The Homeless: Health Care

HL Deb 21 July 1997 vol 581 cc1275-98

8.18 p.m.

Baroness McFarlane of Llandaff

rose to ask Her Majesty's Government what steps they are taking to ensure that there is an appropriate level of health care for the homeless.

The noble Baroness said: My Lords, since there will be no right of reply after the Minister has spoken. I should like to take this opportunity to thank all those who have put their names down to speak. The range of their interests represented means that we shall have a profitable review of the subject.

I am sure that your Lordships look forward to hearing my noble friend Lady Emerton making her maiden speech. We have been professional colleagues in nursing over many years and her experience now as chairman of the Brighton Health Care NHS Trust and as a chief officer of St. John Ambulance equip her to speak with authority on the topic we have before us this evening.

I also look forward to hearing the right reverend Prelate the Bishop of Liverpool. I believe that this could be the last time in which he will take part in the proceedings of the House, though we are delighted that he will be with us for the whole of this week reading prayers. I can think of no one more suited to contribute to our proceedings this evening. He has been a prophet to the Church in his defence of the poor and disadvantaged. He has never allowed us to forget our obligation to show a "bias to the poor" and we look forward to hearing him.

The links between homelessness and health are complex. A report from the South Manchester Health Authority in 1993 stated: The causes of homelessness are largely rooted in public housing, employment and income policies. The main route for improving the health of homeless people lies therefore in improving their prospects for housing, work and adequate benefits". The BMA has stated: Tackling homelessness should be a major priority for social policy on health grounds". In a Written Answer to the noble Earl, Lord Russell, in 1995 about the poor diet of the homeless, the noble Lord, Lord Lucas, indicated that five government departments, including the Department of Health, were involved in the future of the rough sleepers initiative. It is a complex area.

The present Government have expressed their determination to reform social policies and this Unstarred Question seeks to probe their intention to provide and to integrate health care policies and social policies for homeless people. The Help the Aged and Crisis report, Homeless Truths, published this year, stated: There is no single definition of homelessness. It is defined in different ways by policy makers, service providers, academic researchers, the media and the public and this produces varying estimates of the scale of the problem". The Royal College of Physicians, in its report, Homelessness and Ill Health, identified three categories of homeless people. The King's Fund report, Health and Homelessness in London, revised these categories to reflect the pattern of homelessness in London. The categories it used were, first, statutorily homeless people, defined under the Housing Act 1985; secondly, non-statutorily homeless people, staying in hostels, night shelters and so on; and thirdly, people sleeping rough. Other people use a wider definition: the lack of decent, secure, safe and affordable housing. This includes those whose homelessness is hidden from view. In some authorities teams of nurses are actively engaged in case finding for the homeless. It seems fitting to ask Her Majesty's Government what categories of homeless they intend to recognise in their policies and plans for care.

Lack of an adequate quality of accommodation, exposure to severe weather conditions, poor nutrition and limited access to hygiene facilities predispose to poor health. Specific medical disorders are commonly associated with homelessness; for example, respiratory disorders. Many experience chest and breathing problems, including bronchitis and lung cancer. There is a particular concern over the incidence of tuberculosis, especially drug resistant strains. One study found that homeless men are 50 times more likely to suffer from tuberculosis than the rest of the population. And now there is the relationship between HIV and tuberculosis.

Other types of morbidity commonly found include musculoskeletal disorders, foot problems—few of the homeless lie down to sleep—with chronic oedema, damage to the skin, infection and ulceration. Standing and walking for long periods in ill fitting shoes, alcoholism and poor nutrition lead to peripheral neuropathy, and sleeping in wet footwear leads to "trench foot". Then there are the dermatological disorders and infestations which are increased by lack of access to sanitary facilities. Mental health problems can be the cause and the result of homelessness. I am delighted to know that the noble Baroness, Lady Cox, will be dealing with that subject. I leave it in her capable hands.

There is very little information on the dental health of the homeless in the UK. I was delighted to receive a paper from Daly, which brings together four surveys undertaken in the UK. They indicate that homeless people had almost twice as many missing teeth as the general population and three to five times as many decayed teeth. Old, broken and ill fitting dentures were common and 22 per cent. in one survey reported difficulties with chewing and biting and 16 per cent. reported themselves as in pain at the time they were interviewed.

Homelessness places a significant cost on the health system. Shelter estimates that in two London district health authorities acute admissions of homeless people cost £3 million per year. It has been estimated by the Standing Conference on Public Health that cold housing alone costs the health service £800 million every year. Poor housing is estimated to cost the NHS around £2 billion a year more per annum.

During the early 1990s the previous government took a number of initiatives in making provision for the homeless. They launched the rough sleepers initiative and in 1990 the then government and the Mental Health Foundation launched the mentally ill initiative, with £20 million being made available for accommodation and outreach teams. In addition, some 35 primary care schemes for the homeless were centrally funded.

I would ask the Minister to what extent Her Majesty's Government intend to maintain and extend these initiatives and whether they have any new initiatives in mind; for instance, for the young homeless and elderly homeless. Would they be in favour of the policy, which I am told happens in Paris, of sweeping up the homeless, particularly at night?

The provision of health care services is essential. I know that other noble Lords will speak on this topic and so I shall leave it to them. Perhaps I may just touch on the need for dental care and the work going on in Lambeth, Southwark and Lewisham. A full clinical service is maintained at St. Giles and there is a combination of outreach work to hostels and day centres. It is an excellent model. Different models of care—an integrationist model, in which health care is integrated into mainstream health services; specialised schemes to improve access; and separate dedicated services—all have their role.

I have found a tremendous interest in the subject of homelessness. The Churches, the voluntary sector and statutory services seem to work together. There is no want of innovation and creativity. A great deal is being done. I look forward to hearing from the Minister how the Government intend to maintain, shape and fund the necessary services for this vulnerable group in society.

8.27 p.m.

Baroness Cox

My Lords, I believe this evening is an historic occasion in that it is the first time in which three nurses will have spoken in your Lordships' House. I am therefore very happy to thank the noble Baroness, Lady McFarlane, for making this possible and for doing so in the context of a debate on such an important issue which she has introduced so comprehensively.

It is no surprise perhaps that this topic has been chosen for her maiden speech by the noble Baroness, Lady Emerton. It reflects her professional commitment to advocacy on behalf of those who are among the most vulnerable and disadvantaged in our society. That choice is entirely consistent with the great contribution the noble Baroness has made to nursing and to healthcare throughout her professional career. I am sure that we all greatly look forward to hearing her speech.

I shall focus on the needs of those people who suffer from mental health problems and whose predicament is exacerbated by homelessness. Organisations working with and for the mentally ill who are suffering from homelessness, such as the National Schizophrenic Fellowship—NSF—and Mind, indicate and identify a number of interrelated issues which require urgent attention. These are substantiated by several research studies which show strong links between homelessness and mental health problems. For example, various research reports estimate that between 30 and 60 per cent. of homeless people in London have a severe mental illness, such as schizophrenia, manic depression or major depression, and similar, although slightly lower, figures have been recorded for the rest of England and Wales. Problems facing people suffering mental illness have been exacerbated by the closure of hospital beds for the mentally ill without adequate alternatives being made available in the community.

Appropriate housing is the most important element in care plans for people with mental illness. A stable home greatly helps social, psychological and physical well-being. Homelessness by contrast is linked to loneliness, isolation, non-compliance with medication, deterioration in physical health, decreased chances of employment and financial insecurity—in fact, a dismal cycle of multiple deprivation. And very disturbingly, as the noble Baroness, Lady McFarlane, indicated, increasing numbers of younger people are found among the homeless. They have difficulty accessing services in the community and cannot be hospitalised when they need care because of bed-blocking caused by shortages. For example, according to the NSF, acute beds in London are now oversubscribed by a terrifying figure of 200 per cent.

Problems are also experienced by patients being discharged from hospitals, including some of the most dependent and vulnerable patients, who may have been in hospital for many years. For them, the hospital may have become their home, indeed their world, their only constellation of personal relationships. The community to which they are discharged can be a very lonely place.

Other problems confront hospitals which are trying to discharge patients who are potentially a danger to themselves and to others and who need a safe, secure environment at least until treatment enables them to face the risks of living a less structured and supervised way of life. The extreme shortage of secure and medium-secure units for those trying to arrange discharges from hospital for these patients is causing a real crisis, especially for those patients for whom section orders expire and who must be found secure or medium-secure accommodation. There is not sufficient accommodation of this type available.

Time permits reference only to one research study: all these issues are underpinned by research. The study to which I refer is the Homeless (Mentally Ill) Initiative undertaken by Craig and colleagues whose findings were published in 1995. They reported on the work of five specialist teams in three of the former regional health authority areas of London. They confirmed between 30 and 50 per cent. prevalence of severe mental illness among users of night shelters, with schizophrenia as the most common diagnosis. They highlighted a number of issues of which I shall indicate just a few. The first was a need for much more psychiatric support for these vulnerable people.

The findings revealed that about one-third of those covered by the survey had lost their accommodation on account of mental illness, usually after they had been admitted to hospital. In two-thirds of resettlement so-called "failures", there had been a deterioration in a person's mental health which had not been identified and treated quickly enough. Therefore, among many recommendations was the need for joint commissioning and planning by health, social and housing agencies.

I conclude by asking the Minister four questions. I shall fully understand if it is not possible to answer all of them tonight, but I would like to make them available for consideration. First, will the Government fulfil their pre-election promise of a moratorium on psychiatric bed closures at least until adequate and appropriate quality accommodation and support are ensured for those to be discharged? Secondly, will the Minister give an undertaking to promote policies designed to enhance co-ordination and communication between health and social services, the voluntary sector, the police and—very important indeed—the informal carers; and to improve speed of access to services, appropriate referrals, measures to protect vulnerable people from falling through the safety net of care and, in that context, support for those informal carers who play such a crucial role and who are often not recognised and identified with sufficient support?

Thirdly, will the Government consider sympathetically a range of options for different kinds of care for people with mental illness discharged from psychiatric hospitals? For example, will the option of village community-type care, so well established and well proven in this country and in other countries in terms of care effectiveness and cost effectiveness, be included impartially as one possible choice for those being discharged from hospital?

My last question is this. Homelessness is an outcome of the failure of community care in general. NSF believes that £500 million in revenue spending a year would be required to provide appropriate care and support for people with severe mental illness and their carers. Can the Minister give any assurance that appropriate resources will be available for the necessary care of these very vulnerable people?

It has been well said that the extent to which a society is civilised can be judged by the care it provides for its most vulnerable members. The same can be said of governments. One of the challenges facing the Government today is the problem of homelessness in general and of those who are mentally ill in particular, whose problems are exacerbated by homelessness. This debate provides a valuable opportunity for the Government to show how they will rise to these challenges and, if they can, give hope to those who are now suffering from inadequate provisions and encouragement to those who are currently trying to provide that care for the mentally ill with dedication but too often without the resources to do so as effectively as they would wish and as the mentally ill need.

8.36 p.m.

Baroness Emerton

My Lords, it is an honour to be able to address your Lordships' House. I ask for your Lordships' indulgence as I deliver my maiden speech. I first declare an interest in that I am a chairman of a health care trust and a chief officer of St. John Ambulance.

The Patient's Charter states that every individual has a right to receive health care on the basis of their clinical need, not on their ability to pay, their lifestyle or any other factor.

The various categories of homeless people described by the noble Baroness, Lady McFarlane, frequently experience problems in obtaining appropriate health care due to prejudice against the homeless by health professionals and in particular by many general practitioners who refuse to register the homeless. This leads to a reluctance by the homeless to seek health care until diseases become debilitating or there is a suffering of severe pain. In addition, the homeless tend to be a mobile population and therefore continuity of care presents a problem, especially for those suffering a mental illness, as the noble Baroness, Lady Cox, mentioned.

The health status of people sleeping rough is far worse than that of the general population and research has shown that the average life expectancy of people who sleep rough is only to their mid-forties.

In 1981, Sir Donald Acheson, the Chief Medical Officer at the Department of Health, highlighted the imbalance between the generous provision of acute hospitals and the poor overall quality of primary and community health care, the consequences being that many patients ended up being treated in hospital. As far as the homeless are concerned, 16 years later there is evidence that A&E departments are being used inappropriately. A study published last year into the use of a London teaching hospital A&E department demonstrated that, if all the patients who had inappropriately attended the department had attended a more appropriate general practitioner surgery, a saving of £60,000 would have been achieved. If that was applied across all A&E departments, a substantial saving to the National Health Service could be made.

Frequently, those presenting at an A&E department have an overriding problem of alcohol or substance abuse or mental illness and can be very consuming of staff time in their management. Evidence from a research project in Brighton in 1995 demonstrates clearly an inappropriate use of the department in particular by the street homeless.

Accessibility to appropriate health care provision is, therefore, a paramount need for this group of people. The previous government, following a favourable evaluation of two pilot schemes, part-funded 35 schemes across the country. Health authorities were then asked to consider improving access by homeless people to primary health care. In Sussex, 1.1 per cent. of the total population is homeless—that is, 3,453—and of these 1,792 are in Brighton and Hove. This is approximately 50 per cent. of the Sussex homeless population. In the 1991 census, there were 66 people sleeping rough, giving Brighton the highest rate of street homeless per capita in the UK.

I visited one of the pilot schemes situated in Brighton, called First Base, where approximately 160 homeless attend daily for a range of services, including health care. This is a well integrated scheme which meets the needs of both street homeless and those in bed and breakfast accommodation, many suffering from physical or mental illness. The health care provision is made by a nurse practitioner and a nurse who attend the centre on a regular sessional basis. It is quite evident that the relationship between the homeless and the nurses, while professional, is very informal and demonstrates mutual trust. There is also a general practitioner attached to the centre who attends on a sessional basis, but it is the nurse to whom the majority of homeless relate. It is, therefore, the role of the nurse practitioner which has proved to be very useful in filling the gap for homeless people who are not registered with a general practitioner.

An evaluation showed very high levels of patient satisfaction where nurse consultation for minor injuries were introduced: 86 per cent. of patients required no doctor contact at all. With the proper education for nurse practitioners, providing knowledge, skill base and competences to the appropriate standard, there is no reason why evidence-based practice cannot be delivered to a very high standard. The United Kingdom central council has through its policy scope of practice facilitated the development of extended roles and this has been supported by the Royal College of Nursing in programmes of preparation among many other colleges across the country. An increase in nurse practitioners would be a cost-effective route to the provision of appropriate health care for the homeless—and I would ask the Minister to consider this.

The centre I visited recently could, I believe, deliver a more cost-effective and efficient service to the homeless if the nurse prescribing legislation had been such as to allow the nurse practitioner prescribing rights. A review chaired by the noble Baroness, Lady Cumberlege, and the subsequent publication of the report Neighbourhood Nursing—A Focus for Care in 1986, recommended that community nurses be permitted to prescribe from a specified nursing formulary. This was followed by a Private Member's Bill which received Royal Assent in 1992. The statutory instruments allow district nurses and health visitors in specific pilot projects to prescribe from a limited formulary. There is now a nurse prescribing pilot scheme in each English NHS region and two in Scotland. The previous Government's White Paper, Primary Care: Delivering the Future, published in December 1996 announced that nurse prescribing would be extended throughout the country from May 1998.

It is evident that with the rapid growth of practice innovations, highly trained nurses who are specialists in a variety of areas are equipped to know and deliver the most appropriate and clinically effective treatment for their patients. This is particularly true of nurse practitioners treating homeless people. They could well benefit by inclusion in the nurse prescribing group. The Royal College of Nursing is pressing for legislation which would be sufficiently flexible to allow nurses who hold specialist qualifications and have appropriate skills and competences to be considered eligible for prescribing rights. Safeguards, checks and balances would be easy to implement as registered nurses now have to comply with the United Kingdom central council post-registration education project requirements for regular updating.

The formulary is currently restricted to a range of products based around the provision of nursing care involving treatment of wounds, minor injuries and some fungal infections. These alone would allow nurses to give appropriate care effectively to the homeless without the involvement of a doctor.

There is an obvious need for education of health professionals to break down the barriers of prejudice and marginalisation of homeless people and, where possible, to include homeless people in contributing to the planning of the provision of services most appropriate to them. This is not easy and in my experience of involving people with learning difficulties in the planning of services for themselves, it requires patience and understanding—but in the long term it is very worth while. Likewise, homeless people know the type of service they would respond to and can provide a useful contribution to its planning.

In planning services, one must not forget the importance of inter-agency working, and this should include the voluntary sector, which currently provides many services for the homeless. In particular, in my role in St. John Ambulance, I have been involved with the recent launch of a mobile unit pilot scheme in Manchester which provides first aid and primary health care during the evenings for the homeless. Volunteer nurses and volunteers specially trained provide these services. It is hoped to expand the project to two further centres this year. The volunteers provide a non-bureaucratic, easily accessible service, but they have the knowledge and skill to be able to refer clients to appropriate agencies if necessary. Funding of these schemes is, however, difficult for voluntary organisations and development is limited by the availability of funds.

The health care needs of the homeless is an area of need which requires government guidance and support to ensure that homeless people receive health care on the basis of their clinical need as stated in the Patient's Charter.

8.46 p.m.

Lord Pearson of Rannoch

My Lords, it is a great honour to follow the maiden speech of the noble Baroness, Lady Emerton, and thus to have the privilege of congratulating her and of welcoming her on behalf of the whole House. Her long and distinguished career in St. John Ambulance where, among her other executive duties she leads that great organisation's excellent care in the community programme, together with her experience in regional health care, make her unusually qualified to participate in this debate this evening, as we have heard. I understand that the noble Baroness's career began early when she achieved the distinction of being awarded the Grand Prior certificate before she was 16 when she was a cadet. I feel sure that all noble Lords who have heard her this evening will agree that she has achieved a similar success with her maiden speech and that they will join me in hoping that we shall hear her speak again very soon.

I propose to concentrate my own few words tonight on the concern that a growing number of mentally handicapped people may be becoming homeless. I use the words "mentally handicapped" instead of the more usual expression "people with learning disabilities" because I wish to distinguish between mental handicap and mental illness, which has been so admirably dealt with by my noble friend Lady Cox.

I would submit that a mentally handicapped person who is homeless is most unlikely to enjoy an adequate level of health care. Before I go any further, I should declare an interest as the father of a mentally handicapped daughter, and as Honorary President of the National Society for Mentally Handicapped People in Residential Care, known for short as RESCARE.

Perhaps the most disturbing evidence that increasing numbers of mentally handicapped people may be becoming homeless came from the Department of Health itself last year. In its evaluation report on residential care provision, it admitted that there is already a shortfall of some 25,000 residential places for people with a mental handicap, and it predicted increased demand over the next two decades. This is not surprising because many of the parents who are still looking after their mentally handicapped children are not getting any younger and are now very worried about what will happen to those children when they die. There is therefore a growing shortage of residential provision, and community care is, alas, increasingly unable to cope.

There are other worrying developments: one of these is that when people are discharged from long-stay hospitals into community care, their former friends and contacts in their hospital are often being encouraged not to stay in touch with them. I gather the theory is that this will spare them from carrying with them into community care what their social workers and others imagine may be the stigma of having been in a hospital. But of course it means that those who used to care for them and know about them may lose touch with them completely. The fear is that some of them, perhaps many of them, may now be ending up homeless.

Another disturbing report appeared in The Times on 23rd June this year, to the effect that some GPs may be dropping people with a mental handicap from their lists. If this is happening, it would seem to lend support for the retention of centralised hospital services with the kind of village communities which RESCARE favours. In those circumstances, many of us were very encouraged by the pre-election indications from the Labour Party that it would impose a moratorium on further closures of long-stay hospitals for people with a mental handicap and on the sale of the sites in question. But now that the Minister's party is in government, I am not quite sure what its new policy may be. Perhaps its mind is not yet made up.

The Minister may be aware that my noble friends Lady Cox and Lord Renton and I did our best over several years to persuade the previous government to halt these closures until it was really safe to proceed with them, and we failed. We failed also to get the previous government to encourage residential and village communities for mentally handicapped people as one of the choices which should be available to them and to their families. Indeed, a number of long-stay hospitals would be eminently suitable for conversion into residential communities, but such evolution appears to be resisted in the Department of Health and by local services, although there is a huge demand for the lifestyle and care which they provide.

To be specific, I can give the examples of St. Ebba's Hospital, Epsom, and Offerton House, Stockport, where reputable public companies have offered to finance, develop and run such communities. Those projects are strongly supported locally and by the relevant parents' and relatives' organisations, and yet they are being resisted by the local health authorities. If pursued, those projects must also provide invaluable pilot studies of how old style long-stay hospitals can be converted into something modern and useful. So I very much hope that the new Government will take a fresh look at the case for village communities for mentally handicapped people—my noble friend Lady Cox mentioned mentally ill people. That case was succinctly set out by my noble friend in her publication Made to Care in April 1995, the conclusions of which, as far as I know, have never been seriously challenged. Briefly, these are that village communities can provide a much richer and more fulfilling life for some people with a mental handicap, with better on-site medical care than can sometimes be provided under community care. And of course well run village communities remove the danger of homelessness entirely. RESCARE's national survey continues to show that at least half the families of mentally handicapped people want village communities as an option for their relatives. And, finally, although we were not supposed to say so under the previous government, our communities provide all this very much more cheaply than can community care.

This does not mean that our support for village communities is driven largely by considerations of cost. But, as my noble friend Lady Cox repeatedly asked the previous government, if village communities are care effective, and they are, if many of the people concerned desperately want them, and they do, and if they are also cost-effective, why do we not encourage them? Why instead do we resist their development? At the very least, we would hope that the new Government might end the ambiguity pursued by the previous government and put village communities firmly and clearly back on the list of provision which local authorities are encouraged by the Government to support. No one is asking for a monopoly, but the evidence is now overwhelming that village communities should be part of that provision.

If I may, after this debate I shall present the Minister with a free copy of Made to Care. It has an excellent one-page summary on the back, and I very much hope that she may find time to read at least that. Perhaps she, or her appropriate colleague in government, might also find time to meet my noble friends and I, so that we can dispel any doubts she may have about the common sense and compassion of what we propose.

8.55 p.m.

The Lord Bishop of Liverpool

My Lords, I am most grateful to the noble Baroness, Lady McFarlane, for raising this Question on behalf of those who have little or no voice or clout themselves. I thank her also for the kind remarks she made about me. It has been a great privilege to play a part in your Lordships' House over some 17 years. I have a disappointment that it is natural to express at this moment. In my maiden speech I remember expressing my hope that if the nation wanted the Church to be represented in Parliament that that should be on an ecumenical basis and not just one Church. I am saddened that with all the other progress we have made in the Churches, that has not yet come about.

I should like to add my congratulations to the noble Baroness, Lady Emerton, on her maiden speech, made out of detailed and wide knowledge, and with a deep concern for homeless people as people who are worth something.

The Standing Conference on Public Health Working Group report of 1994 identified two most important reasons as to why homeless people may not have good access to health care: first, the mobility of homeless people, which has been spoken about, not necessarily of their own choice; secondly, unsympathetic and occasionally hostile reactions from the providers of health care. The rough sleepers' initiative made money available to address the health needs of homeless people; £20 million from the Department of Health to set up a major project in London concerned with mental illness among homeless people. That included multi-disciplinary teams to find people who were not in touch with statutory services. Money was also put into providing primary health care on a drop-in basis in hospitals or day centres. For example, in Liverpool, the Whitechapel Day Centre offers consultations with GPs, chiropody and eye tests, and has the services of a community psychiatric nurse. It is obvious that we need to go to find people rather than to expect that they will always turn up for appointments.

Churches have substantial involvement in offering services to homeless people. Nationally, the Church Urban Fund has made grants of £2.6 million to projects addressing homelessness and nearly £800,000 for projects concerning health in the community. London churches in particular are involved in many projects for homeless people. The London Churches Group, on behalf of all Churches, published a report last year From Sympathy to Solidarity, picking up the point made by the noble Baroness, Lady Emerton, about drawing people in to share in some of the thinking and decision making. It identified a large number of projects run by churches in London: 85 hostels or night shelters; 19 housing associations; 45 day centres and drop-in lunches; nine assistance advice centres and 31 soup runs. It estimated that 44 per cent. of users had serious problems with alcohol, drugs or mental health. It is crucial that closer links are made with health services for referrals or regular on-site sessions.

It would be misleading to assume that problems of homelessness are, as I used to believe until recently, confined to major cities. In our diocese of Liverpool, we are currently negotiating with the Church Army for the possible full-time appointment of a housing and homelessness officer. A survey by our Diocesan Board for Social Responsibility 1995–96 showed that no fewer than 3,687 households were accepted as homeless by the eight local authorities in the diocese. More than two thirds of them were outside Liverpool: Warrington, with a large number of travellers; Wigan, for example, has a homelessness problem fast approaching that of Liverpool. Of those nearly 3,700 households, the local authorities were able to house 2,200 only. They conclude that the problem of homelessness is getting worse.

Dr. John Balazs is a full-time GP in Stockwell, in south London. Reference has been made to two teams providing services in Lewisham, Southwark and Lambeth. He says that there are financial disincentives for GPs to register homeless patients. Most GPs will not register people who are expected to stay for only a few weeks. Temporary registration means a one-off payment, but no fee, for example, for immunisation, no targets, no health checks and no health promotional activities because there is no incentive.

Dr. Balazs concludes that the current NHS system fails homeless women in particular. For example, a high speed smear service is needed rather than the ordinary service. He says that having female carers available is very important for homeless women. He also says: My conclusion was that although prevention is sometimes a low priority for homeless women. it must he a high priority for their carers". I shall make three further points. First, the delivery of health care to homeless people requires flexibility. That is plain from all that has been said. A good practice will sometimes accept self referral and will offer accessibility without appointment. Outreach workers and health advocates can make vital connections for people who are fearful of health agencies or who are perhaps unable to speak English. The report of the Standing Conference on Public Health, from which I quoted at the beginning of my speech, encourages such flexibility, particularly in meeting its first point about clients' mobility.

Its second point about unsympathetic and occasionally hostile reactions from the providers of healthcare led it to encourage training on how to work sensitively and effectively with homeless people. Sometimes a natural fear is involved in the process which may lie underneath unsympathetic attitudes. Perhaps I may share what your Lordships will understand has been a painful experience. The vicarage door is another place where homeless people go. In particular in urban priority areas, clergy and their families are sometimes the only professional people who live in the parish and are available at weekends and after 5 p.m. Following the tragedy of the killing of one of our clergy last summer outside his vicarage door, naturally there have been fears and an acceptance of the need for training in coping with such doorstep visitors. Staff at Ashworth Hospital have provided extremely helpful training days attended by a high proportion of our clergy and their spouses. I believe that such training may take away some fears and with them some of the hostility of health workers, too.

Thirdly, the London Churches' report highlighted attitudes of providers in its title, From Sympathy to Solidarity. That was echoed in the fine statement made last winter by the Catholic Bishops of England and Wales, The Common Good. It stated: The poor are not a problem: they are our brothers and sisters". There needs to be respect for homeless people as people.

9.3 p.m.

Lord Swinfen

My Lords, the plight of homeless people is raised frequently in this House, but normally only in regard to finding them accommodation, suitable or otherwise. It is important that the noble Baroness, Lady McFarlane, has raised the question of the health of homeless people. It is so often neglected. Furthermore, I am delighted that the noble Baroness, Lady Emerton, chose to use this Unstarred Question to make her maiden speech. I, too, hope that we shall hear her frequently; she is well worth listening to.

In 1991, 4,430 disabled people were accepted as homeless. That was 3 per cent. of the homeless total. By 1996 the number had risen to 6,380, or 5.5 per cent. of the total. Can the Minister advise the House whether that trend continues? She may not have the answer at her fingertips, but perhaps she could advise me later.

In 1996, 5,570 older people were homeless, which was 5.5 per cent. of the total homeless, and 8,330, or 7 per cent., had a mental illness. Therefore, in 1996, more than 17 per cent. of the households accepted as homeless had within them a person who was disabled, elderly or mentally ill.

I understand that many of the people who are homeless and sleeping rough, or who live in direct access hostels, are not considered to be homeless by the local authority, often because they themselves do not seek help or may not know where to find help. It is estimated that of these people one-third have a severe mental illness and half have a physical condition such as bronchitis, pneumonia, arthritis or a visual impairment.

Homeless people in priority need, including disabled people, are put into temporary accommodation. This type of accommodation can of itself be detrimental to health. In 1994, the Standing Conference on Public Health found that such accommodation is liable to be more overcrowded than any other type of tenure. A study last year for the King's Fund found that a cramped environment hinders the development of walking and co-ordination in children, which could lead to problems later in life. Overcrowding also encourages the spread of disease, in particular among children.

Many homeless people, who often have to move frequently, have difficulty in registering with a general medical practitioner, as mentioned by the noble Baroness, Lady Emerton. Consequently, they make use of hospital casualty departments. Can the Minister confirm that the cost of an inappropriate visit to a casualty department is about £44, or three times the cost of a visit to a general practitioner, which is about £15? The inability to register with a GP is a serious problem for some disabled people, as they may have a condition which requires a particular knowledge from the GP and an understanding of the person's history. What do the Government propose to do to improve that situation'?

Local authorities place homeless people in temporary accommodation. That brings great difficulties for people with disabilities. The accommodation is often not accessible nor are the facilities within it and due to the short-term nature of the tenure, it is impractical to make adaptations. Temporary accommodation may well be damp and cold, which also brings serious problems for disabled people. Such accommodation may also be unsafe for people who are blind or who have a visual impairment. They must reorientate themselves in a new environment every time they move. That could well lead to accidents.

When considering sight, it is worth mentioning that homeless people and those in temporary accommodation are not as likely as others to have their sight tested regularly, if at all. Regular sight tests are an integral part of health checks. A sight test can detect treatable eye conditions at an early stage. I am told that a number of homeless people may well have developed advanced conditions such as glaucoma and diabetes retinopathy which could have been treated earlier. What are the Government doing to advise homeless people on benefit that they are exempt from charges for eye tests and that they can be given help towards the costs of glasses or contact lenses?

9.10 p.m.

Earl Russell

My Lords, first, I warmly thank the noble Baroness, Lady McFarlane of Llandaff, for introducing a very necessary debate. Secondly, equally warmly, I congratulate the noble Baroness, Lady Emerton, on her distinguished, thoughtful and experienced maiden speech. My only regret is that she used many lines that I had been hoping to use but I cannot think any worse of her judgment for that.

I thank also the noble Baroness, Lady Masham of Ilton, who first drew my attention to this subject back in 1989 when she asked a Question about the operation of the GP capitation scheme in relation to the registration of the homeless. I first realised the importance of the subject when I saw her difficulty in getting the Minister to face up to the precise content of the Question. But now both the present Minister and the present shadow Minister have faced up to the content of that, and I hope that we may hear some answers this evening.

I should also like to tell the right reverend Prelate the Bishop of Liverpool a story which comes from perhaps rather longer ago than I wish to remember. One of my university contemporaries, subsequently my best man, had submitted an academic paper to the regius professor. His chances of employment depended wholly on the regius professor's opinion of the paper. But when he arrived on the regius professor's doorstep, he found him stamping about in a frenzy of impatience saying, "Sheppard is batting. Come on", and once he observed that sight, he thought that the regius professor's judgment was entirely justified.

This evening, we have again seen Sheppard batting. It is done with the same grace and distinction on the same foundation of hard work and technical skill in one place as it was in the other. I find it very difficult to imagine this House without him.

When we talk about the homeless, we usually think about two different sorts of homeless: not only the street homeless but also those in bed and breakfast accommodation. There is a considerable health problem in both cases. I remember very vividly a debate in this House on 6th July 1992 on a Motion moved by the noble Lord, Lord Henderson of Brompton, recommending a boarder premium for those in bed and breakfast and on income support. That was put to a Division and carried. Nothing has yet happened as a result of that Motion. It was based on the problem of people living in large bed and breakfast buildings where there are, for example, three gas rings between 39 couples; people with a toddler cooking three floors below where they live; and babies pulling saucepans off stoves. One of the local GPs reported a considerable problem with scalds. All of them report problems with diarrhoea. All of them report low rates of immunisation. Those matters need attention.

But the bulk of what I want to say is based, as were the remarks of the noble Baroness, Lady Emerton, on the Shelter report, Go Home and Rest?, the study of the casualty department at University College Hospital. In the sample there, only 30 per cent. have a GP, as against 97 per cent. of the population as a whole. However, even that 30 per cent. probably underestimated the problem, because it may very often have been a GP at the person's old address before he or she became homeless. Indeed, 57 per cent. of the visits were found to be inappropriate. The noble Lord, Lord Swinfen, and the noble Baroness, Lady Emerton, have quoted the figures in that respect, so I shall not repeat them.

The problem with the capitation fees, perhaps the most urgent matter needing attention, is that if a patient registers permanently and then moves on within a quarter of a year, the GP receives no capitation fee at all. However, if the person registers temporarily, the GP gets no financial reimbursement for vaccinations, so health suffers either way. I hope that the problem can be addressed.

In most categories of homeless illness we find a lower threshold of hospital admission. In the sample to which I have referred, pregnancy was twice as likely to lead to hospital admission in the homeless as in the housed. I do not think that I need to explain to the House why. Moreover, among people suffering from injury, 16 per cent. of the homeless were admitted to hospital and only 8 per cent. of the housed. The biggest problem was infected wounds. I do not believe that I need to explain why it is difficult to treat infected wounds while sleeping on the pavement in the Strand.

Among depressives, the study found that 42 per cent. of the homeless were admitted to hospital as compared with 32 per cent. of the housed. I do not know whether that means that depression is worse among the homeless or that they are more easily admitted because they are less able to cope with it. Either way, there is a real cost to be paid for homelessness; and costs, like water, must go somewhere.

There is also the considerable problem about illness caused by homelessness. Indeed, expectation of life is 42 or 47 years, depending upon which study you are reading, compared with 74 for men and 79 for women among the housed. In the study, TB was 25 times the national average among the homeless. In the study quoted by the noble Baroness, Lady McFarlane, it was 50 times and, in an earlier study from Crisis, it was 200 times. They are all small samples, and I do not wish to speculate on which is right; but sometimes it is a good idea to put oneself in a position where one does not have to find out. The rate of asthma among people in the study was double in the homeless what it was in the housed. Again, if one thinks of the diesel particulates along the pavements in the Strand, I believe one can understand why. It was also found that injuries were four times as likely to be the result of assault, and that is something of which the whole country should be ashamed.

Mental health was found to be the second commonest cause of admission for the homeless compared with one tenth among the housed. Again, I do not know whether it is mental health problems which make people homeless or whether it is the homelessness which gives people the mental health problems; alternatively, in some of the cases that I know best, perhaps it is a vicious circle between the two. Either way it needs attention. I strongly agree with—indeed, I strongly support—what the noble Baroness, Lady Cox, and the noble Lord, Lord Pearson of Rannoch, said about the closure of mental hospital beds. We need better facilities for the homeless and we need fewer homeless people. Without one, we will not get the other, and, without the other, we will not get the one.

9.17 p.m.

Baroness Cumberlege

My Lords, like other noble Lords, I should like to add my congratulations to the noble Baroness, Lady McFarlane, for initiating tonight's debate. Indeed, it is a subject which needs a very honest and forthright hearing, and I believe we have had just that tonight. I noticed that the noble Baroness, quite rightly, had some problems in citing definitions of homelessness. However, I am grateful to her for exploring that and also for her thoughtful exploration of the whole subject. Perhaps I may also thank the noble Baroness for her tribute to the previous government.

We also heard a remarkably authoritative contribution from our maiden speaker; but then the noble Baroness, Lady Emerton (of Tunbridge Wells and Clerkenwell), is no stranger to authority. I am not sure how many of your Lordships have seen the noble Baroness in her uniform of St. John, but I can certainly say that she is just terrifying when she is wearing it. Of course, there is a softer side to the noble Baroness; for example, I know that she has a penchant for teddy bears. If she is very diligent, I think she might find one or two even among your Lordships.

However, we have also seen a further aspect of the noble Baroness this evening. I should like to pay tribute to her for her knowledge, her wisdom and her understanding not only of nursing, of which of course she is one of this country's outstanding leaders, but also of this complex and difficult subject that we are discussing tonight. We have heard from her of some of the imaginative initiatives being undertaken in Brighton, an acute trust which I know from personal experience she chairs with great distinction.

I also know Brighton quite well. It is a town which over many years has worked hard to establish itself as a smart conference and commercial centre, and indeed it has succeeded. But there is a darker side to this seaside resort and it has pockets of terrible deprivation. Even now its character is not entirely removed from Graham Greene's novel Brighton Rock. A few years ago it was said that Brighton had a murder a month. I am not sure whether that is true today, but it has its quota of homeless and unhappy people who, quite properly, are cared for by the social services, the local health authority and trusts and voluntary organisations, of which there are many of a high quality. However, these organisations find it difficult and challenging to support the numbers of homeless people within Brighton.

In a field study undertaken by Maureen Crane, a nurse researcher who won an award for her work, 159 men and 66 women, all aged over 55, were interviewed in London, Sheffield, Leeds and Manchester. Nearly two-thirds of those interviewed had been homeless for more than five years and half of these have been homeless for over 20 years. The interesting point to note is that before becoming homeless 40 per cent. had been owner occupiers or tenants—a much larger proportion than I would have anticipated—a fifth had been living with their parents and the rest had been in private lodgings, barracks, ships, prisons, mental hospitals, children's homes or living with relatives or cohabitees.

Her fieldwork revealed a number of common themes as to why these people had become homeless. Nearly 60 per cent. reported broken or disturbed homes, sometimes during their childhood or teenage years. Some had become homeless as a result of marital or other relationships breaking down. This often occurred quite late in life. A significant number had been in the Armed Forces or Merchant Navy, many of whom had never been able to establish or maintain a stable relationship or family life.

Maureen Crane found that two-thirds reported or exhibited some form of mental health problem, although—this has been mentioned tonight—only a tenth said that they were receiving any form of treatment. Not surprisingly, in common with the results of other studies, most also had physical problems which were untreated. These included respiratory conditions, hypertension, arthritis, oedema and peripheral vascular disease, gastro-intestinal complaints, alcohol related problems and trauma. I mention all this because I want to put what can be an overwhelming problem into some sort of context.

The noble Baroness, Lady Emerton, mentioned Brighton's First Base day centre which is a welcoming and well run place and which looks after these types of people suffering from these sorts of conditions. I share the admiration of the noble Baroness for the centre and the people who work in it. They show great humanity, much skill and sometimes considerable courage. As she said, and studies show—this was further endorsed by the noble Earl, Lord Russell—these are the people who are most reluctant to register with a GP. Not surprisingly there are many GPs who are reluctant to have them on their books. However, a nurse is less threatening, especially when he or she is working in an environment the homeless person knows well and finds comfortable and non-threatening. Once accepted a skilled nurse practitioner is valued, used and consulted without fear. However, there is a rub. Despite having a diploma—and the vast majority of nurses now do, and in the future all will—and despite many of them having degrees, a nurse practitioner with all that knowledge, commitment and expertise does not have the authority to prescribe the most simple medicines or therapeutic aids.

I am aware that the noble Baroness, Lady Jay, may well be growing weary of my persistence on this subject. Although I do not have the skills to mount what I can describe only as a Countess of Mar campaign—which, incidentally, I greatly admire—I wish tonight to issue a government health warning. I shall be persistent and deeply boring on this subject. I shall be persistent because I have seen at first hand the benefits and advantages which nurse prescribing brings: benefits to patients, doctors and the nursing profession. They are benefits which are far reaching in terms of time saving: time saved in reducing the suffering and discomfort of patients; time saved by doctors and nurses in getting a prescription signed.

Is it not ridiculous that middle-aged, professional women should have to wait outside a GP's door for the doctor to end his consultation in order to get a piece of paper signed? The recent study by the RCN showed that the GP's signature simply endorsed the decision made by the specialist nurse. I have even heard one doctor say that he would sign a prescription for a Chieftain tank if that was what the nurse wanted.

But is it not ridiculous that here we have a nurse practitioner equipped with a broad range of skills, some diagnostic, who through her nurse practitioner course has acquired pharmacological and prescribing knowledge and who is able to deliver the most comprehensive primary care possible to homeless people but as yet is not able legally to prescribe the most modest and limited medication? A homeless man with a chesty cough should not have to be admitted to an expensive hospital bed, as was mentioned by my noble friend Lord Swinfen, when he could be treated with a simple antibiotic. A woman with mild thrush should not have to suffer the pain and discomfort of a lesion for the want of a simple anti-fungal agent.

The Minister will be aware of the eight nurse-prescribing pilot sites which have now been running successfully for two to three years. The sites were evaluated, but not all the results were crystal clear. They varied. Some showed a reduction in prescribing costs, some a modest increase, but when closely examined the increase was sometimes because prescribing had started from a very low base in that practice and sometimes because one or two "expensive" patients had come into the area and required relatively expensive drugs. Whatever the reasons, in none of the eight sites was there an increase above the national average increase for drugs overall.

In all the evaluations there were no worries expressed by the patients. On the contrary, they could not understand why this was considered to be an innovation. They thought that it was common sense that the nurse should be allowed to prescribe from an agreed formulary of simple agents and nursing aids.

I am sure that the noble Baroness, Lady Jay of Paddington, will tell me that she is waiting for the results of the Bolton Trust, which until April of this year was the only district to have rolled out nurse prescribing throughout the whole of its area. I have no doubt that the trust will produce some interesting information. But the purpose of the scheme was not for more research but as a means of phasing in the programme, as was the initiative to set up a nurse-prescribing trust in every region, all of which are now under way.

What is the Government's commitment to nurse prescribing? When do they intend to roll it out? The noble Baroness will know that the previous Government gave an undertaking to do so, as was mentioned by the noble Baroness, Lady Emerton.

Lastly, in the light of the Crown Committee's deliberations, will the Minister please say what the link will be between those possible recommendations and the Primary Care Directorate? As I understand it, in future no nurse will be on that directorate. I should like to know where the link comes, especially in the context of nurse prescribing.

9.28 p.m.

Baroness Jay of Paddington

My Lords, I thank the noble Baroness, Lady McFarlane of Llandaff, for introducing this important debate; and congratulate the noble Baroness, Lady Emerton, on what I believe we all agree was a wise and powerful maiden speech. I look forward, as I am sure do all noble Lords, to many further contributions in a similar vein. I am sad that we have heard the swan song of the right reverend Prelate in your Lordships' House. I feel that I can perhaps refer to it as his "final innings", as I was a schoolgirl fan at about the same time as the anecdote of the noble Earl, Lord Russell. In any case, I am sure that we shall all hear his voice of insight and compassion through other channels if not any longer, sadly, in your Lordships' House.

At the beginning of my reply to the debate, I wish to restate emphatically the Government's commitment to reducing the numbers of homeless people in our society. We have to attack the root causes of homelessness. For too long the homeless population have represented the growing divide, the inexcusable inequality, in this country. Their plight has defaced our city streets.

It is, no doubt, a very complex problem, as the noble Baroness, Lady McFarlane, said in her introduction. The noble Baroness drew attention to a wide range of illnesses associated with homelessness, as did the noble Lord, Lord Swinfen. The noble Baroness rightly emphasised the need to approach the problem as part of a general social agenda.

The Government have already taken action to improve the housing situation. Legislation has been introduced for the phased release of capital receipts for council house sales to increase the stock of housing for rent. Specific measures in this area are being taken in relation to the homeless. Last Thursday, 17th July, new regulations on the allocation of housing were debated in another place; and this Friday, 25th July, my noble friend Lady Hayman will introduce them in this House.

As the law now stands, a local authority can provide accommodation only for a household which it accepts as homeless for two years. The authority cannot generally rehouse that household directly into long-term housing, even though a secure home may be just what the household needs to overcome its many problems.

The new regulations will alter Part VI of the 1996 Housing Act so that local authorities' duties to homeless households must ensure that homeless families, and indeed vulnerable individuals, have the priority that they deserve in social housing queues. We hope that that may ease the practical problem of finding somewhere to live.

On a wider front, my right honourable and honourable friends, as well as my colleagues in this House in every government department, are particularly concerned about youth homelessness in all its forms. The Welfare to Work scheme, announced in last month's Budget and now being implemented by the Department for Education and Employment, is the start of a systematic programme of investing in young people to give those who may now be living on the street the realistic hope of a job and a different start in life.

Homelessness is an affront to a civilised society. We must not simply accept that it is an immovable social problem. Although we rightly discuss health provisions for the homeless, as in the terms of this debate, we should not believe that ameliorating activity is anything more than a sticking-plaster on a social wound that we must find fundamental ways of healing.

The Government are extremely concerned about the links between poverty and ill health—an issue largely ignored by the previous administration. The first Minister for Public Health, my honourable friend Tessa Jowell, has already set out the broad lines of a policy which embraces the impact on health of social factors such as homelessness, bad housing, unemployment and pollution. Those will be developed in a White Paper later in this parliamentary Session. Last week, my right honourable friend the Secretary of State for Health, met representatives of Shelter to discuss the particular health concerns of homeless people. Much of the discussion focused on their needs for primary care and the problems that they often encounter because they are not registered with GPs. It is a matter to which several speakers quite rightly drew attention in their contributions this evening. Several noble Lords referred to the disturbing report, Go Home and Rest?, which examines the use of accident and emergency services by homeless people—the inappropriate use of services, as the noble Lord, Lord Pearson of Rannoch, described it.

There is often legitimate concern that homeless people simply are not entitled to access to a GP because they have no permanent address under which to register. However, I want to make it absolutely clear that a permanent address is not necessary for registration with a GP, and all health authorities and GPs should be aware of that.

Both the Government and the Royal College of General Practitioners would prefer that homeless people should be permanently registered wherever possible so that they may be integrated into all the health service and promotion activity within a GP practice. The noble Earl, Lord Russell, drew attention to the complications brought about when that does not occur.

Where the homeless do not stay in any one area, they may still have access to GP services as temporary residents on what is termed an immediately necessary basis. How do you find a GP, though, if you are homeless? I suspect that there may be a need for the wider distribution of information. It is a matter that I shall certainly look into.

Health authorities can provide a list of GPs in an area; to register, patients should approach the GP of their choice who is willing to accept them. They may then be required to hand in a medical card or to complete a simple form. It remains a decision for GPs as to whether or not they will accept a patient as a permanent registration and some may choose, for the reasons that the noble Earl suggested, to offer the services only under the temporary residence provision. But there is no question of the NHS abandoning any person who is entitled to NHS general medical services, whether they live in permanent or temporary accommodation.

In addition, the Government are anxious to reinforce the guidance issued by the General Medical Council which makes it clear to general practitioners that it is unacceptable to discriminate against patients on grounds of age, sex, sexual orientation, religious belief, perceived economic worth or the amount of work that they are likely to generate by virtue of their clinical condition. I am grateful to the noble Baroness, Lady Emerton, the noble Lord, Lord Pearson of Rannoch, and the noble Baroness, Lady Cox, for drawing attention to this need not to discriminate in general practice.

The Government are also providing funding of over £0.5 million in the current financial year for the provision of GP sessions which provide medical services in places where homeless people congregate. The GP, who is often supported by other professionals, will visit places such as day centres, night shelters or hostels and seek where possible to get the homeless person on to the list of a local doctor. In some cases it has been possible to persuade people first meeting a doctor at a day care centre session subsequently to attend that doctor's surgery. That is, of course, precisely the kind of place where such things as eye tests, to which the noble Lord, Lord Swinfen, referred, should be carried out and where better information on such matters should be more widely distributed.

Funding for these peripatetic GP sessions will continue to be available for the whole of the current financial year and for 1998–99.

We hope to be able to take further initiatives under the primary care Act pilots which will come into force next April. The House will be interested to know that the Government have received a number of expressions of interest in pilots under the primary care Act aimed specifically at improving the provision of personal medical services to people who have difficulty registering with GPs for the reasons which noble Lords have identified and I have just described.

The new contractual arrangements in these pilots will, for example, allow salaried GPs to be employed by trusts. This option could lead to medical services at the primary care level being better tailored for groups such as the homeless. For example, as several noble Lords have mentioned, homeless people often present themselves at A&E departments rather than at a GP's surgery, and I can confirm that that is certainly a more expensive way of giving care. But the new contractual arrangements currently to be piloted under the primary care Act may facilitate joint working between GPs and A&E departments and we shall look very carefully at the details of these proposals when they come to us later in the year.

The noble Baroness, Lady McFarlane, will recall the unsuccessful attempts that she and I made during the passage of the primary care Act at the end of the last Parliament to have nurses included as leaders and organisers of such pilots. Had such provisions been part of the Act, there is no doubt that they would have usefully extended the scope of additional services in the community.

Nevertheless I join the noble Baroness and the noble Baronesses, Lady Emerton, Lady Cox and Lady Cumberlege, in underlining the importance of nurse-led initiatives both in London and, as was described, in Brighton which do exist under the present arrangements. They bring primary health care and health promotion to homeless people.

I know, in addition, that the nursing profession believe that its work in this field and perhaps in many others could be improved if nurse-prescribing were rolled out nationally, and I understand the concern of the noble Baroness, Lady Cumberlege, with regard to that matter. I am keen to see the existing scheme for nurse-prescribing implemented nationally as quickly as is feasible. As the noble Baroness, Lady Cumberlege, said, the current pilots in each NHS region will show us how best to do this. I am, however, reluctant to take any lectures from the noble Baroness, Lady Cumberlege, about the speed with which we are doing this, as we have so far been in power for less than 18 weeks compared to the 18 years of the previous administration.

Some of the most crucial work that nurses are doing with homeless people is as part of multi-disciplinary teams trying to combat the particularly difficult problems of those who are both homeless and mentally ill. As has been described by several of your Lordships, this has become a vicious cycle. The noble Baroness, Lady Cox, developed very vividly the matters which arise when one is talking about people who have neither a home nor the satisfaction of proper mental stability.

I hope that the noble Baroness and indeed the noble Lord, Lord Pearson of Rannoch, will forgive me if tonight I do not go into a detailed response to their specific questions about different types of community care. I hope they will both accept that the Government are taking a fresh look at the interface between social care and health care. I hesitate to use the word "review", since the Government are constantly criticised at the moment for trying to reassess problems of this kind. My honourable friend Mr. Paul Boateng, the Minister responsible for this area, is at the moment conducting a series of consultations and meetings in different parts of the country designed to look at the variety of different solutions about the interface between social and health care. Of course, that will be a central subject and an important topic for the Government's Royal Commission on long-term care, for which we shall be announcing the format quite shortly.

Perhaps I can reassure the noble Baroness, Lady Cox, that some initiatives are going forward in trying to meet the health care needs of the mentally ill and homeless. The Government are providing funds in the current year for the homeless mentally-ill initiative. Its aim is to reintroduce this group of people to mainstream services by encouraging them into temporary accommodation, where they can be offered suitable care and assistance before, it is to be hoped, they move into more secure homes.

So far, some of these measures have been successful and additional funding is being provided to the initiative. New services are being developed in the central London area as well as expanding to other towns and cities where there is a significant rough sleeping population combined with mental illness. The expansion of this initiative is happening in partnership with the expansion of the rough sleeping initiative of the Department of the Environment, Transport and the Regions, to which the Government gave an additional £20 million in June.

The rough sleepers programme is an excellent example of the partnership approach between statutory agencies and the voluntary sector. It is the type of approach that we welcome. I should like to reassure the noble Baroness, Lady Cox, about that also. But we should like to reach a situation in which we could ensure that there was no need for anyone to sleep rough.

Tackling the health of the homeless and the problem of the homeless is part of the Government's broad social agenda to tackle discrimination and disadvantage on a very broad front and to give people a decent quality of life in every aspect of their lives. I am very grateful to the noble Baroness, Lady McFarlane of Llandaff, for drawing your Lordships' attention to a significant aspect of that agenda. I look forward to further consideration in detail as our programmes develop.

Baroness Cumberlege

My Lords, before the noble Baroness sits down, may I confirm that her Government are unable to match the last government's commitment to roll out nurse prescribing next year?

Baroness Jay of Paddington

My Lords, I can merely repeat what I said. The current pilots in each NHS region on this question will show us the best way to do this. I am keen to see the existing scheme implemented nationally as quickly as is feasible.

House adjourned at eighteen minutes before ten o'clock.