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Will the White Paper spell out how the Government's proposals relate to those contained in the White Paper "Working for Patients"? Will self-governing trusts have responsibility for ensuring that adequate community care provision is available for discharging those in need, such as the elderly after an acute illness? Who will be responsible for community units that opt out? Will it be the Secretary of State, the health authority or local government? What guarantee will there be that health authorities will provide the medical services such as geriatric care, including geriatric psychiatry, that any care in the community requires? Will they retain enough funds to provide community services, or will those funds be drained off by the acute sectors, the hospitals?

The dividing line between medical care and social care is not always apparent or easy to define. It is important that an atmosphere of co- operation and co-ordination exists between all agencies so that the client and carer do not find themselves stuck in no man's land, which often happens now. One of the important measures to assist in that direction will be to ensure that each agency has sufficient funds to prevent the practice of dumping.

It is important also to ensure that all sectors are involved and represented at strategic planning level and in the plans for the everyday operation. Without clear-cut lines of responsibility between the agencies and without safeguards for the consumer, there could be catastrophe. Changes to the National Health Service taking place at the same time as community care services will create chaos. I only hope that both services come through them in a recognisable form. It will be virtually impossible to plan for the future, as there will be so many unpredictables. One essential step is to extend the statutory duty of local government to include all community care client groups. The proposals that are set out in the White Paper, which we hope will create a system that is based on individual selection and packages of care, must include national guidelines and standards of care, with the mechanisms to monitor them, so that we can ensure a degree of equity and access to services along with quality of services.

The client and the carer should have easy access to information that sets out their rights and their entitlements, including the right to be consulted and involved in the decisions that affect them. They have a right to advocacy and to a simple procedure for complaints.

On 12 July, the Secretary of State said :

"The great bulk of community care will continue, as now, to be provided by family, friends and neighbours."--[ Official Report, 12 July 1989 ; Vol. 156, c. 976.]

I hope that the right hon. and learned Gentleman has taken on board some of the comments and concerns that have been expressed by the Carers Association. I have the honour of holding office within it in the branch that is local to me. Demographic trends show clearly that the elderly population is increasing rapidly while the proportion of those who are available to care for the elderly is declining. Another factor is the trend of Government Departments to pursue polices that are designed to attract women into the work force. I hope that the White Paper will contain a package of care for informal carers that takes into account their loss of earnings and career opportunities as well as the need for a wide range of support services, including short and long-term respite care.

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I call upon the Government to show their good faith by implementing in full the Disabled Persons (Services, Consultation and Representation) Act 1986, which among other things provides for local authorities to take the needs of the carer into account when making assessments. If the Government were to provide the resources to enable local government to carry out its duties under the 1986 Act, I would have rather more confidence in assurances that adequate resources will be provided for whatever the White Paper may contain. If the Government were to accept the premise that care in the community is not a cheap option and commit themselves to providing sufficient funds, they might find an improvement in the popularity of the Conservative party among the electorate. A MORI poll, which was published in Reader's Digest under the heading "Britain, a Caring Society", shows that on average people are prepared to add £2.28 to their individual tax bill to support disadvantaged groups. In the order of priority it was those groups in need of community care that appeared at the top of the list.

Community care should not be left to charity. It is one of the rights that is part of being born into a privileged and civilised society.

6.5 pm

Mr. David Atkinson (Bournemouth, East) : I welcome the Government's response to the Griffiths report as, I believe, do all the organisations which are involved in the caring services, even including, perhaps, the British Medical Association.

My right hon. and learned Friend the Secretary of State is right to reaffirm the principle of community care and to seek to build on what has been achieved already which has been considerable during the past 10 years. There has been a 40 per cent. increase in resources in both health and social services for community care. That it is no mean achievement and the Government deserve full credit for bringing it about. The increase in benefits for supporting people in private residential homes increased from £10 million a year in 1979 to no less than £878 million last year. That is remarkable.

It is vital that the rate of increase be maintained, for three good reasons. First, we must ensure that the Griffiths recommendations are properly implemented by the new community care authorities. Secondly, we must be able to cope with the increasing number of elderly people, about which we are increasingly being warned. We are told that the problem will hit the country generally, but we in my constituency have more experience than most of accommodating an elderly population, and I think that we do so quite successfully. Thirdly, I believe that there is a serious underestimate of the numbers of the mentally ill who are in need of care. Their numbers will increase in the years to come as a result of the breakdown of family life and of marriage. The trends are upwards. There are also the consequences of an inability to cope with the technological changes that are taking place, which will undoubtedly continue in future. All of us have met such people in our surgeries and have done our best to help them. In passing the buck of community care to social service authorities we must ensure that they will have enough bucks to do the job. The Dorset authority is concerned because neither it nor the Government have undertaken

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any accurate quantification of demand and cost. The authority feels that there will be a shortfall and it looks to the White Paper for reassurance. It is concerned especially, as I am, that social security payments to people in the community for board and lodging have not kept pace with the increase in the cost of living. From the representations that I continue to receive from members of Dorset Association for Sheltered Homes, who I believe undertake one of the most valuable and underrated forms of community care in offering hostel and sheltered lodging for the mentally ill and those who would otherwise be homeless, it would appear that current payments no longer meet the cost of living, especially as the maximum rate for hostels has been pegged since 1986. I do not see how such establishments can be expected to survive much longer on that basis. I must warn my hon. Friend the Under-Secretary that unless the private and voluntary sectors that are involved in community care are financially viable, far from filling the greatly enhanced role that is expected of them, as recommended by the Griffiths report, they will contract and the recommendations set out in the report will not succeed.

It is right, however, that the social service authorities should be the new community care authorities. Having chaired a social services area committee, I believe that county councillors, who are in close partnership with their officers and with local carers, are in a unique position to identify local needs and to initiate new ideas. Why cannot those who represent areas that are covered by neighbourhood watch schemes ascertain what can be done to extend the security aspects of the schemes to include care?

A widespread complaint that I receive from carers is that there is insufficient information about the care services that are available. Perhaps county councillors can ensure that sufficient information is available.

The new community care authorities will have some extremely challenging decisions to make, not least the future of local residential homes. As my right hon. and learned Friend the Secretary of State has emphasised, and as my hon. and learned Friend the Minister said when he opened the debate, the authorities will have new roles as enablers and funders of care, for which they will have a budget, rather than being mere providers of social and residential care.

This policy, however, must be phased over years. The sudden announcement of a proposed closure of a residential home without any immediate apparent alternative would not encourage public support for community care. It would have a devastating effect on the residents in the home, who had expected to live out their remaining years in what had become for them their one and only home with their fellow residents and the staff, who had become to them their family. There is such a case in my constituency with the recommended closure of the Henley Court home. The residents--my constituents--are understandably concerned and confused about what will happen to them, but no one in authority can yet tell them what their future will be. Elderly people, for whom the local authority has undertaken to care, cannot be treated in that way.

The same principle should apply to the proposed closure of a residential home as that which the

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Government rightly insist should apply to the closure of mental hospitals--that is, that a clear plan for suitable alternative provision for the residents must accompany any plan for closure. All the residents should be kept together if that is possible, and if it is their wish. My hon. Friend the Member for Bournemouth, West (Mr. Butterfill), whose constituency also faces the closure of the Labourne House home, has asked to be associated with the concerns that I have expressed.

As social service authorities become the enablers of care, there will be a wider interest in residential and nursing care opportunities outside their own areas, but I question whether there is an adequate centralised source of information available. I commend to my hon. Friend the Minister the Elderly Accommodation Council, a charity for which I act as honorary adviser, without an interest. It has computerised information on most of the residential and nursing homes and sheltered housing throughout the country and provides a unique placement service for carers.

There remains considerable scope in the private sector for better inspection and monitoring of residential and nursing homes, notwithstanding the improvements that the Government have introduced during recent years, and which both the Griffiths and Wagner reports recommended. I fear that frail, elderly and confused people may be regarded as a soft touch by unscrupulous and insensitive carers, who provide services devoid of any quality and imagination. They must be snuffed out.

I wish to confine my remaining remarks to the care of the mentally ill, in which I take a personal interest as parliamentary consultant to the National Schizophrenia Fellowship. As many hon. Members are aware, that organisation is composed of the relatives and friends of sufferers. They are the real community carers, who work without pay, support, training or holidays, and often for a lifetime. In many ways, they are more expert than the experts in dealing with schizophrenia because they must live with what is happening on the ground. They did much to campaign for the Griffiths review, and they are delighted with the concept of the comprehensive care package as outlined by my hon. Friend the Minister in his statement on 13 July. However, they remain concerned at the rising percentage of readmissions, which suggests a lack of social support for those who have stayed in hospital for less than six months. Of the 26,000 people diagnosed as suffering from schizophrenia in 1986, 24,000 left hospital after a stay of less than six months. As most of those are not covered by section 117 of the Mental Health Act 1983, many experience squalor, misery and neglect, which in turn leads to crime and suicide. My private Member's Bill dealing with schizophrenia after-care was especially directed at those people. It is still before the House, and it seeks to disapply the after-care of schizophrenics from current legislation concerned with the mentally ill, and to provide a package of measures exclusively for those people, so that following discharge they do not slip through the net of community care. I urge my hon. and learned Friend the Minister to ensure that his individually tailored care programmes for those dis-charged will include all that my Bill proposes.

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6.14 pm

Mr. Frank Field (Birkenhead) : I think that this is the first time that I have followed a speech of the hon. Member for Bournemouth, East (Mr. Atkinson). I was somewhat confused when listening to him because he suggested that out of the proposals would come a community care authority. My criticism is that while that name may be used, in reality there will be no such body emerging from the proposals that the Government put before the House prior to the Summer recess. Like the hon. Member for Eastleigh (Sir D. Price), I am pleased that the matter is being debated prior to the publication of the White Paper because the Government might listen to what we say today. The hon. Gentleman was right to remind the House that the Government are now a thinking and listening Government, but my old gran used to say that the proof of the pudding was in the eating. We shall await the White Paper to determine whether there has been any change in substance.

The hon. Member for Eastleigh made a powerful and important speech. He probably knows more about this topic than any other hon. Member in the Chamber. He said that it was unlikely that there would be a community care authority--not for the reasons that I shall give, but because most care takes place in the family, unnoticed unrecorded and unaided. I hope that the new caring, thinking Government will, before they produce the White Paper, dwell on that point and come up with some concrete proposals which, although they will not cost a great deal of money, will mean a great deal to those who care for others in the community.

It is an interesting point that when Ministers come to the Dispatch Box they talk about the wonderful "job" that carers do ; they do not talk about an "activity" or a "pastime". Most of us understand the meaning of "job". It is work and employment. Yet for all the reasons given by my hon. Friend the Member for Livingston (Mr. Cook), the Government treat it as far from a job. When carers cease their caring activities they are not eligible for any benefits in their own rights, yet the provision of benefit is important to them. They face real difficulty re-entering the labour market, so I hope that the White Paper will cover training schemes for some of the younger carers who wish to re-enter the labour market when those for whom they care have died. They should also be eligible for unemployment benefit. Those would be two small but important reforms, which should be announced in the White Paper if we are really serious about changing the status of carers.

I am facing the difficulty faced by all my hon. Friends when we have to follow the opening speeches of my hon. Friend the Member for Livingston. Indeed, while sitting here today I thought of a reason why I should not vote for him in the shadow Cabinet

elections--although I assure him that I will not follow that through. There is real difficulty following him because, on the terms of the motion before us, he has actually completed the debate. Perhaps we should be big enough to say that the debate is over, that we await the Government's response, and all go home. I do not intend to cover the ground covered by my hon. Friend, but shall take the debate a step further.

The Government say that their proposals are the Griffiths proposals, but, as my hon. Friend clearly said, they are not. I therefore fear that there will be the opposite in community care to that which the Government say they

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want from their health proposals, which is money following the patients. If the Government go down the road announced by the Secretary of State, the opposite will be the case and a major opportunity will be lost. It is one reason why I disagree with the hon. Member for Bournemouth, East. If there were to be a community care agency, the Government would be radical and brave and bring together all the functions of the different statutory authorities, whether the local authority, the family practitioner committee, social services, education or housing, and put them into one health and community care authority.

Indeed, we could go one stage further--as the hon. Member for Eastleigh has done in private conversation, which I am sure he will not mind me putting on the record--and that would be to put such a body in charge of the whole budget. The reason that the manager, or whatever he will be called, will not be able to deliver on the care package referred to by the hon. Member for Bournemouth, East is that he will have to deal with all those different authorities. We know perfectly well who will win. I want reforms that will deliver to the consumer. It is political consumerism that will dominate the next decade and the decade after that. Unfortunately, the Government's proposals are backward looking, backing the producer and those with vested interests. Many hon. Members with constituents with an interest in receiving a necessary package of care will find that their needs take second place to those of the producer.

Mr. Morgan : I want to confirm what my hon. Friend has said about the package of care that should be produced by the combined resources of the health authority and the local social services department. It was drawn to my attention last night that in Cardiff, following the withdrawal of the community evening nursing service, there has already, pre-Griffiths, been a deterioration. One elderly person, a stroke victim, has had his community evening nursing service withdrawn. Therefore, he has to be put to bed by the afternoon nursing service at 4 pm and does not get up until 19 hours later. He is mildly incontinent and, since the withdrawal of the community evening service, he has developed pressure sores which are turning into septicaemia. He will probably have to spend the rest of his life in hospital, costing the state a great deal more. That appears to be care in the community, Tory vintage 1989. That is not good enough.

Mr. Field : No, it is not. If the Government were serious about delivering the community care that the consumers--the people in need of care and the carers--need, the package that we are discussing today would be very different.

Let me make three suggestions to the Government. If they wanted to modify their proposals now and make sure that the money follows the patient rather than vice versa, those three suggestions would find a prominent place in the White Paper.

First, as we know that our constituents would lose out against the producers of the different services, it is crucial that each year part of the budget of those statutory authorities becomes footloose so that workers in hospitals can fulfil part of their contract working in the community.

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No amount of saying that community nursing is needed will deliver community nursing if people are trapped, via their contracts, into working in hospitals.

Secondly, while many people in need of care and those caring for them will be grateful not to have choices and to have delivered what the social services deliver to them, many others--a growing proportion--want a crucial say in the care that they get. If the Government do not want to turn the world upside down, they should be saying that part of the budget--an increasing part of the budget, if that is what consumers want--should be given to those who need care, or who care, in the form of vouchers. In that way they will be able to have more home helps or more community nurses and rather less institutional care. I fear that the institutions have vested interests and that they will deliver packages suitable to them, which may or may not be suitable to their constituents.

Thirdly, the Government should look carefully at one of their reforms about which they have forgotten and build up the side of community care which gives money to our constituents who need care and who are caring. If I were to ask hon. Members whether they knew what the independent living fund was, most would have only a vague recollection of having discussed it at some time. I shall give way to any hon. Members who can tell me how many of their constituents draw help from the independent living fund. None of my constituents do, but I hope to put that right shortly. Yet that Government initiative allows those who need to buy in care to do so, whether it costs as little as £2 a week or as much as hundreds upon hundreds of pounds a week.

If we were serious about a consumer-led community care policy, the Government would remove that benefit from the Official Secrets Act. Will the Minister give an undertaking tonight that some forms will be printed about that benefit and that they will be made available in post offices, citizens' advice bureaux, social security offices and general practitioners' waiting rooms? Hon. Members might even be given a few as well. The Minister should then say that that will be the development of the future rather than the forgotten benefit that the Government announced because they were so embarrassed about what they were doing to disabled people in the change to income support in 1968. That should become the flagship of the future development of community care. Rather than being covered by the Official Secrets Act, that benefit should play an increasing part. Many of our constituents would benefit enormously from receiving such a benefit. Let me give one example of what that benefit meant to a family in Wigan where the mother, because of her age, is finding it increasingly difficult to remember what is going on. Her daughters sleep with her during the week, but, because of the independent living fund, they are relieved of that responsibility at the weekend. Neighbours are paid--not a fantastic amount--to look after that lady, a resident in their road. The mother has dignity because she is paying for that care rather than putting on her neighbours. That makes a great difference to her and to her daughters and it makes a great difference to her neighbours and to the hospital services which would otherwise have to look after that lady across the river in Wigan.

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I understand why the Government have made the change from an open-gate system whereby anybody who is eligible for income support can pick up income support and go into residential care. However, until my hon. Friend the Member for Livingston spoke, I did not understand just how clever the Government would be in ensuring that the total budget does not go to the community.

For all its faults, the old system had one wonderful advantage, which was apparent to me from my surgeries, as I am sure it was to Conservative Members. In the absence of an adequate inspection system, daughters carried out inspections. I say daughters, because we are mostly dealing with old ladies being cared for by their daughters. Women live much longer than men. As my hon. Friend the Member for Livingston said, for all sorts of reasons it is women who have taken the lead role.

Because the money follows the old ladies, as soon as a daughter finds that a home is inferior, she works like billy-o to find another. Entry to that home was open because its owner knew that the money was coming from social security with the mother. However, I fear that, even if all the money goes to the social services departments, they will offer a list from which to select a home. We would then have the problem that residents of council accommodation experience when they want to move and the authorities ask what is wrong with where they are living since all sorts of other people are living there and why should they be so fussy about it. Once the bureaucrats take hold, the freedom to choose is lost.

I hope that I have effectively put across two points. We have a thinking, listening Government. The hon. Member for Eastleigh suggested that we cut the cant about worrying about the carer and start delivering something. The first easy move would be to ensure that when a carer ceases his work of caring he should have a full national insurance record for a pension and unemployment pay. Secondly, younger carers will have difficulty returning to the labour market. Let us make sure that we have training schemes to help them to do so. Many of them have missed 25 years of their career fulfilling their caring functions.

Thirdly, as I said in an intervention in the speech of my hon. Friend the Member for Livingston, I am struck by the number of carers who, six months after the death of the person for whom they cared, have a breakdown. It is at that point that the strain breaks through. We should be thinking not only about preventing such breakdowns but about providing adequate support if we fail to do so.

Despite all the Government's talk about making the consumer the sovereign body, I fear that in the hotch-potch of proposals which they call the Griffiths proposals, the consumer will be in the back seat rather than in the driving seat.

I advanced three proposals : first, that new contracts be issued to allow flexible staffing among the different bodies providing care ; secondly, that vouchers be introduced to enable people to choose the statutory body from which they wished to buy their care ; and, thirdly, that the Government put behind them their secrecy about the independent living fund and proclaim that, above all their other proposals, as the flagship for community care in the future.

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6.30 pm

Mr. Nicholas Winterton (Macclesfield) : The hon. Member for Birkenhead (Mr. Field) has done the House a great service with his contribution. The hon. Gentleman chairs the Select Committee on Social Services with considerable knowledge, compassion and commitment, and I believe that my hon. Friend the Under-Secretary of State is now on an upward learning curve for the purposes of his inquiries into the independent living fund. Perhaps, however, the hon. Gentleman was a little unfair to my hon. Friend in that that aspect is not really his responsibility, but that of my hon. Friend the Minister for Social Security.

Let me endorse the articulate message in the hon. Gentleman's plea about provision for carers. There is too much cant in this place about the importance of carers, and all too infrequently do we do anything about them. As my hon. Friend the Member for Eastleigh (Sir D. Price) said, without carers tens of thousands of people would have to be found places in residential accommodation or hospitals. Carers are therefore of paramount importance, and the White Paper on the Griffiths report should clearly devote much more thought to provision for them.

I thank my hon. Friend the Under-Secretary for visiting my constituency during the recess, thereby honouring a commitment that he made in the House in July. When he came to Macclesfield in September, he paid quite a lengthy visit to the Parkside hospital for the mentally ill, and also visited the young persons' unit in Macclesfield, which caters for young people with emotional and behavioural disorders. I know that he was immensely impressed not only with the facilities at Parkside hospital and the level of care provided by its staff, but with the tremendous work undertaken by Dr. Peter Wells at the young persons' unit, which is probably more successful than any comparable unit in the country. I hope that my hon. Friend will ensure- -as far as his responsibilities enable him to do--that the environment and level of care at Parkside hospital are not reduced when parts of the hospital are sold off for development, and that Dr. Wells's team can continue to provide fantastic rehabilitation, care and treatment for young people.

I also endorse what has been said by almost every speaker : that although we may be disappointed that there is not yet a White Paper on Griffiths, the Government are genuinely listening to the debate and will take on board the extremely good points that so many hon. Members have made. Those who have spoken so far are immensely knowledgeable : far from voicing instinctive views on issues about which they, in isolation, hold fervent beliefs, they have advanced informed proposals based on a knowledge resulting from lengthy involvement in community care.

How right my hon. Friend the Member for Eastleigh was to quote Lord Kelvin, who said that anyone who spoke of such matters should have the facts at his fingertips. Let me pick up the point made so articulately by my hon. Friend the Member for Bournemouth, East (Mr. Atkinson), who does a great deal of work for the National Schizophrenia Fellowship--with which I, too, work closely. He mentioned the 1986 figures relating to the admission of schizophrenics to mental hospitals in England, which totalled over 25,000. That figure is not plucked from the clouds ; it matches the figures for 1984 and 1985, and thus presents a typical picture.

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My hon. Friend did not, however, mention what I consider a particularly important figure. In 1986, 90 per cent. of schizophrenics admitted to mental hospitals were being readmitted after having a relapse. I mention that because it is clear to me that long-stay psychiatric hospitals are needed--in the right environment, of course, and rehabilitated and brought up to date. It would be a tragedy for us to allow such wonderful sites, some lying within communities, to be destroyed. My hon. Friend the Minister has seen Parkside hospital in my constituency : it has a superb environment of peace and tranquillity, and it is vital that that facility--as well as the building itself, and the superb staff who go with it--should continue in being.

I warmly welcome much of the Griffiths report ; I think it important, however, to put down a number of priority markers. In respect of assessment, I consider it vital to draw up a national scale of need so that even standards may be ensured throughout the country. That has been suggested by many organisations--not only those in the public sector, but private-sector bodies such as the National Care Homes Association. I welcome the Government's determination to achieve better standards. Surely, however, what is needed is a national registration and inspection system-- independent of any one sector and covering all residential homes--so that the independent private sector is not monitored only by the public sector, and the public sector does not in turn neglect its own house, which would be very dangerous.

As for resources and funding, it is essential--as the hon. Member for Livingston (Mr. Cook) said--that the care element of cost should be ring- fenced to prevent diversion of money for other purposes. If the Government are serious about Griffiths, they must ensure that that is done ; otherwise people will suspect--rightly or wrongly--that they are trying to get away with making the change on the cheap. That would be a tragedy.

As my hon. Friend the Member for Eastleigh said, the Social Services Select Committee carried out an in-depth inquiry into community care for the mentally ill and mentally handicapped, the report of which was published in the 1984-85 Session. The Committee concluded that, far from requiring less money, community care would inevitably require much more. Those involved in community care would have total trust in the steps proposed by the Government if they admitted that fact and were prepared to provide specific grants. There must be comprehensive and continuous monitoring of the performance of local authority social service departments, and local authorities would be happy for that to happen. The only way to ensure the delivery of the community care we need is to achieve proper standards throughout the country through an effective permanent body answerable to the Secretary of State, and I support those who recommend the establishment of a national community care agency or other body. Local authorities and the independent private sector would like to see such a body set up.

I have been committed for many years to the area of provision for the mentally ill. The Minister recognises that the mentally ill represent a special problem and I am aware of the representations that he has received from, among others, SANE and the National Schizophrenia Fellowship. Those representations have led him to take a close interest in what is happening to the mentally ill. I am pleased that the Government have issued instructions to the effect that no patient shall be discharged

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from a psychiatric hospital unless there is proper care and accommodation at an alternative site or within the community. I am pleased that the Minister stressed the importance of the fact that no mental hospital, such as Parkside, shall be closed until there is adequate provision, accommodation and care elsewhere in the community for the patients of that hospital.

Having taken an active interest in matters relating to the mentally ill for 10 or more years, my sincere view is that there is and always will be a need for long-stay hospital care, particularly for the more acute patients suffering from schizophrenia. I hope that when any application is made to the Department by a health authority for the closure of a hospital for development or other purposes--remembering how valuable such sites are and how badly many regional and district health authorities require the money-- the Minister will consider the request carefully to ensure that the standard of care and extent of provision for the mentally ill is in no way eroded by the closure. Indeed, he should feel sure that the standard of care and provision of accommodation for the mentally ill will be enhanced by such a closure and the money that might result from the development of the site.

I hope that the Minister, who now has a considerable understanding of the difficulties facing the mentally ill, will have taken on board the points that I and others have made and will ensure that when the White Paper is published, the mentally ill are, and will continue to be, a priority.

6.43 pm

Mrs. Gwyneth Dunwoody (Crewe and Nantwich) : A frightening aspect of the Government's attitude towards health policy is their ability to take what is basically an important idea--such as care in the community--and turn it into something different, like an organist who takes the song of a nightingale and turns it into the sound of a cash register.

It is clear from the debate that hon. Members on both sides fear what is really behind the Government's attitude towards care in the community. Indeed, already in the constituencies we can see some of the practical effects of the changes that have occurred. The hon. Member for Macclesfield (Mr. Winterton) spoke of mental health care. He and I, with the hon. Member for Congleton (Mrs. Winterton), have a common interest in a large hospital at Cranwich, where we see in microcosm many difficulties that I foresee arising from the attitude to Griffiths that is being taken by the Government.

Cranwich hospital is a large Victorian establishment spread over many acres. A great deal of money had to be spent on it, and despite some valiant efforts to update it, much remained to be done. The agreement among the patients and their families towards changes that would result in many of the patients going out into the community, and otherwise being cared for in changed circumstances, was obtained on the undertaking that, within the grounds of that enormous Victorian hospital, special village accommodation would be built. During the time I have been in the constituency, a different picture has emerged. There have been constant moves towards developing the acreage for housing and pressure to move the patients out of the existing buildings

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and into the community, in some cases irrespective of the quality of care that they would receive. There has been no agreement to develop the plans for building a village for the patients requiring to remain within the mental health care services.

That is the reality of the situation, and when we consider the steps that the Government propose, we are frightened about what will happen next. Having listened carefully to the Minister's remarks, I heard not one clear undertaking that he is prepared to go in for the necessary training, to provide the money that is needed and to find ways to seek suitable management facilities for the changes that he is proposing. There is no clear evidence that local authorities will be able to provide the increasing sums that will have to be made available to make those changes work. The difficulties that are now emerging in my constituency and elsewhere will lead to continuing problems.

There have been cases of purpose-built old people's homes run by county authorities closing because the authorities can no longer support them and provide the level of care that is necessary. Those authorities have been forced, despite tremendous local opposition, to close homes. I have in mind an elderly persons' home on a site which only one political party tried to retain on that site. The only alternative to what the local authority proposed was the suggestion that the home be put into a private trust.

Let us consider what happens when NHS or social service facilities are hived off into private trusts, and I speak with authority on this issue because what I have described has happened more than once. In the first instance, people are happy to give a commitment to retain a facility that they appreciate is essential. They then spend great effort and time trying to raise the necessary money. Within a short while, however, it becomes clear to them that the constant raising of cash to support such voluntary organisations makes it impossible for the facility to continue on a professional basis, as was the case when the state supported it.

I foresee, at a time when a determined attempt is taking place at what I can only call the balkanisation of the NHS, nothing but total chaos ahead, especially if the Government's proposals go ahead in parallel with hospitals being allowed to opt out and GPs having constantly to worry about the extent of their budgets and the facilities they can provide.

Who will police adequately the standards of care of the elderly in the community? Elderly folk in my constituency are already being told that there is no NHS facility available for them and that they will have to go into the private sector. When they are offered the list of homes to which they can go, they immediately find a discrepancy between the money available from social security and the fees that have to be paid in the private sector. Some people can absorb that difference, but many people cannot, and it represents an increasing difficulty.

What does one say to a state registered nurse, herself desperately trying to keep a private unit viable, when she says, "I have an elderly gentleman, who is doubly incontinent and who has had a stroke. He has been with me for three years, but I cannot get an increase from the state for his support and he has no living relatives or any assets to find the difference between my fees and the amount of money paid for his care"? If the Minister can give me the answer I shall be comforted. I assure him that

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that example demonstrates that the onus of care for an elderly person has been moved from the state and from those who should decide on the right level of care to the management of a private home, which is then faced with almost insuperable difficulties. In the future that problem will become more and more common. Those nursing homes will be forced to ask whether they should evict those who have been in their care and then worry about whether they will be picked up from the street outside or whether they should continue on a declining path until they reach the point when they can no longer produce viable profits to meet the economic demands necessary to keep those homes going.

This is the Government who insisted on the explosion of private health care and it is they who are closing down the local authority alternatives. For purely dogmatic reasons, they are making it impossible for many elderly people who want to remain within the state system to find a suitable place.

Time and again today the case has been made for real support for the carer. There is little reality in the glossy phrases used to praise those carers. We know that they find no joy in their situation even though they dearly love their relatives. When they are utterly exhausted they find it impossible to see that justice will be done to them under the existing system.

During my time in the House my grandmother, who was 98 and nearing the end of her life, was nursed at home. To give her 24-hour cover took five adults and three of them had medical or paramedical qualifications. I assure the Minister that few people in my constituency could offer that degree of cover. To say to a women of 5ft 1in that for all but one hour a day she must nurse an 18 stone, 6ft 1in man who has suffered a massive stroke is to condemn that woman to an insufferable life. Such care diminishes the quality of the carer's existence and frequently leads to a deterioration in the health and future life of that carer.

The paper before us gives no clear future plan for how health care will be delivered to the elderly or, especially, to the mentally ill. It is a glossy representation of an empty policy. If the Minister is sincere he will say not just that the Government are prepared to commit resources to meet the changes that they are suggesting, but that they are prepared to give training and to decide who will do the assessments and how they will be carried out. Above all, in the interim, the Government should make it clear that they will give sufficient resources to local authorities so that there is an alternative to private care. In that way, those who do not want to go out to the private sector can remain within local authority care in the places that they know and where they are and will be happy. I can tell the House what happens when one decants, to use the fashionable phrase, a number of elderly people from a home where they have lived for a long time. They save one a lot of bother ; most of them die. That is not my answer to health care, and nor should it be the Minister's.

6.54 pm

Mr. John Marshall (Hendon, South) : In the summer when I spoke in the debate on community care, I did so for precisely three minutes. I cannot promise to be equally brief tonight, but I am conscious of Mr. Speaker's advice that we should speak for no more than 10 minutes. Since the summer I have spoken to a number of people who have been the victims of the community care policies

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followed until now. I refer to the relatives and parents of schizophrenics who suffer twice over--they suffer the agony of the illness of their sons, daughters or relatives and they also suffer a sense of dissatisfaction at the hopelessness of the treatment offered to their relatives.

Common characteristics have been apparent in the cases that have been brought to my attention. The first is the acute difficulty that relatives encounter in having their sons or daughters sectioned. In one case, the parents told me that their son had been in and out of a mental hospital six times, but he had been sectioned only once. Another set of parents told me that their daughter had been in and out of mental hospitals for 10 years, but never once had she been sectioned. In another case a father walked into my surgery in an extremely distressed state. His son had walked out of Napsbury hospital, gone to the local building society, taken out all his money and travelled to Marseilles. The father had been asked to go to collect him or to ensure that he could be brought home.

There is no doubt that until the 1950s we were far too willing to force people to go into mental hospitals. I believe, however, that we have moved from one extreme to the other and that now it is too difficult for someone to be detained compulsorily. When someone deals with an individual suffering from a physical illness he knows that that person will agree to accept a course of treatment. We must accept, however, that in mental illness the course of medication may be unpleasant and that the victim may be unwilling to suffer it until the end of the course. When such people move into the community for care they are often unwilling to continue with their medication. Frequently that medication is unpleasant, frequently the patient feels cured and, frequently, there is inadequate supervision. Many patients discharged from mental hospitals are not registered with general practitioners. Who will supervise them? There is an inadequate supply of community psychiatric nurses and as a result many such patients go unsupervised. The parent of a schizophrenic wrote to me saying, "Brian never turned up for treatment and no one ensured that he did.". No one took any action to ensure that that individual who needed treatment undertook it. As a result of such neglect, a number of those who have been let out and who have been recommended for care in the community turn to violence.

In one case I was told that Dr. X struck off the individual because of his bad behaviour and that no other practice was willing to accept him. That man has no solicitor either. The solicitor refused to act for him because of his impossible behaviour. The man has no home. The hostel that the probation officer found for him has banned him because of his aggressive and impossible behaviour. It is ironic that some of those who sleep rough are people who have been sent into the community for care, but they end up with no doctor, no solicitor and no home. As a result, a number of such individuals turn to crime. It was written of one of my constituents :

"He returned to live in Barnet. Since then he has been arrested by the local police a few times. They have called the crisis team who do nothing. Next morning Hendon Magistrates Court do nothing." It is a supreme irony that we are closing mental hospitals, which are expert at treating the mentally ill, and we are building additional prisons where some of the mentally ill who have been sent into the community for care in the community will end up. Many of those who are sent to receive so-called care in the community indulge in

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anti-social behaviour. I remember a deputation coming to one of my surgeries and asking for help. They lived in a block of council flats where one of their neighbours was a discharged patient receiving care in the community. He played his hi-fi system for 16 hours a day starting at 8 o'clock at night. That was not care in the community for him and he was causing many problems for his neighbours. It was written of another of my constituents :

"His neighbours live in fear of his verbal abuse, loud music played day and night and at times violent behaviour."

All that is a denial of care in the community. It is good neither for the victims nor their neighbours and relatives.

Of course, these stories cover only a minority of schizophrenics. Many will recover, but I am referring to the hard core who will always be vulnerable. For them a mental hospital is a genuine asylum ; a refuge for them, their relatives and the rest of society. We must accept a greater role for compulsory care. There must be a greater willingness to issue a section notice. For those who are going into the community, a community treatment order would ensure that the treatment that they were meant to receive was undertaken. Surely it is nonsense that people should be encouraged to go into the community to receive treatment and then not receive adequate treatment with no one to check up and find out what is going wrong. Only if that happens will the individual have a chance of recovering. Everyone who leaves a mental hospital must be registered with a general practitioner before entering the community. What hope has he if he goes into the community without being registered with a GP? Finally, Dr. Tannoch was surely right to say that there should be a computerised list of all those who have been released into the community so that people can check up every six months that they are receiving the care and attention they deserve. Every six months we all receive a notice from our dentist requesting the pleasure of our company. We do not always reply saying we would like the pleasure of his. If a dentist can check up on us, there is no reason why we cannot check that those who are meant to receive care in the community are receiving it.

It is clear that the quality of care in the community could and should be improved. There is inadequate supervision and support, and too few psychiatric nurses, day centres and occupational therapists. As mental hospitals close, they generate substantial capital receipts. If a business man was relocating production in a new factory, he would not wait until the existing factory was closed before he built a new one. The National Health Service financial rules which tell a health authority that it can invest the money only when the facility has been closed are wrong. I see no reason why health autorities should not be allowed to borrow on the strength that an asset is about to close and invest that money so that it can provide new and adequate facilities as soon as the hospital closes. We must also look at the rest of the world. In Japan they compulsorily detain 250,000 patients. Italy passed a law saying that no one could be compulsorily detained, so instead they renamed them "hospital guests" and the effect is the same. We should not indulge in either extreme. We must recognise, first, that for some people there will be a constant need for long-term treatment in hospital ; and, secondly, that care in the community cannot be care on the cheap, but must be seen as more effective care. It has not

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always been seen as that, and it has not always been that, but that must be our goal. We must also remember that to have decent care in the community we need to have a strong economy, and I believe that this Government are more likely to provide it.

Mr. Deputy Speaker (Sir Paul Dean) : Order. I remind the House that the 10-minute limit on speeches is now in operation.

7.5 pm

Mr. Gerald Bermingham (St. Helens, South) : When I read the letter dated 12 February 1988 from Sir Roy Griffiths to the then Secretary of State, paragraph 18 was of particular interest to me because in my constituency there is a very large mental hospital called Rainhill, which has existed for many years. When I first became a Member of Parliament, there were more than 1,000 patients. At present there are fewer than 500 patients there, which means that in the past six years at least 500 patients have been discharged into the community. Paragraph 18 of the letter reads :

"Dominant in discusssions and visits was the question of the closure of the large mental hospitals."

One sometimes gets the impression that some of these large mental hospitals are not being closed simply because they are large mental hosptials. I may be overtly suspicious by nature, but the fact that Rainhill is surrounded by some 200-plus acres of prime building land, may have something to do with the view taken by Rainhill hospital by those who run our health authorities. However, I do not have much time for health authorities whose prime object in life appears to be to dispose of large assets without providing alternative facilities in advance of the closure of the hospitals said to be out-of-date, as the hon. Member for Hendon, South (Mr. Marshall) rightly said. Nor do I have much time for the assurances of Ministers, if my own experience at St. Helens is anything to go by. In St. Helens we are a bit short of beds for the elderly. I think that we have about 0.5 out of 10 instead of the 10 out of 10 needed to meet our requirements. A delegation of the community health council, councillors from all political parties and myself went to see the Minister with our all-party all-body agreement complaining about the closure of geriatric wards at Whiston hospital and the closure of other wards at another hospital so that those beds could pass into the private sector, with no replacement in the public sector. Several months later, as I had half expected, we heard that the Minister was not coming to our aid.

In my constituency, not only is a large mental hospital being run down but we face the reduction of public sector geriatric beds. We have also seen the steady development of the private sector and one understands that the private sector is developing in that area, as my hon. Friend the Member for Crewe and Nantwich (Mrs. Dunwoody) said only a few moments ago and as I know from my own surgery last Saturday. An elderly couple came to see me saying, "Our brother-in-law is in an old people's home in the private sector. The fees are so much and the trouble is that the money that we get from the social security does not meet the fees. We are about to retire, and the shortfall that we have now carried for many months and years is £25 a week. We cannot afford £25 a week. We have run out of savings. He has terminal cancer and is dying. The doctors say, Don't move him,' so what shall we do?

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What should we do? We are talking about human beings. The letter written on 12 February 1988 says that dominant in our thinking must be the need to protect people being released from long-stay hospitals. Paragraph 6.37 states :

"Those services must include the nomination of a care manager for each long stay patient discharged."

When I go and talk to nurses and staff at Rainhill hospital--who have done a magnificent job over the years--and I ask where those patients have gone, they tell me to try the streets of Birkenhead and Liverpool, and a trip to the church there and to the old people's homes in Colwyn Bay. They are people who lived in that hospital for 30 years. Many of them have now gone to meet their maker. They have died because, as my hon. Friend the Member for Crewe and Nantwich said, everything they ever had was taken away from them. After 30 years in a mental hospital, it was their home, where they had their friends and their social life.

The hospital is not perfect. It is not wonderful. Conditions are sometimes not very good. Nevertheless, we take that all away from somebody aged 60 or 70 and tip them back into the community, but which community? The one whence they first came? It may well be that she got pregnant in 1928 and the easiest thing in the world was to put her into a mental hospital because that is what we did in those days. The Minister talks about care in the community. We tip them out. It is a death sentence. By all means let us have care in the community, but let us not mess about. Let us do it properly As hon. Members on both sides of the House have said time and time again, care in the community costs. Let us have proper mental hospitals. As a practising lawyer, I declare an interest. I am fed up with going into prisons to see people who should be in mental hospitals. We are a modern society, but what do we do with people who are least able to defend themselves? It is not their fault that they are mentally sick, or mentally handicapped at birth, but it is our responsibility.

The hon. Member for Eastleigh (Sir D. Price) is quite right to refer back to the old Privy Council rules. Two hundred years ago we talked about village care, because the village and the community cared for the weakest among them.

When Griffiths comes to be enacted, we must be prepared to ring-fence and allocate the necessary money because local authorities such as mine, which has a large number of patients who are yet to be discharged, and which has nowhere else for them to go need it. Such patients have to stay in St. Helens. It is the only place they know. They were not born there, but we have a duty to them. We have to be given the facilities to build homes and to maintain them at standards people need.

As has been said, we need long-term hospitals. There is a desperate need for them because some patients need long-term treatment or they cannot be cured. In and out does not do them any good. The handicapped need care and support at all levels.

We must not pursue cheap and easy solutions. We have to invest in the future and build a structure that we can be proud of rather than the one we have at the moment, which we can only be ashamed of.

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