junior health Minister I had the responsibility for taking the 1983 Bill through the House. I could never be satisfied that the mechanism was there to ensure that some over-zealous doctor did not discharge a patient just because he had been told by a town hall bureaucrat that they could look after him. I always felt that that was not possible. I would like to know whether we now feel that this problem can be overcome. One of the reasons why people are still drifting around is the semi-promises given to hospital doctors which are not carried out.

Baroness Cumberlege

My Lords, I hope that psychiatrists are robust enough to follow their clinical judgment and that undue pressures are not put on them. It is very difficult for them because they have to balance human rights with containment and the interests of the patient coming first. There are also the interests of the general public to be considered. I believe that in time, with the care programme approach, more careful assessment and more appropriate facilities supplied for these people, not only in the community but with the 24-hour nursed beds, the crisis teams, the working of 24-hour community teams, intensive home support and a whole range of other services that need to be supplied, we will make the psychiatrist's job that much easier.

Baroness Jay of Paddington

My Lords, before the noble Baroness sits down, will she confirm that her reply to her noble friend Lord Mottistone about the five documents to be published did not include the full review of health authority mental health services, on which we understood the Statement was based?

Baroness Cumberlege

My Lords, I should have made that plain. It is actually sub-titled The Spectrum of Care.