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Mr. Teddy Taylor (Southend, East) : On a point of order, Mr. Speaker. Is it in order for the motion that we are about to consider to be considered under Standing Order No. 102(5) when the Standing Committee which met to consider the document did so only yesterday and the Hansard report of its proceedings reached the Vote Office only this morning?
As Standing Order No. 102(5) provides that you can select for debate any amendment tabled by any hon. Member, does it not undermine the rights of Members if they do not have, until the day in question, the report of the Committee's proceedings? That might appear to be rather a niggling point, but it is an important one which I hope you will consider.
The Euro instruments on machine safety were unanimously recommended for debate by the Select Committee in its November report on the basis that this was one of the most ambitious plans for the internal market and that it could increase substantially the costs of industrial firms. In its January report, it explained that it would automatically require the amendment of two major Acts of Parliament. We know that the Council of Ministers effectively settled these matters in December 1988, but the Committee did not even consider them until yesterday, when there was no debate, apart from a two-minute speech by the Minister, who apologised for their having already been settled in Brussels.
If, Mr. Speaker, you do not agree that the motion is out of order, can you not declare it null and void under Standing Order No. 41, which deals with irrelevance? Why should the time of the House be wasted on silly motions to approve or disapprove when sovereignty has gone and the decision was made in Brussels in December? This makes nonsense of our consideration of European legislation. May we have a decision on the motion, or else do away with it entirely, instead of wasting the time of the House, the Clerks and yourself?
Unlike the hon. Member for Southend, East (Mr. Taylor), I do not think that the fact that this was decided in Brussels before debate is strictly relevant to the central point. If on the Order Paper there appears a motion on a document that was sent to Committee by resolution of the House under the appropriate Standing Order, surely there should be at least an interval of a day between the appearance of the Official Report of the Committee's proceedings and of a motion in the House. That would enable hon. Members to table amendments to it for discussion the following day.
I do not dissent from what the hon. Member for Southend, East said about the importance and unusual nature of this matter, but, whatever the content of the Committee's resolution, my point stands.
Mr. William Cash (Staford) : Further to that point of order, Mr. Speaker. A resolution of the House of 1980 declares that in all possible circumstances there should be a debate before the adoption of a common position on a
Column 399matter of this sort. If that is not strictly adhered to, our difficulties when considering matters vital to the future of industry in this country will increase. I should be grateful if this could be given further consideration in the appropriate quarters.
Mr. Hugh Dykes (Harrow, East) : Further to that point of order, Mr. Speaker. I apologise to my hon. Friend the Member for Southend, East (Mr. Taylor) for missing his first few remarks after the Division. Although our views about membership of the Community may vary, I echo my hon. Friend's remarks--he may look surprised--and those of my hon. Friend the Member for Stafford (Mr. Cash) and of the hon. Member for Newham, South (Mr. Spearing), the Chairman of the Select Committee on European Legislation.
Whatever our views, procedures must be correctly followed. The House needs the essential elements of a scrutiny procedure to be effective. Recently, and for all sorts of reasons, there has been a disturbing increase in the number of decisions taken by the collective institutions of the Community before matters have been properly considered by the House. That must be put right. It behoves us all to get it right. Hon. Members are worried, and we seek your guidance, Mr. Speaker.
The Lord President of the Council and Leader of the House of Commons (Mr. John Wakeham) : I have not had much time to consider this matter, but, in view of the remarks made by hon. Members on both sides of the House, it would perhaps be better if the Government did not move the motion tonight so that I can look into it.
Motion made, and Question proposed, That this House do now adjourn.-- [Mr. Durant.]
Mrs. Gillian Shephard (Norfolk, South-West) : I am grateful for the chance to raise this subject. I hope that the heat and light engendered by the publication of the NHS review yesterday will not deflect attention for too long from Government action on community care following the Griffiths report.
What is community care? My hon. Friend the Parliamentary Under-Secretary may be interested to know that a seminar of 80 hon. Members held in the House last July gave at least 80 answers. The evidence of the Department of Health and Social Security to the Select Committee on Social Services in 1984-85 gave a catch-all definition :
"Its objective is to enable an individual to remain in his own home wherever possible rather than be cared for in a hospital or a residential home."
That definition, whose blandness is due, no doubt, to the fact that it has to encompass a wide variety of patient and client groups, is almost meaningless for mental illness and especially for schizophrenia, which fills more hospital beds than any other illness and to which I intend to devote this debate.
We know the facts about the incidence of mental illness, but they will stand repetition. Even if one knows academically that one in six people will need professional help for a mental health problem during a lifetime or that one person in 100 suffers from schizophrenia, one does not realise it until it hits one's friend or family or oneself. Community care for the mentally ill is not new. Since 1962, there has been active encouragement of the development of local alternatives within the community to the large Victorian hospitals. The anti-psychotic drugs, introduced in the mid-1950s, helped many patients to live almost normal lives in the community. Proof of that is that in the mid-1950s the psychiatric hospital population stood at about 150,000 and it is now about 60,000. A more significant figure is that there are 200,000 admissions and discharges to and from psychiatric hospitals each year.
Mr. Patrick Thompson (Norwich, North) : I wonder whether my hon. Friend is aware that nine out of 10 hospital admissions for people suffering from schizophrenia are readmissions. Does she agree that districts should, therefore, review, slow down or even stop the closure of mental hospitals until at least adequate alternatives have been found? I should be interested in my hon. Friend's comments on that.
Mrs. Shephard : I am grateful to my hon. Friend for his intervention. I know that he takes a keen interest in the subject. I shall be dealing with the question that he has raised. The point about readmissions for schizophrenic patients is that it is the nature of their illness that causes them to relapse. I hope to deal with that matter later.
Mental illness is costly. The Government spend about £1.4 billion on it every year and to that we must add social security payments, the cost of social services provision and a huge drugs bill. The psychiatric drugs bill amounts to about a quarter of the national total. Can we be sure that we are obtaining real value and the best care for patients
Column 401and their families from such a substantial sum? Is the 10 per cent. of it that is devoted to community care enough if we mean what we say about its importance?
In its report last April, the Public Accounts Committee asked some searching questions about community care. It pointed out the need to ensure in any review of the policy that not only should there be adequate provision for individuals, but that care should give value for money. It said that, although community care had been an official policy for years, there had been no systematic monitoring of the way in which it was working. It said that the operation of joint planning and its financing was still not satisfactory. I have often said, in the House and elsewhere, that in joint financing every pound is handled 12 times by a combination of committees and procedures, and one has to assume that that reduces its value to the individual patient. One of the Committee's most significant points was that, while improvements in planning and efficiency were being required of health authorities, they were not and could not be of local authorities and that sometimes resulted in an uneven match between the closure of large hospitals and appropriate systems of local authority care.
The overall picture in the report was not of a service lacking in resources, but of a service in which resources have to be used in a way that is difficult to manage because of budgetary conventions and without clear policy guidelines and information about the effectiveness of the policy in the first place. I hope that when the Government issue their response to the Griffiths report those questions will be considered, and in no area more urgently than schizophrenia.
We know that some areas of the country have developed effective services in the community for the mentally ill. In my constituency, the West Norfolk and Wisbech health authority has a substantial budget of £3.5 million with which to help its mentally ill patients. There are 60 acute beds with 26 for long-stay patients, a further 88 beds for the elderly mentally ill and 140 day places, some of which are run successfully with the voluntary sector. Future plans involve drop-in centres and a sensible use of section 117 with the social services.
Monitoring the effectiveness of the services is being carried out in another part of my constituency by the Norwich health authority, with a research project, mounted with the university of East Anglia. I know that the Department of Health is conscious of the lack of information with which to evaluate community care and mental illness services in general. As the Minister's predecessor, my hon. Friend the Member for Derbyshire, South (Mrs. Currie) said to MIND in her speech in November :
"we need a clearer picture of what is going on at a local level. During this year and next we will be looking closely at what we have on the ground. Particularly from the point of view of the patient." I am delighted that that question is being vigorously tackled in the Department and feel sure that much good practice will be discovered to help areas where provision and practice are not so good.
However, I believe that in all areas there is one group of patients which the system is at present failing. They are either avoided or they are not offered adequate support when not resident in hospital. The problems that they and their families encounter have been given useful publicity by the National Schizophrenia Fellowship and the campaigning group SANE, which stands for
Column 402Schizophrenia: A National Emergency, which rightly recognises that much public education as well as better organised services are desperately needed.
The problem of who should treat small groups of severely ill patients who, as part of their illness, do not recognise the need for medication and who, if they do not take that medication outside hospital, present severe problems for themselves can be tackled. I shall propose a number of solutions--I hope that my hon. Friend the Minister is relieved to hear that.
However, I should first like to give some examples of such patients and their families. They illustrate that for those patients, no matter how good the community care network, discharge from hospital can lead--and all too often does--to relapse due to lack of medication, to breakdown, often in harrowing circumstances, and to their eventual readmission to hospital.
One mother wrote to me about her schizophrenic son :
"Like most schizophrenics he will not go voluntarily to hospital. So when his social worker finally decides that he is a danger to himself' his removal to hospital involves his GP, his psychiatrist, his social worker, and at least one police officer. At this stage his home has deteriorated into almost unbelievable squalor What is needed are section orders that can run for much longer than 6 months and/or community treatment orders whereby those who need continuing treatment to keep them stable can be compulsorily treated at home." Another letter states :
"I wholeheartedly support efforts to put into place a Community Treatment Order. When our daughter gets treatment early in the episode it can last as little as 3 weeks. When neglected she gets into all manner of troubles and can be as long as 8 months in the recovery."
Those two examples, from many hundreds that I could have chosen, illustrate that the problem for that group is agonising and that it is at least as agonising for the families, who have to live with the notion of their relative becoming a hostile stranger and with the gnawing uncertainty of what will happen when he or she leaves hospital. The scale and nature of the problem faced by those people has been highlighted by an excellent series of articles in The Times and The Sunday Times by Marjorie Wallace and in a number of programmes on television.
What can be done? I have three groups of suggestions. The first is non- controversial ; the second is financial so my hon. Friend will make up his own mind about whether it is controversial ; and the third is very controversial as it involves changes in mental health law and has implications for the patients' civil liberty. First, there should be increased public awareness of the problem. MIND, the National Schizophrenia Fellowship and SANE have done invaluable work in giving publicity to schizophrenia. The public needs to be educated about the fact that the illness can strike suddenly, without warning and in any family. A public that is educated will also be educated about ways to help. There should also be a code of practice to be used in conjunction with the Mental Health Act. I hope and believe that this is in course of preparation in the Department of Health, and it is eagerly awaited.
There is no excuse for any group of patients ever to be disadvantaged because of faulty co-operation between agencies or professionals, yet this is precisely what can happen to people with schizophrenic breakdown in the
Column 403community. We need clear guidelines, personal accountability by professionals, and monitoring standards, and I hope that the code, when it appears, will provide all of these.
There needs, too, to be much more information about what actually happens to individual patients on discharge. I have said already that, although everyone pays lip service to the concept of community care, we have no idea if different forms of it are effective.
I understand that SANE is hoping to launch a survey, to be conducted by Professor Jones of York university, which is to follow 1,000 patients discharged from seven hospitals. The survey will trace where and when breakdown occurs, if it does, and will be able to offer thoughts on what has been good practice. SANE is raising a sum of money to offer towards this research. I believe that it hopes to meet my hon. Friend or his colleagues in the near future, and I hope that its request that that sum be matched will be considered favourably.
Those who plan services must recognise that both sufferers and their families want asylum and hospital admission to be part of the range of services to which they can have speedy and hassle-free access at times of breakdown. Support for the families might even prevent breakdown in a certain number of cases.
My second set of solutions concerns finance. The Government are spending huge sums of money on the treatment of mental illness and on community care. The cost of keeping large, old-fashioned hospitals open is a heavy burden on any budget, while the funds that would be released by closure could help in both revenue and capital terms. I am not arguing that these large, old hospitals should be closed before the alternatives, including asylum, are in place, but the peculiarities of health and local government year-on-year budgeting make the co-ordination of closure and replacement provision almost impossible to achieve.
I have great hopes of the review in that it itself suggested a number of flexible ways in which health authorities might look at their budgeting, and that that flexibility, which perhaps could involve mortgaging against assets, or borrowing against assets, could be applied to this area where it is much needed. The arrangements for bridging and for dowries for patients that were introduced in 1983 were of great help, but they were hardly the mechanism one would choose if one were setting up the system from scratch. I think the funds are there but are locked up, and they need to be unlocked for the benefit of patients.
Finally, there is the more controversial suggestion, which enters the difficult moral sphere of civil liberty. It seems clear to me that what is needed, now that much care of the mentally ill and, therefore, of schizophrenic patients will take place in the community, is a recognition of that fact in mental health law. It is true that a sensible application of sections 2 and 3 of the Act, which could be made clear in the code, would help matters without a change in the law.
It is also true that more extensive use of section 7 guardianship, which as yet has hardly been tried by the local authorities, would also give help without a change in the law. But many schizophrenic patients and their families argue for something stronger, some form of
Column 404amendment to the Act that will allow for compulsory treatment within the community. Indeed, amendment will be needed in any case since, under the Act, compulsory treatment is allowed only in hospitals, and in future many patients will be in hostels or other residential facilities.
The Royal College of Psychiatrists has, I believe, considered community treatment orders. So has NAHA. The advantages of a community treatment order include the fact that community treatment is available as an alternative to detention in hospital, and the order can provide a legal framework to encourage compliance in the matter of medication and thus prevent breakdown and readmission. There can be no doubt that such an order would do an enormous amount to increase the confidence of families having to care for schizophrenic patients, in that they would know that at least breakdown due to a lack of medication would be avoided. On the other hand, many would argue that such an order goes against the very idea of civil liberty.
The Mental Health Act Commission makes two further suggestions for amendment of the Act, both of which I hope my hon. Friend will consider carefully. They concern the power of guardianship. In section 7 the power to require the patient to attend at places and times specified for the purposes of medical treatment is not accompanied by a specific authority to convey. The disadvantages of that are obvious and need not be illustrated. Clearly, if guardianship is to be regarded as a serious alternative, the patient must be conveyed to the place, but as the law stands there is still an omission. The power to convey could get the patient to the place--as a horse can be led to water--but unless a power were added to require him to take the medical treatment as prescribed by his responsible medical officer it would be of little use conveying him anywhere.
In any eventual legal solution--I am confident that there will have to be such a solution to reflect the change in practice which is being encouraged --I hope that the interest of the patient and his family will be paramount, and not those of warring professional groups. That sentiment, indeed, goes for the whole debate. The plight of schizophrenic patients and their families through the nature of their illness is too acute to be ignored, and I hope that the Government's eventual consideration of the Griffiths report will include specific solutions for them. They should not be forgotten. 10.50 pm
The Parliamentary Under-Secretary of State for Health (Mr. Roger Freeman) : I am grateful to my hon. Friend the Member for Norfolk, South-West (Mrs. Shephard) for raising this important subject. I consider it one of the most important with which I have to deal at the Department, and my view is clearly shared by many hon. Members on both sides of the House.
My hon. Friend has spoken with authority, based on what must be a unique combination of experience as a member of a local authority social services committee, chairman of a health authority and a Mental Health Act commissioner. She has made several very pertinent observations, and some practical suggestions, to which I shall respond as positively as I can.
With your permission, Mr. Speaker, I shall take a few seconds--as this is the first opportunity for me to do so--to pay tribute to the former Member for Kettering, Mr.
Column 405William Homewood, who has recently died. He lived in Market Harborough, worked in Corby and represented Kettering between 1979 and 1983. I am sure that many other hon. Members on both sides of the House will wish to send best wishes and condolences to his widow. His work in the House will be long remembered.
Ever since the early 1970s it has been common ground that, as resources allow, health services for those suffering from schizophrenia and other forms of mental illness should be locally based rather than focused on the traditional, old-style mental hospitals with which we are all familiar. The aim is for a comprehensive range of local hospital and community services, associated with appropriate social services provision and voluntary sector facilities, to meet local needs. I think that all hon. Members agree with those principles.
As those local services are developing, the number of beds in the older hospitals are being reduced, and some of the hospitals are closing. Locally based services have been developing. For example, in the 10 years to 1986, the number of day hospital places in England increased from 11,000 to nearly 19,000, and day centre places from nearly 5,000 to over 9,000. I emphasise, however, that hospital closures should be occurring only as a consequence of the development of better alternative forms of provision. The closure of hospitals per se is in no sense a primary aim of Government policy. While, I believe, virtually everyone supports this policy in principle, there are genuine concerns about how it is being implemented in practice. For example, the National Schizophrenia Fellowship, an organisation that we much respect, believes that there is a danger that the total number of hospital beds has already fallen--or soon will fall--below the level required for patients needing full-time care. In the last year or so, two new organisations--Schizophrenia: A National Emergency, or SANE, and Concern--have been established to express broadly similar worries. As my predecessor made clear in her speech to last year's MIND annual conference, there is no going back to the old days of hospitals with 2,000 or more beds and wards of 60 patients. Equally, we are determined that the move to locally based services should be properly planned and implemented, so that those needing treatment can receive it in the setting appropriate to their circumstances, whether as out-patients or in-patients.
We take the concerns expressed by the National Schizophrenia Fellowship, SANE and Concern very seriously. My officials maintain close contact with all three, and I hope to meet representatives of all three very shortly.
During the current year we shall be examining the position in each of the 14 English health authority regions, and I hope to visit as many as possible to discuss the point that my hon. Friend has raised--the transfer of patients from the old mental illness hospitals into the community, and how our policies are working out locally. We shall be talking to the regional health authorities, seeking a social services perspective from the social services inspectorate, and linking directly with voluntary organisations who represent sufferers and their relatives. Our aim is to gain a fuller understanding of how national policy is being implemented. My hon. Friend referred to relevant research on the follow-up of patients being sponsored by SANE and undertaken by Professor Kathleen Jones of York
Column 406university. We know of that research, and next week my officials will be meeting SANE and Professor Jones to discuss the research proposed. I can assure my hon. Friend that I shall be following that meeting with great interest and care. I know of the request for funding under section 64, and I shall certainly give it sympathetic consideration. The House may wish to know that the Medical Research Council spends about £4 million per annum and the Department of Health about £1 million per annum directly on research into mental health matters.
My hon. Friend referred to finance. That is, of course, important in order to develop new services before older hospitals close, but there is considerable scope for using more effectively the massive sums already tied up in services, particularly the capital value of the older mental hospitals, which often occupy 100 to 200 acres of land. The obvious problem with such disposals is that local services must be built before a closure is effected.
My hon. Friend suggests bridging finance to release capital from old mental hospital sites destined for closure, so that adequate provision can be made for care facilities in the community now. I am sympathetic to that plea and I can give my hon. Friend an assurance that the Government will be exploring actively how that can be achieved better, possibly with the co- operation of the private sector.
I draw the attention of my hon. Friend, and others interested in the matter, to the White Paper on the NHS review. It contains an interesting section about our approach to working with the private sector in order to release the capital value of sites, such as those of larger mental hospitals, that are in due course to close, and trying to release them earlier so that we can accelerate the construction of facilities in the community. My hon. Friend already knows that each region can use bridging finance for closures. For example, the East Anglia regional health authority has long been practising that policy.
My hon. Friend has also drawn attention to the possible contribution of legislation. Before I respond on the possibility of orders for compulsory treatment in the community, which would require new legislation, I want briefly to refer to the position in respect of a relevant piece of legislation already on the statute book, but not yet activated--section 7 of the Disabled Persons (Services, Consultation and Representation) Act 1986.
My hon. Friend will be aware of the importance of that Act in strengthening and extending legal provisions for disabled people and reinforcing their rights in society. That, of course, includes mentally ill people. Section 7 will require health and local authorities to assess the needs of people discharged from hospital after treatment for a mental disorder of six months or more, and officials from the Department are currently involved in a series of meetings with representatives of both health and local authorities, identifying the processes, procedures and costs that will make up the requirements under this important section of the Act.
I am taking a personal interest in those discussions, and I can assure my hon. Friend that we treat the matter seriously. Section 7 is not far from the forefront of my mind. I appreciate the significance of the notification to local authorities and the need to ensure that care is followed through and given to those discharged from mental hospitals.
Despite all efforts, it may be that some mentally ill people will refuse further treatment after they leave
Column 407hospital, even if that is considered essential by the treatment team responsible for their care. Legal measures to enable compulsory treatment to be given in the community have been suggested as one way forward with a small group of patients, and there have been discussions within such organisations as the Mental Health Act Commission, of which my hon. Friend will know, the Royal College of Psychiatrists and MIND. This is a complex area. Important civil liberty issues arise and there are strongly-held views on all sides about the applicability of compulsory treatment orders once a patient has been discharged from mental hospitals into the community and the extent to which an individual can be compelled to undergo treatment. Officials from my Department are listening to the debate with close attention, but to date no firm proposals have been put to us and little research is available from this country as yet. No changes in this difficult area would be considered without full consultations with all those concerned with mental health. This debate has assisted that consultation in no small measure.
My hon. Friend also drew attention to an extension of the powers of guardianship contained in the Mental Health Act 1984. I concur with my hon. Friend that there is no legal authority under the Act's guardianship provisions to convey a person anywhere, and nor is there a power requiring a person received into guardianship to take medication. The introduction of such a power is one of the options put forward by the Mental Health Act Commission in the debate on whether there would be a power compulsorily to treat people in the community. That is a suggestion worthy of serious consideration, and I shall certainly reflect on my hon. Friend's remarks. I know that my Department's officials will pay particular attention to her comments on that subject.
My hon. Friend referred to the code of practice. We are working on the code of practice required under the Mental Health Act 1984 and I intend saying something definite on that subject very shortly. My hon. Friend may press me as to what "very shortly" really means. As far as I am concerned, it means within the coming months. It is most important to get the code of practice right, and I would much prefer to take an extra week or month doing that rather than rush into publication.
Even more important than treating those who fall ill is seeking to prevent illness. Much action on prevention must await scientific advances and a better understanding of the origins of the major mental illnesses. However, enough is known already for it to be realistic and urgent to place greater emphasis on services promoting good emotional and psychological health among children and adolescents,
Column 408and on ways of reducing the risk of relapses for those who have suffered from the major disabling conditions such as schizophrenia. My hon. Friend the Member for Norwich, North (Mr. Thompson) referred to that aspect in his intervention. He is right to draw attention to the fact that, sadly, those who are readmitted for the second or third time are those who have, by definition, suffered in the past. This is not the moment for me to elaborate on our plans for that area, but I simply register the fact that, henceforth, prevention will be a key element of Government mental health policy. My predecessor played a valuable role in highlighting the importance of health promotion and the prevention of ill health in respect of physical disabilities. I see it as my task to extend her work into the field of mental illness, and to deal with its prevention. My hon. Friend the Member for Norfolk, South-West raised the question of the need for increased public awareness, and the House will be interested to know that the Health Education Authority has submitted proposals for the coming year that include the development of a mental health programme. One of its aims is to raise public awareness.
Before concluding, I must make reference to the deep interest that there is in all parts of the House in community care issues in general and in Sir Roy Griffiths' report in particular. Community care is a subject to which the Government attach great importance. It is of vital concern to the many thousands of people throughout the country who themselves need care, or who help provide it to their friends and relatives. We are fully committed to playing our part in ensuring that their needs are met. That is why we have taken time fully to explore the various options before us, and to take careful account of the numerous representations that we have received. We have not as yet reached a final conclusion, but we are actively engaged in working out our plans for the future of community care. I assure the House that the Government are mindful of concern that action should not be unduly delayed--we share that concern. For that reason, and as my right hon. and learned Friend the Secretary of State for Health told the House last week, and repeated earlier this week, we hope to be in a position to bring forward our own proposals in the near future.
In conclusion, I am grateful to my hon. Friend for raising the issue of services for those with a mental illness, and for her balanced and practical approach. I hope that the House will, in turn, welcome what I have said in response.
The motion having been made after Ten o'clock, and the debate having continued for half an hour, Mr Speaker-- adjourned the House without Question put, pursuant to the Standing Order.
Adjourned accordingly at three minutes past Eleven o'clock.
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