House of Commons Hansard Debates for 20 Jun 1995

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or discussions with housing agencies, day centres and the like. All that will require more staff time, which must be properly resourced. Moreover, although the Bill provides for the cost of the additional number of tribunals, it does not appear to provide for the cost of the additional time required for psychiatrists and social workers to prepare reports for the additional tribunal hearings. The Ritchie report recommended new funding for specialist psychiatric teams to supervise discharged patients needing intensive after-care. Without such extra resources, the Bill will undoubtedly result in a reduction in staff time and other resources for patients who are not subject to after-care under supervision, but who are still severely ill. That is bound to make those patients a risk to others--as well as to themselves, through self-neglect or attempted suicide--and will only add to the number of those needing care under supervision. In other words, without extra resources, the Bill could prove counter-productive and self-defeating, rather than fulfilling its intention of making the community safe for patients and making patients safe in the community.

I have a second reservation, which has already been voiced by a number of speakers. I believe that the Bill is no substitute for a fundamental review of the 1983 Act. I was a member of the Standing Committee that scrutinised that legislation; it was one of those rare Bills that are subjected to the Special Standing Committee procedure, which allowed us to invite representations and to question experts. In my view, the eventual Bill was all the better for that, and I am sorry that most legislation is not subject to the same process: I think that, if it were, it would be better legislation.

The 1983 Bill was enacted at a time when patients were treated in long-stay residential settings, and is no longer relevant to today's approach to care. We cannot ignore the case of Stephen Laudat, who stabbed a man to death having previously refused to take his medication, and had declined psychiatric follow-up treatment; nor can we ignore the Blom-Cooper inquiry into the case of Andrew Robinson, which called for powers to allow compulsory treatment for patients who decide not to comply with their recommended care programme. I hope that, when the Minister winds up the debate, although he has already told us that he has an open mind about a review of the 1983 Act, he will tell us whether he accepts the recommendation of the British Medical Association that appropriate safeguards should be in place, and that compulsory treatment should be imposed only when patients pose a serious danger to themselves and others. I hope that he will give some thought to what the safeguards should be. 5.15 pm

Mr. Archy Kirkwood (Roxburgh and Berwickshire): I remind the House and the hon. Member for Bournemouth, East (Mr. Atkinson) that it is a mistake to make too powerful and perceptive a speech in the hearing of a member of the Committee of Selection. As the hon. Member for Worcestershire, South (Mr. Spicer)--who also made an interesting speech-- was not present to hear the argument of the hon. Member for Bournemouth, East and the answer to his question about resources, I propose to ensure that both of them are selected to be members of

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the Standing Committee. Indeed, I might appoint myself to the Committee so that I can watch the fun as the argument between them develops. I shall include the Minister as well, just so that he does not feel left out.

Like the Minister, I hope that the Bill can be discussed on a non-party political basis, as it was in the House of Lords. I do not think it necessary to be politically partisan. I was encouraged by the sensible and rational speech that we heard from the official Opposition spokesman--

Mr. Nicholas Brown: Not surprisingly.

Mr. Kirkwood: No, it is not surprising, but I have heard one or two Opposition Front-Bench speeches in my time.

I am sure that the Bill, and the work of the Standing Committee, will be the better for that non-partisan approach, although I feel that it should really have gone straight into a Special Standing Committee. I endorse what the hon. Member for Bournemouth, East said about the Special Standing Committee procedure that was used in the case of what became the 1983 Act. I do not know why the Government have set their face against that procedure; perhaps the House of Lords was considered a substitute for a Special Standing Committee, but I do not think that it was. Legislation such as this would be much better framed if we had direct access to the views of the National Schizophrenia Fellowship and other pressure groups, although some views have been expressed adequately to hon. Members in writing.

I pay tribute to the work that the hon. Member for Bournemouth, East has done for many years. Schizophrenia is a terrible illness. We have all read case histories that tell of the destruction of families who have tried to deal with the condition. I accept that it is difficult for the Government to respond, and I therefore think it important for us to do what we can on a cross-party basis to get the legislation right.

On a slightly carping note, I want to raise a procedural matter. As a Scots Member and, in a previous incarnation, a humble provincial solicitor--none of the big silk hankie brigade for me--I feel that we must rid ourselves of a certain habit. I address my complaint to the Under-Secretary of State for Scotland--the hon. Member for Edinburgh, West (Lord James Douglas-Hamilton) --who is seated diligently in his place. We must stop mixing Scottish and English legislation: it is fiendishly difficult for practitioners who are trying to disentangle Acts of Parliament to find Scottish legislation in unified United Kingdom Bills, because the legal systems are so different. The powers of the sheriff and the rules of guardianship are substantially different.

I understand that there are problems with finding enough compos mentis Scottish Tory Back Benchers for Standing Committees. The Under-Secretary of State for Scotland disagrees, but I know that there are difficulties. When the Government decided to move on this matter, they should have introduced two separate pieces of legislation. I hope that the Bill will be the first step towards a proper review in the new atmosphere of the whole framework of legislation in this field. I say that in passing because the point was made adequately earlier in the debate and I tried to make it in an intervention. The Minister said that he has an open mind. Ministers always

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have open minds. I am grateful for small mercies and take that response at face value because I know that he is genuinely concerned. I hope that his open mind will focus on getting the legislative time that he needs for the fundamental review for which the whole House appreciates the need.

These are difficult matters. Clunis and Silcock and the other events that have been mentioned, all of which were individual tragedies, give a heightened, almost hysterical, background against which we have to try to deal with this intractable problem. By far the biggest problem concerns mentally ill patients who damage themselves, commit suicide or leave themselves in terrible positions which destroy their families. When contemplating legislation, we must put in the balance not just the cases that get the headlines; we must also address the desperately distressing cases of neglect and worse among the mentally ill.

Resources are an important part of the argument. If there were adequate facilities for after-care, housing, employment, training and recreation, the problem would not be nearly as bad, particularly in inner cities. I do not have any special expertise in that respect because mine is a rural constituency, but the problem is bad enough there. I know that my colleagues, who know about these things and have studied them in more detail than I have been able to do, are concerned about the lack of facilities in areas such as central London. That must be dealt with.

Some of the representations that all hon. Members have had from the British Medical Association, the Association of County Councils and some other bodies such as the National Association for Mental Health and the Scottish Association for Mental Health cannot but cause concern about alleged omissions and anomalies and the Government's lack of a proper and systematic approach to this problem. When the Bill is in Committee, we will have to address some of those problems as best we can.

I think that the Scottish Affairs Select Committee's report is due almost any day now. It is currently preparing a report on the problems associated with the closure of psychiatric institutions in Scotland. I hope that the report will not be ignored by the Standing Committee and that any conclusions reached by that important Select Committee will inform the work of the Standing Committee, certainly in relation to the Scottish sections of the Bill. I would not like to think that it was too late to weigh the Select Committee's conclusions in the balance of arguments in the Standing Committee. More than anything else, resources must be taken into account. I hope that the Committee will have an opportunity for sensible discussions about that. There is obviously a good deal of difference between the Government and the Opposition parties about the increase in resources that has occurred, how the money has been spent and whether it has been put to proper use. It would be in the public interest for the Committee to try to get to the bottom of the statistics and to establish how they work out in practice. If I heard him correctly, the Minister estimated that there are about 20 cases to which supervision orders might apply in each health authority area. That figure is new to me. I found it difficult to discover how many people the Bill would affect. I assume that the figure relates to England and Wales. It is very small. Is it a firm figure? I

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know that there is uncertainty about statistics and I shall happily give way to the Minister if he would like to clarify the matter.

Mr. Bowis: The figure that I gave was the estimate of an average for each district health authority. A figure of about 3,000 nationally has often been quoted and when that is divided by the number of health authorities the result is about 20. The figure would obviously depend on each health authority, the practice of individual clinicians, decisions by psychiatrists and facilities that are already in the community. My figures are no firmer than that, but I thought that they were helpful in terms of the scale of the operation.

Mr. Kirkwood: I appreciate that helpful intervention. If the Minister had not made the position clear, I could have set off in a spurious direction. The figure could mask substantial discrepancies between inner-city areas and other parts of the country, but I am grateful to the Minister for his clarification.

The Committee will also have to look at co-ordination. I am not convinced that the Bill does anything like enough to get appropriate co-ordination between the various agencies. I am on the parliamentary panel of the Royal College of Nursing and try to work with it, obviously on an honorary basis. It is worried about the extra resources that might be needed to get properly trained mental health nurses, give them further training and deal with the increased work load if the Bill reaches the statute book.

There are a number of detailed questions I should like to ask, but it would not serve the purpose of the House to go through them at length. I am still a bit sceptical and have not yet formulated a final view, but as the Committee's deliberations proceed I shall be interested to see whether a purely legal approach of this kind is the right way forward. Some people say that such an approach is not right and that we should go for a better resourced, administrative solution. The Committee may want to turn to that. There is a real worry that the new supervised discharge system that we are considering will not sit all that comfortably with community care-- certainly not in Scotland. The term "community care order" is a misnomer and the Committee should spend some time considering whether it is the right name. Community care orders are driven by psychiatrists; care in the community should be driven by social workers. There could be a great deal of confusion if we do not get these matters right at the beginning.

I think that it was the hon. Member for Greenock and Port Glasgow (Dr. Godman) who asked about the powers that are to be made available to sheriffs. There is real concern north of the border that the powers given to sheriffs are indeterminate and too vague. I am still unclear about the extent to which the Bill will affect children and young people. I do not think that it can north of the border because they will be subject to the panel procedure, although it will affect young people in England and Wales, but I am not sure about that. Does the Bill apply to people with learning difficulties? Questions such as that cause me concern but they may be clear to the Minister. There is enough confusion in people's minds for it to be important to use the Committee to clarify some of these matters. The Minister was kind enough to refer to my noble Friend the fifth Earl Russell who is no less a person than the author of a book entitled

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"The Crises in Parliaments, English History from 1509 to 1660". I am unlikely, therefore, to controvert anything that my noble Friend says.

This is a good Bill, but it is not perfect. I am persuaded by the argument in the reasoned amendment but, if we support it, it will not be because we are totally and implacably opposed to the principle of the Bill, as the hon. Member for Newcastle upon Tyne, East (Mr. Brown) said, but because we think that much work will have to be done in Standing Committee to get the Bill right before it goes on to the statute book.

5.29 pm

Mr. David Nicholson (Taunton): I welcome the Bill for what it contains and points to, but in particular I welcome the opportunity that it gives us--here I echo the thoughts of the hon. Member for Roxburgh and Berwickshire (Mr. Kirkwood)--to reconsider, analyse, discuss and debate the care in the community system as it affects people with severe mental difficulty. Naturally, I regret that the Opposition have moved an amendment and will be dividing on Second Reading, but I welcome much of the speech by the hon. Member for Newcastle upon Tyne, East (Mr. Brown), as I welcome that of the hon. Member for Roxburgh and Berwickshire, who spoke for the Liberal party.

I was especially glad that the hon. Gentleman echoed a point that the National Schizophrenia Fellowship has made: although the few cases where severe mentally ill people, often suffering from schizophrenia, have attacked and occasionally killed members of the public--which have been accompanied by sensational publicity--may have triggered the legislation and concern, alas, less attention has been paid to the mortality rate of people with schizophrenia, which is estimated at twice that of the general population, mainly because of suicide. Through our families, friends and constituencies, we probably all know individuals whose lives, even in recent years, have had a tragic end in those circumstances.

In addition to the direct interest of families and neighbours of people who suffer in that particular way, there is a much wider interest in us getting the system right. Even now I hear, in letters or in conversation--although I am glad to say that it is less frequently stated--"This is all a disaster and completely wrong. Wouldn't it be better to have these people incarcerated in those Victorian buildings out in the countryside?" That attitude is wrong, but Parliament and all the people involved in operating the care in the community system must constantly work to assure the general population that the new system, which is very recent--it came into practice only two or three years ago--is the right way to deal with these matters and does provide proper protection for the safety and amenity of the general population, as well as being in the best interests of patients.

My interest in this subject has increased from, I must confess, near zero when I was first elected, largely through discussions with interested constituents, whether they be doctors, nurses, practitioners, the families of patients, or the small group that the National Schizophrenia Fellowship has established in my constituency and, I hope, in many other constituencies. Regular meetings are held with practitioners, families of sufferers or sufferers themselves. I have been grateful to have been invited to some of those discussions to talk in

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a calm and measured way about the concerns that those people have. I have been grateful for the insights that that has given me. If we intend to use--and I think that we will--the Standing Committee to probe and to explore this matter, of course we will depend on those outside organisations to help us with briefing and raising questions. My hon. Friend the Member for Bournemouth, East (Mr. Atkinson) may recall that we were reminded of that some weeks ago. Parliament, especially when it considers a Bill in detail, cannot operate in an ivory tower, separate from what happens outside. We are anxious, through certain other matters that are being considered by people in high office, properly to regulate the way in which outside interests--they may be economic and commercial, but often they may be caring institutions and organisations--influence and inform our procedures here and to make progress in that respect.

I have been personally involved in some cases in my constituency. In one case, I took part in having someone, alas, sectioned. In others, I have tried to ensure that schizophrenia sufferers were properly looked after when their families were convinced that they were not taking their proper medicine. Like the hon. Member for Blyth Valley (Mr. Campbell), I am a member of the Select Committee on the Parliamentary Commissioner for Administration--the parliamentary ombudsman--who also acts as the health service commissioner. The Select Committee has had cases before it--I mentioned one in a debate on the parliamentary ombudsman just before Christmas--where it has been shown that the system has not worked. It is vital that we take what measures we can to minimise those occasions where this cumbersome system has not worked, involving practitioners from various specialties.

I am interested in the passage in the Opposition's amendment about Government Departments co-ordinating. Of course it is vital that Government Departments, local authorities and, if necessary, the police and various other bodies should properly co-ordinate. When something goes wrong, it is vital that individuals in a community get together to put it right as quickly as possible. I hope that, as the Bill proceeds, we will consider how that works.

My wife is president of Taunton Mencap; that is a slightly related matter. I am glad that the Prime Minister's wife and the Prime Minister himself take a great interest in that charity. I am particularly pleased to say that both my hon. Friends the Under-Secretary of State for Health and the Under-Secretary of State for Scotland, who will be responsible for the Scottish aspects of the Bill, are excellent Ministers. I knew them both long before they entered the House--indeed, I have known them for more than 30 years, so I could not believe that this matter would be in better hands.

Mr. Menzies Campbell (Fife, North-East): Do not say that, they will put it in their election address.

Mr. Nicholson: I do not know what election address the hon. and learned Member for Fife, North-East (Mr. Campbell) is talking about. Before I discuss some of the concerns that have been raised, I shall refer to some of the successes that the local services, including the Avalon, Somerset national health

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service trust, have had. This might be nearer to the election address to which the hon. and learned Gentleman referred. It is well known and, I think, my hon. Friend the Minister will recognise that Somerset was one of the relatively few regions where co- ordination and co-operation between the health authority and county council social services were of such excellence that Somerset was ready to go ahead with care in the community at the earlier date envisaged by the Government. After care in the community was finally set up, it progressed extremely well in Somerset. I salute all the people who have been responsible for that in the local community.

I shall give the House some figures to show how progress has been made in past 10 years. In 1985, the number of Somerset hospital beds for mental health was 746 in six locations and the number of day places was 97 in four locations. Ten years later, the figures had changed to 382 beds in 21 locations and 413 day places in 21 locations, with community mental health teams working with social services, primary health care teams and the voluntary and private sectors to ensure that people had a range of options for dealing with their mental health problems, bringing them into the community, which is the purpose of the exercise. In the past year, occupancy levels for hospital beds averaged 81 per cent., ensuring that it was always possible to find a bed in Somerset if one was needed. One may not have been available at the nearest unit, but a bed has always been available.

Another important factor that reflects the massive changes that have taken place is the closure of large Victorian institutions. Tone Vale, in the middle of my constituency, closed in March, and a housing estate and other facilities will be developed on the site. I have visited the new units at Rydon house and Pyrland house for mental health patients and other people needing care, and I was most impressed by the work that went on there.

Over the past three years the proportion of staff employed in direct patient care has increased by 3 per cent. as a consequence of the changes in service delivery--mainly because of a reduction in estate staff and others needed to maintain large obsolete buildings, and an increase in nursing and medical staff. However, I am told that there is still a problem with the number of consultant psychiatrists and junior medical staff available to cover a community-based service.

Although the closure of large hospitals has reduced the number of beds, the value of the estate employed in the care of mentally ill people has increased considerably. In 1993 that estate was valued at £14.8 million; in March 1995 it was valued at £28 million. The buildings are now purpose-designed, with low maintenance costs, and are liked and valued by users of the service. That shows the practical way in which changes have taken place in Somerset. My hon. Friend the Member for Bournemouth, East referred to some of the concerns raised by the National Schizophrenia Fellowship, and I simply echo some of those. A small minority of people, perhaps about 3,000 of them, are never offered appropriate care or reject it. That can happen because the services do not exist, or are not co- ordinated, or because they concentrate on those who are easier to work with. But it can also happen because the patient is suspicious of everyone, has lost all motivation and stays in bed all the time, or dislikes the services offered or those offering them--those are

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common features of schizophrenia. Or the patient may be too ill or too disorganised to keep appointments or to take prescribed medication. The NSF says that that is the group of patients whom the Bill aims to help.

The NSF also says, and my hon. Friend the Member for Bournemouth, East reiterated, that the Bill requires involvement with no fewer than eight professionals and non-professionals at six-monthly intervals--more often if some change is proposed--through requirements either to give information or to consult patients. Staff time costs money, so there will be costs there.

Indeed, I have just received a letter from the director of social services for Somerset county council saying that revenue support grant needs to be increased to allow for the growing pressures and for capping to be relaxed. We debated capping last week, and Somerset's experience is somewhat happier than that of some other counties. Nevertheless, the director says that capping needs to be eased in line with the new demands, because for more and more people the promise of community care will not be satisfied unless that happens.

Finally, I shall develop the argument about resources in a wider sense. I heard the Minister say that, as a Minister, he did not want to widen the issues, but when we talk about care in the community wider issues inevitably crop up.

Mr. Deputy Speaker (Mr. Michael Morris): Order. I do not wish to anticipate what the hon. Gentleman intends to say, but I hope that we shall not hear about revenue support grant, capping, area cost adjustment or any of those aspects.

Mr. Nicholson: I am happy to say, Mr. Deputy Speaker, that I have finished talking about those matters.

I hope that the Minister will continue his work on the resource aspects that arise when elderly people need geriatric care in private nursing homes. That is a big issue facing us now, and although the causes are not the same, the problems that those people have are not very different from the problems of the people with whom the Bill attempts to deal.

Secondly, referring also to people with mental difficulties, I wish to raise the problem of the people whom we see on the streets of our large cities, especially London, begging and sleeping rough. Many initiatives have been taken by the various Departments responsible for helping them. I know that they are generally described as "the homeless", but we all know that homelessness is not their main problem. Some suffer from drug abuse, alcohol abuse or other forms of abuse.

I recall what was said about the state of mental health services in London and the south-east. Many of those people have mental difficulties, and I should like to impress on the Minister the need for all responsible Departments to co-ordinate action effectively so that those people, whom we now see every day and every night, are dealt with and helped. A sight that is becoming offensive to many of us could then be removed.

With those provisos, I welcome the Bill.

5.45 pm

Dr. Jeremy Bray (Motherwell, South): Undoubtedly new legislation is needed, but this is not the Bill with which many Opposition Members would have chosen to start. However, it could be substantially improved in

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Committee, and I hope that when we reach that stage the Minister will be as open minded as his colleagues were in the House of Lords. The Bill is not about improving the delivery of community care services for the great majority of mental health service users. As at present drafted it is essentially about the control and containment of the severely mentally ill. I do not underestimate the importance of that need, and I attach particular importance to what was said by the hon. Members for Taunton (Mr. Nicholson) and for Bournemouth, East (Mr. Atkinson) when they paid tribute to the role of the National Schizophrenia Fellowship, many of whose members strongly support the Bill and say that it is much needed.

The Bill is about the control and containment of a small proportion of the mentally ill who have been "sectioned"--that is, detained under sections 3 or 17 of the Mental Health Act 1983 or the equivalent provisions for Scotland. The Government introduced it in response to some distressing incidents of violence. However, as several hon. Members have said, the number of people injured or killed by the mentally ill is tiny compared with the number of deaths caused, say, by road accidents, or even by drunken drivers alone. The person most likely to be injured--sadly, all too often fatally--is the mentally ill person himself.

The best that can be said of the Bill is that it could be significantly and usefully amended to stimulate the development of services appropriate to the needs both of those who have been formally detained and of others.

The representations that have been submitted to the all-party mental health group, of which I am proud to be chairman, all emphasise the importance of involving the users of mental health services in their care plans. There is little of that in the Bill as originally drafted, although, as the Minister said, amendments made in the House of Lords have improved the emphasis on informing patients and, if they consent, their closest relative--and, to a more limited extent, their informal carers, to whom in practice so much of their care devolves.

However, much more could be done to amend the Bill so that users could be more fully involved in their care plan programme. The benefits are genuine. Obviously, a user's consent makes the life of the mental health worker or social worker easier. But in a more profound way, involving the user in his or her care plan improves the effectiveness and appropriateness of treatment. It can build a therapeutic relationship and gives the user more control and a better incentive to recover.

Involvement is a key concept in a number of recent reports, including Department of Health reports such as "Advocacy--a code of practice", "Black mental health dialogue--a dialogue for change", and especially "Guidelines for a local charter for users of mental health services", which was produced by the mental health task force user group of the national health service executive.

The Mental Health Acts of 1983 and 1984 placed on Ministers a duty to draw up, after consultation, a code of practice for mental health workers; to lay it before Parliament and to update it regularly. In England, the code of practice has been recently updated; the Scottish code, first published in 1989, still awaits its first revision. Both codes will need to be revised in the light of the Bill. I hope that the Minister, in replying to the debate, will be

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able to tell the House that consultations will start soon and will involve user groups, as well as those who deliver the service. There is a point that is not dealt with in the Bill and I hope that the Minister will carefully consider it. In parallel with the code of practice, there should be a new duty laid on Ministers in Scotland and in England and Wales to provide a charter for mental health users. When I say "a duty on Ministers to provide a charter", I am well aware that the guidelines are for a local charter for users of mental health services.

It is interesting that in the model charter that is provided, only two lines make provision for local input--the names of people to whom resource can be had. There are, nevertheless, local factors which, if they could be taken into account effectively in so many different situations, would clearly be helpful.

In the report, a user commented:

"Much work is needed on general care of the patient. Even basic care like bath, shampoo, shave, dental care, clean clothing is being neglected."

I doubt whether that is the case in Taunton, but certainly it is in Brixton.

Another user commented:

"Black patients, and other patients from minority groups, feel isolated with their illness, doubly, because their opinions and cultural needs are overlooked. For example, native food and drinks are not seen as important. Roots food, tonic remedies, herbal treatment and therapeutic massage are sources of alternative care that must be considered."

The perpetual cry from every user organisation that is ever consulted is echoed by this comment:

"Emergency care is needed out of hours to talk and defuse situations, not just medication. It is wrong that the police should be involved".

If there were a duty on Ministers to provide a charter for mental health users, it would be perfectly possible to provide for local additions to it dealing with the sort of problems that I have outlined and being specific about the channels of access to those resources.

An enlightened code of practice would, of course, interact with the charter and could help to change the climate of mental care and--I hope that this is still regarded as important--safeguard the civil rights of the mentally ill.

The Bill should require that each time a patient is informed of a supervision order or of changes to a supervision order, he should be given a copy of the charter and have its provisions explained orally. Likewise, the patient's closest relative and his or her informal carer should be fully informed. Those are the people who are crucial to the patient's well- being and their involvement is vital. Some would query whether the persons sectioned are the right client group to involve in a charter for mental health users. I would argue that it is necessary to start with them. Patients who have been sectioned are not necessarily the most violent or severely or chronically ill, or even the most disturbed. They are simply those seen by doctors or social workers as liable to endanger others or themselves.

In its operation, sectioning is a rather arbitrary act. Some people have been sectioned for one brief, traumatic breakdown and live the rest of their lives without any sign

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of mental instability. Some may be sectioned during one episode of illness and not the next. For others, the illness is a long-term problem with, perhaps, repeated admissions to hospital. They may sometimes be sectioned and sometimes not. The consultant's attitude, rather than the severity of the illness, may be the determining factor.

It is right to involve the users precisely because they are the people who in hospital are deprived of their liberty and to whom the Bill relates. They, above all, merit the sort of respect, involvement and empowerment that the charter for mental health users offers. Users, above all, need appropriate treatment. The Bill says a good deal about appropriate things but little about appropriate treatment. The charter is not an easy option and it would be a way of giving practical effect to appropriateness of treatment which, at present, is not covered in the system.

In giving people rights, we also place on them responsibilities. The task of keeping well is very difficult for many people whose lives are shot through with mental illness. It is a serious matter. I hope that the Mental Health (Patients in the Community) Bill can be so amended as to help formerly detained patients to keep well and maintain their dignity and self -respect.

5.55 pm

Mr. John Marshall (Hendon, South): I apologise to the House for not being able to attend the beginning of the debate. Some hon. Members may know that the Prime Minister was addressing a meeting of the Conservative Friends of Israel. As an officer of the CFI, I thought it only right and proper to be there.

I should like to declare an interest. I am a member of the advisory council of JAMI, the Jewish Association for the Mentally Ill. The advice comes from it to me, rather than from me to it. I pay tribute to the work that that wonderful charity does and emphasise the difficulty that it faces, from time to time, because some local authorities take advantage of its services but refuse to pay anything in the way of a contribution towards the cost of providing those services.

Like my hon. Friends the Members for Bournemouth, East (Mr. Atkinson) and for Taunton (Mr. Nicholson), I should like to pay tribute to the work of the National Schizophrenia Fellowship. It was one of the first groups that I saw after I was elected in 1987. The stories that I was told by individual parents underlined the difficulties that were being created by the care in the community policy.

I went up to one member and asked, "What is your problem? Who is affected? Is it your daughter or your son?" She said that her daughter was schizophrenic. I asked where she was and she told me that her daughter was sleeping somewhere on a park bench in London and that she did not know where she was. That was typical of the problems that I heard about. It was not a unique situation. One of the tragedies of mental health in London is that many of those who sleep rough in London are people who were sent out of mental hospitals to be treated in the community. They have ended up with a quality of life that is substantially poorer than that which they once enjoyed. There was another case I saw that evening of a lady who was concerned about the treatment that her son was

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receiving from psychiatrists. Unfortunately, despite many letters, the psychiatrist did not listen and, last year, the boy committed suicide.

One of the problems, and one with which the Bill seeks to deal, is that many of those who are released into the community refuse to co-operate with the treatment that is suggested for them. Their medication is unpleasant and it is very difficult to tell patients that they are sufficiently well to go into the community but sufficiently ill to need to carry on with their treatment. All too often, the result is that they say, "Yes, we are well enough to go into the community, therefore we are well enough not to have this rather unpleasant treatment." The result of that is that they become violent, lose their friends and end up in a different form of institutional care. It is quite wrong that people should be released into the community from an institution that is caring for them and then end up in prison as a result of committing some crime. The Bill is obviously going to help deal with that through the concept of supervised discharge. However, I believe that that must be viewed as part of a package because for too long, the mentally ill have been the Cinderella of the health service.

In all these great issues, the pendulum swings too far one way and then too far the other way. In the 1940s and 1950s, it was far too easy to have someone admitted to a mental hospital. The Victorian asylums were too large and too impersonal, but unfortunately society, in a crisis of conscience, went from one extreme to the other. In the revulsion against our history in this matter, we have gone on to make different mistakes. The fact that too many people were admitted to mental hospitals led to a failure to recognise that many who would be released into the community might be better off in an asylum which, traditionally, is a place of care and rest. The fact that the Victorian institutions were too large and too impersonal led to a failure to recognise that smaller hospitals might be necessary. In 1961, Enoch Powell decided to close all the large mental institutions by 2000. There is no doubt that the Treasury was seduced by the capital receipts that it anticipated and that it believed that care in the community might become a cheap option. The Treasury did not realise, however, that care in the community, if it is to be done properly, is more expensive than hospitalisation because it requires a lot of investment in training and people. Care in the community is labour intensive and cash intensive; that was not recognised by the Treasury or by others in the beginning.

Whatever the situation may be in sunny Taunton, there is no doubt that in London and the south-east, we suffer from a lack of beds for the mentally ill. All the evidence is that there is an inadequate number of beds for the mentally ill in London and the south-east. It is also the case that in London and the south-east, we do not have sufficient psychiatric nurses to deal with the number of schizophrenics we have. A third of those needing psychiatric services in London are homeless. That underlines the problems, which the Department and my hon. Friend the Minister recognise.

Those who say that the supervised discharge offends against individual civil liberties do not hit the right point. First, it is a paradox to say to someone, "You are sufficiently ill to need treatment, but you are sufficiently sane to recognise the fact that you need treatment and to

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say that you will undergo that treatment." A small number of people do not recognise that fact and then cause problems for themselves and for others.

Secondly, many of the relatives of those who will be affected by the Bill are praying for it to become law because of the traumas that they suffer when they see their sons and daughters not responding to treatment, when they know that their children are sleeping rough in London and not having the treatment that they need. I suggest that anyone who talks about civil liberties should talk to the relatives of those who will benefit from the Bill; they will get a very rough answer. The relatives worry the whole time whether their sons or daughters will commit suicide, they worry about whether they will become violent towards an innocent individual and they worry about their quality of life. For some who are released into the community, the quality of life is little more than a scandal.

The other civil liberty to be considered is the civil liberty of an innocent individual who may be harmed if we do not have the power of supervised discharge. There is no doubt that a number of murders have taken place--a relatively small number perhaps, but one unnecessary murder is the denial of someone's civil liberties and there is no greater liberty than the freedom to live. We are dealing, however, not only with the civil liberties of those who are killed by people who are not taking treatment.

Let us face the fact that there are many schizophrenics who have been released into the community and who then commit suicide. The official figures show that there were 266 suicides in three years, but that severely understates the number. There is a reluctance on the part of coroners to say that someone took his own life because some people have a religious revulsion at the thought of suicide. Sometimes there may be insurance policies which will not be honoured in the case of suicide and it is not unknown for the coroner to take that fact into account.

There are many people whose civil liberties will be affected if we do not pass the Bill; we must bear that in mind. I very much hope that the Bill will pass speedily through its Committee stage. The hon. Member for Roxburgh and Berwickshire (Mr. Kirkwood), who is a member of the Committee of Selection, is present this evening. I volunteer to be a member of the Standing Committee; we have had three volunteers already this evening, which means that we may have a relatively short Committee stage. I hope so because the Bill is important and will benefit part of our society which has been neglected for too long.

6.5 pm

Ms Ann Coffey (Stockport): The Bill provides for the after-care supervision of patients who have been subject to treatment or hospital orders. As some of my hon. Friends have already pointed out, there are concerns about how the after-care supervision will be implemented and by whom, and there are issues about the role of the supervisor that will be considered carefully in Committee. The supervision orders will apply to a minority of patients whose illness is chronic--patients whose behaviour may place them at risk or may place other people at risk. It is right and proper that we should be concerned about those patients. The intention seems to be twofold. First, it is to secure for a patient after-care services, which will be provided under section 117 of the

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Mental Health Act 1983. Secondly, supervisors will have to ensure that patients attend for treatment, occupational therapy, education, training or whatever--a wider policing role.

As the Bill explains, there should be no additional cost for health authorities and local authorities. However, after-care services self- evidently require resourcing, so it is hardly surprising that the Bill is viewed as legislation that emphasises the social policing role of social workers and health workers. They are the people at whom the finger can be pointed when something goes wrong, enabling the Minister to wash his hands of any responsibility to provide resources for them to do their jobs. As the Minister is aware, even social policemen need resourcing.

Before the Minister asks where the resources will come from, I point out that when the trusts were set up in Stockport, the taxpayer had to pay for a £1 million increase in the salary bill. If I am asked where extra resources for mental health care should come from, I can say that they could easily come from the administrative costs resulting from setting up the trusts. One million pounds would have gone a long way towards helping mentally ill people in Stockport; unfortunately, they did not get that money.

Mental health is the Cinderella of the health service for a number of reasons. There is, unfortunately, a great deal of fear among some of the population who regard all mentally ill people as exceedingly dangerous. That is far from the truth. Many mentally ill people face sad and painful lives with great courage--more courage than the rest of us may have. Mental illness can also be a source of shame and embarrassment for those who suffer from it because their difficulty in coping may be seen as a mark of failure.

I do not know the exact figures, but I know that a high proportion of the population will suffer an acute period of depression or a disabling anxiety episode in their lives. Most will recover but, sadly, some will not. Stress at work and at home, when communities have become less supportive, has increased the likelihood of breakdown in the general population. For some, schizophrenia and recurring psychoses are totally disabling. The high proportion of such people among the homeless is a sign of their ultimate fate and shows what community care has brought for them.

There is not a magic division between mental health and mental illness. Death, redundancy, mental breakdown and other crises can bring even the strongest of us to the brink of disintegration. Perhaps the fact that vast investment has gone into bringing about technological changes, while we are unable still to heal a traumatised child or return to health a schizophrenic person reflects our priorities as a society. In the absence of such help, it is crucial that resources are available in the community and hospitals to offer care and support for those who may never get better and also for those who, with help, can overcome their difficulties. Resources such as day provision, acute beds, long-term beds, community nurses, social workers, funding for self-help and support groups, carers and supported employment are all necessary for an infrastructure of community care. In reality, that infrastructure is not there. Since the closure of long-stay hospitals and the transfer

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of beds to local district hospitals, often hospitals cannot fulfil conflicting needs for beds. Over the past five years, there has been a 30 per cent. increase in the number of patients admitted to hospital under the Mental Health Act 1983. Unfortunately, the shortage of resources means that beds have not been available for voluntary patients or hard-pressed relatives who require respite care.

Indeed, I recently had to take up an issue concerning that very problem on behalf of one of my constituents. My constituent was informed by the hospital that as 42 per cent. of the beds at that time were occupied by people under compulsory admission, there was not--unfortunately--a bed for someone who was exhausted by having to cope with a husband who had a long- term mental illness.

Against that background, my concern is that, with no new resources being made available for wider community care, staff time will be taken up with implementing supervision orders. That will mean fewer community nurses available to support people such as my constituents. Without such valuable help, more families will be stressed, there will be further diminution of community care and it will be more likely that the health of people will deteriorate to the point at which they will have to be admitted to hospital. If services were available earlier, some of that illness could be prevented. Where are the after-care resources to come from? We are talking about suitable housing, because we cannot just dump somebody in the community. Often much work has to be done with neighbours, who are sometimes very hostile to mentally ill patients. All that requires staff time. Day centres require money, but it is very important for patients to be able to attend them to talk, receive support and get help. Community nurses are invaluable--we need more of them. Where are they? Support for employment is also vital.

All those provisions are necessary in identifying and providing after-care services for patients on supervision orders. After all, good-quality after- care services are those that the patient needs, and they cannot be provided by trying to fit the patient into the available after-care services. Such a mismatch leads to coercion in the supervision order, when patients know that they are going somewhere that is not able to meet their needs, while being told that there is not an alternative.

If resources are to be pooled to meet supervision orders--no new resources are being made available by the Government--what will happen to the other mentally ill people who need help? It is all very well talking about targeting resources--if they can be prioritised--but mental illness covers two groups of patients with different needs. People with long-term psychiatric problems will need on-going help, but the illnesses of patients with acute problems can be prevented from getting worse, with help when they need it. Both those groups need prioritising. I am concerned about the latter group, because those people will not receive the necessary services, which will inevitably lead to the development of longer-term illnesses. The Minister is right to be concerned with those who trouble society--we are all concerned about that--but he should also be concerned with those members of our society who are troubled. He should seek ways in which to help and support them. He should take this opportunity to tackle the problems of mental illness on behalf of all those who suffer from it. At the end of the day, it is they who bear the burden.

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