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Lord Williams of Elvel: My Lords, since the noble and learned Lord, Lord Hailsham, thinks that all the questions asked of the Government which cannot be answered are unfair, let me ask another unfair question. Does the Minister agree with the authors of the report that,

Do the Government agree with that or not?

Lord Hailsham of Saint Marylebone: Yes or no!

Viscount Ullswater: My Lords, yes. The PSI recognises that the drop in levels of disconnection has reflected Ofwat's guidance, and in 1993-94 the 10 water and sewerage companies carried out fewer disconnections than in 1986 before privatisation.

Business of the House: Easter Recess

3.31 p.m.

Lord Strathclyde: My Lords, it may be for the convenience of the House to know that, subject to the progress of business, the House will rise for the Easter Recess on Thursday 6th April and return on Tuesday 18th April. It is expected that the House will sit at 11 a.m. on Thursday 6th April.

Mental Health (Patients in the Community) Bill [H.L.]

3.32 p.m.

The Parliamentary Under-Secretary of State, Department of Health (Baroness Cumberlege): My Lords, I beg to move that this Bill be now read a second time. The Bill makes important changes to mental health legislation in England, Wales, and Scotland. It underlines the Government's commitment to care in the community by introducing key measures to strengthen it. Though the community care principles continue to enjoy widespread support a number of recent cases have served to heighten public concern. The Government recognise those concerns and this Bill addresses them. It deserves the support of all those who want the policy to work and who recognise that the safety and protection for the public are important—indeed are inseparable—from the interests of mentally ill people. Since a major part of the part of the Bill refers to Scottish law my noble and learned friend Lord Fraser of Carmyllie will respond to the debate and deal with any issues that refer to the Scottish provisions in the Bill.

I should like to start by setting the Bill in context. The public have become conscious of the needs of severely mentally ill people through a handful of well-publicised cases which have gone tragically wrong. But the full story is far from being one of tragedy and failure. We have made great strides in moving people out of large

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and often forbidding asylums, into towns, cities and villages where the rest of us live. We have seen people become de-institutionalised; leave the isolated institutions where they existed out of sight out of mind, and go into houses, flats and bungalows. People who had been denied a normal social life can now carry out the day-to-day activities that the rest of us take for granted, such as shopping, attending church, spending an evening down the pub.

Some severely ill people who prior to the introduction of new treatments and therapeutic drug regimes would have spent years in hospital can now hold down responsible jobs. People with a mental illness can, and do, become part of the community in which they live; and a recent survey showed that the majority of people in the country (75 per cent.) agree that opportunities should be given to those who can be supported.

The gains have been enormous. We do, however, recognise the dangers. There is a very small minority of severely mentally ill people who on discharge from hospital fail to take their medication or comply with agreements reached in terms of their continuing care. Then they can become a risk to themselves, their families and the public. That risk is not acceptable and policy and practice have to work to minimise it. The Government have brought forward this Bill to address this important issue.

So far as concerns England and Wales the Bill does three things: first, it introduces the new power of supervised discharge, referred to in the Bill as after-care supervision for mentally ill patients leaving hospital; secondly, it extends the period of leave of absence which detained patients may be granted before their final discharge; and, thirdly, it closes a loophole in the present Act by which a patient who goes absent without leave can no longer be detained if he or she has been away for 28 days. These provisions are covered in three clauses amending the 1983 Mental Health Act. The Scottish provisions follow the same broad structure.

Clause 1 deals with supervised discharge, and is the most important element in the English part of the Bill. It meets the 1993 commitment made by my right honourable friend the Secretary of State for Health to ensure that the most vulnerable people do not slip through the net after they leave hospital.

My right honourable friend had made clear her view that stronger legal powers were needed to back up care in the community well before the subject started to hit the headlines. Others shared this concern. The Royal College of Psychiatrists published its own proposals for community supervision orders in January 1993. They provided the starting point for my right honourable friend's review of legal powers from which came the proposals for supervised discharge. Subsequent consultation showed widespread support for our view that a new legal provision was needed.

Supervised discharge is the most important part, but only a part, of a comprehensive strategy announced by my right honourable friend in August 1993 to strengthen care in the community. Other effective measures include supervision registers, introduced last April for patients considered to be at risk to themselves and/or to others. Those registers are designed to ensure that contact is

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maintained with patients after they are discharged. We also issued comprehensive guidance last May. That guidance is clear and firm. Patients must not be discharged unless and until the clinicians responsible for their care are satisfied that it is safe to do so, and that the patient poses no significant risks to himself or herself, or to others in the community. The guidance is to be supplemented soon by our detailed guide to co-operative working, on which we have also consulted widely. Wales has its own comprehensive arrangements for dealing with mental health. My right honourable friend the Secretary of State for Wales is considering issuing further guidance on assessment and care management, including discharge and after-care arrangements, to strengthen co-ordination of care for severely mentally ill people.

Supervised discharge will provide a new power to ensure that patients keep to the care arrangements which are considered necessary to enable them to live safely in the community. If arrangements are broken, then the patient's case will be reviewed and that could lead to readmission to hospital under the 1983 Mental Health Act. Patients subject to supervised discharge are those who have been detained in hospital under the 1983 Act and who need special support in the community. These are patients who present a significant risk of substantial danger to themselves or others but are not in the category of restricted patients who have committed serious offences and are subject to the Home Secretary's special powers defined in the Act.

The application for supervised after-care will be made by the consultant who has been responsible for the patient's care in hospital. That consultant is referred to in the Bill as the "responsible medical officer". The application will be made to the health authority, which will be responsible (with the local authority) for providing the after-care services the patient requires. In making the application the responsible medical officer must consult the patient, and others professionally concerned with his or her care. He or she must also consult any informal carers. The application must be supported by a further medical opinion and a recommendation from an approved social worker. A statement of the after-care services to be provided must be submitted with the application.

On accepting the application the health authority must tell the patient and his or her professional and informal carers. Unless the patient objects, the health authority will also consult the nearest relative as defined in the 1983 Act.

Once the patient has left hospital, the Bill provides for a supervisor—normally the patient's key worker—to supervise and monitor the after-care services. Under the powers in the Bill, the patient may be required to reside at a specified place or to attend for medical treatment, occupation, education or training. The supervisor, or a person authorised by him or her, may take the patient to a place where he or she is required to reside or attend. There will, however, be no power to administer medication or any other form of medical treatment against the patient's will.

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The responsible health and local authorities have a duty to keep the after-care services under review. There would be an immediate review if the patient ceased to accept the after-care services. In this case, the professional care team would consider whether supervision was still appropriate. It may consider that the patient should be readmitted to hospital under the existing provisions of the Mental Health Act. It is clearly important that when patients are not prepared to comply with the terms of their supervision the option of taking them back into hospital is considered. Otherwise there is a real risk that they will lose contact with the care they need and go on to pose a danger to themselves or to others.

A patient will be subject to supervision for an initial period of six months. If the original conditions are still satisfied that may be extended for a further six months and then for periods of a year at a time, but only after consultation with others concerned in the patient's care. The patient may also be discharged from supervision at any time, but again only after consultation.

Patients subject to supervision, and their nearest relatives, will have the right to appeal to a mental health review tribunal when supervised discharge is first imposed or is subsequently renewed. These rights are specified in Schedule 1.

Supervised discharge will underpin the principles of the care programme approach, which we introduced in 1991 and upon which the after-care of all psychiatric patients should be based. We do not believe that it will impose extra cost because it does not introduce new requirements. Rather, it gives legal backing to what is already recognised as good practice.

NHS spending on services for mentally ill people has increased by 40 per cent. in real terms since 1979. The corresponding figure for local authority services is 171 per cent. Local authority spending is strongly supported by the mental illness specific grant, which we introduced in 1991. That stands at £36 million in the current year and we are increasing it to £47.5 million next year, which is a rise of one-third. The benefits of this growth in spending can be plainly seen; for example, a fourfold increase in the past 12 years in the number of community mental health nurses. These are expanding and developing services. Supervised discharge, with our related initiatives such as supervision registers, will help to ensure that extra spending is targeted at the most vulnerable mentally ill people who need it most.

Local authority guardianship under the 1983 Act will remain available for those patients for whom it is considered more suitable. There is a clear difference in the character of the two powers. Supervised discharge, as I have said, embodies the principles of the care programme approach and gives a specific role to healthcare professionals. We do not believe that its purpose could have been achieved by simply extending guardianship.

I now move on to Clauses 2 and 3. Clause 2 closes the loophole in the 1983 Mental Health Act by which patients who are absent without leave may not be taken into custody more than 28 days after the day on which they absconded. That is a strange anachronism which

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dates back at least to the 1890 Lunacy Act. The new provision will allow a patient to be taken into custody at any time up to six months from the date on which he or she absconded or, if later, the end of his or her existing authority for detention in hospital or guardianship. Where a patient is taken into custody or returned after more than 28 days the responsible medical officer must reassess him or her within seven days of the patient's return. The patient will remain liable to be detained only if the responsible medical officer so recommends.

The clause also provides for the return of patients who have absconded to the Republic of Ireland. Apart from the provision relating to the Republic of Ireland, none of this applies to restricted patients. The Act already allows them to be returned at any time and we are not changing this.

The return of absconding patients appears to be a straightforward matter. It is, nevertheless, important to take account of all the relevant factors, which include our international obligations under the European Convention on Human Rights. We have consulted widely about these provisions and we are confident that we have got the balance right.

Finally, as regards England and Wales, Clause 3 extends the period for which a patient may be given leave of absence from hospital. That is currently a maximum of six months. Clause 3 increases that to a year. A patient on leave of absence remains in the care of the responsible medical officer and it can be an important first step towards rehabilitation in the community. The extension to 12 months was also proposed in my right honourable friend's review and has been widely supported.

I now turn to the Scottish provisions. My noble and learned friend Lord Fraser has kept in close touch with our policy development in England and Wales and our officials have worked together on our respective legislative frameworks and practices. Your Lordships will be well aware of our different legal systems, so different but equivalent approaches have been adopted to our respective provisions and, accordingly, I will address what is proposed for Scotland in a slightly different way. First, I turn to leave of absence. Unlike the equivalent provision in England and Wales—where there was a limit of six months and is now to be one of a year—leave of absence is open-ended in Scotland. In light of the judgment of Sheriff Younger in 1987, my noble and learned friend has concluded that the use of leave of absence on a long-term basis carried a risk of legal challenge. It was also based on an apparently illogical premise; that if the patient is well enough to stay in the community on a long-term, almost indefinite basis, then why is he still liable to be detained in a hospital?

That said, leave of absence is a valuable and effective community rehabilitation and treatment option and there is no desire to lose it altogether. So, as proposed for patients south of the Border, Clause 5 of the Bill introduces a limit of one year to its duration. The need to reduce the legal difficulties associated with leave of absence has been the main impetus for change in

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Scotland. To that extent, my noble and learned friend has come to the issue from a different angle to ours, but we have arrived at similar conclusions.

However, introducing this new limit on leave of absence in Scotland does leave a gap in the legal framework for the care and treatment of mentally ill people in the community. Following consultation, my noble and learned friend has decided to develop a new community care order to fill the gap. Clause 4 of the Bill introduces this order. It has been tailored to fit the separate and different Scottish Mental Health Act and different legal system.

The community care order will provide a broadly similar safeguard to the supervised discharge proposals for England and Wales. The different terminology and the more formal approach of the Scottish proposals reflect the principles of the 1984 Act and Scottish practice. That acknowledges the key role of the sheriff and the Mental Welfare Commission for Scotland in that system. Community care orders are intended for the same categories of mentally disordered people as will be covered by the proposals for supervised discharge. The process will be triggered when the patient's responsible medical officer and another medical practitioner are satisfied that the patient's medical condition justifies a community care order, that an order is needed to ensure that the patient receives treatment and support services and that it is necessary in the interests of the patient's own health or safety or for the protection of others.

An application for the order may then be made to the sheriff by the responsible medical officer, supported by the second doctor and a recommendation from a social worker.

If the sheriff makes the order it will specify the conditions with which the patient should comply and give the names of his special medical officer and the after-care officer. Any variation in the conditions will have to be discussed with those concerned with the patient's care and treatment and requires the sheriff's approval. If the patient objects to any variation, there has to be a hearing. As with supervised discharge in England and Wales, the initial order will apply for six months, after which it may be renewed by the special medical officer for six months and, if appropriate, yearly thereafter.

Patients will have a right to a hearing when the order is made and may appeal to the sheriff on its renewal. The protective functions of the Mental Welfare Commission for Scotland will be extended to include patients subject to an order, and the commission will have the power of revocation in appropriate cases. The Mental Health Act Commission, which looks after the interests of detained patients in England and Wales, has a different remit which will not be extended to cover those subject to after-care under supervision. This reflects its much more specific role under the Mental Health Act 1983. However, we have consulted it over our proposals.

A new feature proposed for Scottish legislation is the inclusion of a provision for reassessment in hospital for any patient subject to an order whose condition has deteriorated and is, or is likely to become, such as to

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give grounds for serious concern regarding his health or safety or the protection of other persons. Such a reassessment—for a period of up to seven days—would have to be justified by two doctors on objective mental health criteria. Following this, the order may be continued or revoked; or an application for detention in hospital be made. As with after-care under supervision, there will be no provision for compulsory medication in the community.

Finally for Scotland, Clause 6 makes a provision equivalent to that proposed for detained patients who abscond from hospitals in England and Wales, or those subject to guardianship; that is, a period of six months, or the current period of detention or guardianship, within which he may be taken into custody and returned.

In the main text of the Bill this only leaves Clause 7 covering the formal provisions for the short title, commencement and extent. Other detailed matters are covered in the two schedules. For England and Wales these confirm, among other things, the appeal rights of patients subject to supervised discharge, and for Scotland, the role of the Mental Welfare Commission.

We are confident that the new supervision arrangements in England and Wales, the equivalent provisions in Scotland, and the other measures with which they are linked, add up to a coherent and consistent approach. They preserve the vital principles of care in the community for vulnerable people. They also provide the safeguards which are essential for patients and the public alike. The Bill will strengthen care in the community and reinforce public confidence in it. Care in the community is a long-standing policy which has enjoyed the support of all parties and a high proportion of the public. It deserves that support. This Bill displays the Government's continuing commitment to this policy which is right and which is working. I commend the Bill to your Lordships' House.

Moved, That the Bill be now read a second time.—(Baroness Cumberlege).

3.53 p.m.

Baroness Jay of Paddington: My Lords, I thank the Minister for introducing this, her second piece of important legislation in the same number of weeks, and for outlining the proposals very precisely. I am glad that before Committee stage we are to have an opportunity to consider the details with the Minister at a special meeting. My noble friend Lord Carmichael of Kelvingrove will speak later this afternoon and will take forward the special issues in relation to Scotland as the Bill proceeds.

Although the Bill is relatively short, it is, as we will have gathered from the Minister's clear explanation, relatively complicated. Its provisions embrace difficult areas of jurisprudence and ethics way beyond the practical concerns of health care. We shall wish to consider carefully the issues of civil rights and the relative rights and duties of both patients and professionals as the Bill makes its way forward.

On these Benches, we believe it is a serious indictment of government policy that this complex Bill is needed at all. It represents the admission that an

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important part of care in the community has failed. As the Minister said, community care for the mentally ill has been widely supported for more than a decade. There has been general clinical and political agreement about closing the old-style long-stay hospitals and developing services to help patients lead their lives outside institutions in what we hoped would be a normal environment.

That is the vision of community care. Sadly the vision has never been properly achieved because it has never been properly resourced and supported. Today we have the shameful spectacle of mentally ill people wandering the streets, often homeless and apparently totally uncared for. Many health authorities, particularly in the big cities, talk of service provisions being dangerously inadequate.

In September 1994, just six months ago, the Mental Health Task Force, a national body set up by the Department of Health, published its findings on Inner London and reported a serious problem of access to appropriate care. The task force stated:

    "Patients with severe and chronic mental disabilities are being discharged without adequate supervision, or the provision necessary to meet their housing, social and health needs. This could incur risks not only to public safety but also to the safety of the individuals concerned".

At the same time, specialist voluntary organisations, like the Matthew Trust, have experienced an enormous increase in demand for their charitable grants and services. In the three years to 1994 applications to the Matthew Trust from mentally ill people who had exhausted official channels of support, rose by 300 per cent. Just last month the trust produced a commentary called Victims of Care. That is a powerful document which, through individual stories, highlights the failure of the new care system to help vulnerable people, people whose daily lives are dominated by a struggle against mental illness and poverty.

It is worth reminding your Lordships of the overall financial context of mental health care. NHS spending on mental hospitals and community services has remained at roughly 11 per cent. of the total budget for a number of years. The Mental Health Foundation now suggests that spending on community services may be actually falling. Savings from the proceeds of the closure of long stay hospitals have often "leaked" into other services. In the health market, it would be realistic to assume that competing trusts have little enthusiasm for expanding the expensive and unglamorous services for the mentally ill. And yet we were told this afternoon by the Minister that this Bill will make services more effective but will not give rise to any additional costs. There will be no need for extra staff. Instead, apparently, a dreadful situation will be improved solely by a new statutory supervising system. There will be no additional resources for health authorities or social services departments.

The central proposal that we are considering for supervised aftercare is, as the Minister said, obviously the result of some high profile tragedies which created legitimate public anxiety. But I hope that I will not offend when I say that in some ways the Bill reminds me of the Dangerous Dogs Act—a few very serious

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incidents leading to a reactive measure which seeks more to reassure tabloid opinion than to solve the problem.

However, in the field of mental illness, there seems to be a reluctant acceptance by most of those involved in therapeutic relations with patients that, for a very small minority, some form of additionally supervised care in the community may be necessary, not so much to deal with the rare cases of random aggressive violence, as with the severely ill who find compliance with any care programme very difficult. As MIND has pointed out, 90 per cent. of those who are diagnosed as mentally ill and living in the community are not violent. The Royal College of Nursing has said that

    "A mentally ill person is more likely to harm himself than others and the rate of homicides by mentally ill people reflects the rate amongst the population as a whole".

The RCN thinks that the Bill before us offers false reassurance to patients and the public about violent incidents.

The central question is, given the present appalling state of community services, some form of extra supervision may be needed: how is that best achieved? Your Lordships will recall the Ritchie Report in 1994 on the case of the schizophrenic Christopher Clunis, who murdered Jonathan Zito on the London Underground. The report laid great emphasis on the failure to co-ordinate services, and included the pathetic statements of Clunis himself, who described himself being passed from one person to another, and not knowing who was in charge.

The Ritchie Report concluded:

    "The aftercare which is provided must be properly co-ordinated and supervised; it is severely to the patient's detriment if each member of the team acts in isolation. The consultant psychiatrist and care manager from social services must together be responsible for supervising aftercare".

That recommendation seems quite clear. But, in the present proposals, lines of responsibility for supervision are imprecisely developed. The Zito Trust which, as your Lordships will remember, has been courageously established by Mrs. Jane Zito following the report on her husband's death, has commented on this part of the Bill:

    "Lack of clarity and clear lines of accountability in this context are not only unhelpful but may be potentially fatal".

In the trust's response to the Bill it

    "asks that the Bill is more explicit in its definitions regarding the role and responsibilities of the supervisor under its provisions".

As stated at present, it seems that supervised care will be the personal responsibility of a nominated supervisor, working with a community GP, trying to co-ordinate services from different agencies. It is not obvious who is likely to be named as the supervisor. Although the initial application for supervision will be made to a health authority, it is generally supposed—and I would be grateful if the Ministers would correct me if I am wrong—that the responsible supervisor will in fact be a nominated social worker.

There are already professional concerns that, if the supervision breaks down, the unfortunate social worker would become very exposed—a scapegoat—and the centre, no doubt, of widespread unpleasant publicity. No

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wonder managers are already doubting their ability to get colleagues to take those obviously very difficult roles, if they are expected to act without sufficient support and additional resources. The precise nature of the responsibility for continuing care under supervision, and who will be accountable if there is a failure or breakdown, must be clearly stated and spelt out.

It has also been suggested that there is nothing in the Bill to prevent either a health authority or, for that matter, a social service department refusing a supervision application. What then happens to the miserable patient? Does he have to stay in hospital?

Other specific concerns have been raised about the nature of consultation on supervised aftercare, both with supervising agencies and, most importantly, with the patients. Many professionals are worried that the so-called "therapeutic alliance" with patients may be seriously threatened if the heavy hand of potential coercion is emphasised in supervised discharge plans. Many of the community-based voluntary service organisations agree that they only want to work with patients on the basis that the service users themselves want to use the service. We will need to examine in detail the issues of whether there will be genuine consultation, and free consent to treatment plans in supervised aftercare, at a later stage. It will be particularly important to see how a patient's relatives, friends and informal carers will be properly involved and not just "informed" as the Bill suggests in several places.

Those are significant details about the present Bill, but we should return to the central question of whether the new powers are really needed at all. Although the Minister said that that was not the case, it still seems to me to be possible to achieve all that is important under the existing guardianship orders—orders which, after all, have been in existence under the Mental Health Act since 1959. The concept of guardianship was reasserted in the 1983 Act and —this is most important—the code of practice says:

    "The purpose is to enable patients to receive community care where it cannot be provided without the use of compulsory powers. It enables the establishment of an authoritative framework for working with a patient with the minimum of constraint to achieve as independent a life as possible within the community. Where it is used"—

and this was something that the Minister said was not possible; but it is explicit in the guidelines—

    "it must be part of the patient's overall care and treatment plan".

Surely that code contains the basic aim of the new proposals.

Therefore, why not use the guardianship laws, combined with the existing discharge planning requirements under Section 117 of the 1983 Act, and the care programme approach adopted in the past few years? In that way, it seems that a care agency can already achieve what the Bill sets out to achieve. That approach was underlined by the report of the Law Commission on Mental Incapacity published on 28th February this year, two weeks after the Bill was published. The report supports and seeks to extend the powers of guardianship. For example, the commission suggests amending the 1993 Act to give a guardian

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additional power to convey a patient to a residence specified by the guardian. The power to convey, as the Minister mentioned, is regarded by the Government as one of the essential new provisions of the new Bill.

However, the Law Commission report shows that that could have been achieved by amending the 1983 Act. The commission also recommended that the powers of the Mental Health Act Commission should be extended to include people in guardianship, a provision which, as the Minister mentioned, is rather surprisingly not included in the new Bill for the new type of supervision. In addition, the commission also creates a new emergency protection scheme which, to quote Mr. Justice Brooke, the chairman of the Law Commission,

    "is designed to enable local authorities to act effectively to protect vulnerable people who may be at risk of harm, without interfering with their autonomy".

I hope that the Minister will indicate precisely why, given the existence of guardianship and the new proposals from the Law Commission, the Government now think it necessary to introduce this new, complicated statutory procedure. One is tempted to think that it is simply so that they are seen to be doing something. We will want to pursue the detail of the similarities and distinctions between the proposal for supervised aftercare and guardianship at a later stage.

I am told that guardianship has sometimes not been very widely used partly because responsible care workers have judged that they have insufficient resources to make it work effectively. Presumably, that must also be true of the new proposed arrangement. The lesson must surely be that if supervised aftercare is to succeed, it should be accompanied by statutory provision for a minimum set of services in the community for everyone who is receiving that type of aftercare. It is the services which are crucial: they are what is needed.

Indeed, many doctors and healthcare managers see the introduction of a new statute as simply adding another administrative layer to their already existing burdens. We should be under no illusions about how heavy such burdens already are. Since the Bill was published, I have talked to a large number of people who work in all different capacities directly with the mentally ill, both in hospital and in the community. During those meetings my admiration for their dedication and commitment has grown even stronger than it was before. They feel that they, and their patients and clients, are struggling at the moment against almost overwhelming odds. When asked what could improve their situation, their priorities include: better training and limited caseloads for community psychiatric nurses; more intensively staffed crisis homes where severely ill people can be looked after on a temporary basis; crisis cards so that there can be easy admission to such places; and a wider network of support staff to help people at home. They are not agitating for additional, legal powers. I am glad that some of those front-line workers will be able to be involved in our informal meeting before the Committee stage of the Bill.

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The overall problem is clearly inadequate services, not inadequate laws. The chairman of the Law Commission recently said that the law in this area has grown up piecemeal and is,

    "now out of date and full of gaps".

But the solution must be to conduct a thorough review and reform of the Mental Health Act 1983 and to make our legislation, which was originally designed for hospital services, more relevant to community care. The Bill before us today is trying to patch up a crisis; but that crisis needs different long-term solutions.

The Zito Trust has kindly shown me the case studies of many of the people whom they are trying to help in their victim support programme. The story of Mary Collins is typical. In October 1994, Mrs. Collins' son, a diagnosed schizophrenic, stabbed her husband to death and attempted to kill his mother. This man had been sectioned to hospital care on several occasions but, most recently, had been a voluntary patient and was discharged, against his will, on the pretext that he was better. One suspects that this may have been because pressured medical staff needed his bed. Following discharge he was provided with a flat, but with no furniture and he was given little support. His mental health deteriorated and Mary's attempts to remain in contact with her son, to improve his care, led to the fatal attack. Even after this new Bill, Mrs. Collins's son would not have been subject to the supervised after-care arrangements. He would have fallen through the legal net. He, like many others, needed structured and intense support. We must find foolproof ways to provide it.

4.10 p.m.

Baroness Robson of Kiddington: My Lords, I, too, wish to thank the Minister for the clear way in which she introduced the Bill. I also wish to announce at this point that my noble friend Lord Mar and Kellie will deal with the Scottish part of the Bill.

We on these Benches very much welcome the aims of the present Bill. We are pleased that the Government have recognised the need for reform of the current Mental Health Act. But that does not by any means mean that we approve of every detail of the Bill. We have deep reservations about many of its details. However, it gives us the opportunity to discuss the problem in detail and we hope to improve the Bill by introducing amendments at a later stage.

First, I wish to look at the Bill from the point of view of its implications under the European Convention on Human Rights. Article 5 of that convention provides that everyone has the right to liberty and security of the person. However, that right can be limited in relation to persons of unsound mind. The Bill before us states that a patient may be detained if he represents a danger to himself or others. The court has held that this constitutes a deprivation of liberty. However, the present Bill goes further. New Section 25A(4) (b) states that after-care supervision can be sought for a patient who is at risk of being seriously exploited. The proposed infringement of liberty contained in the Bill is not warranted in relation to those who are at risk of being seriously exploited.

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They should be supported in the community and protected in the community without the threat of being taken away and conveyed to a place of safety.

New Section 25D(4) gives the power to take away and convey the patient to a place where the patient is required to attend for the purpose of medical treatment. It implies that the Bill will also allow medication to be administered without the patient's consent, even though he is not, in the true sense, a detained patient. There is nothing in the Bill, apart from the explanatory memorandum, to confirm that a patient cannot be required to take medication against his will. This freedom must be safeguarded in the Bill itself.

The three amendments to the current Act contained in the Bill are particularly welcome. First, the right of a patient to apply to a mental health tribunal for supervision to be terminated; secondly, the extension of the limit on the period for which patients may be given leave of absence; and, thirdly, the extension of the period during which patients who are absent without leave may be taken into custody and returned.

The patient's right of appeal to the mental health review tribunal to be discharged from supervision is in itself welcome, but the procedure envisaged in the Bill is not. The fact that the burden of proof that the supervision is not necessary rests on the patient will heavily militate against a discharge being granted. Further, hearings before the mental health review tribunals are subject to considerable delays during which time the conditions of the supervision order will have to be complied with. The right to apply to the mental health review tribunal will only be safeguarded if the burden of proof is reversed and if patients can be guaranteed a speedy hearing.

The Bill assumes that the new powers will enable more resources to be concentrated on those patients subject to supervised discharge, but makes no provision for an overall increase in the level of resources. Concentrating resources on one client group will inevitably lead to fewer resources being available to the vast majority of mentally ill people who already receive inadequate support in the community, and consequently may lead to an increase in the need for supervised discharge powers.

We are also concerned about the limited number of hospital beds now available for those patients who are considered to require hospital treatment. With a shortage of beds patients run the risk of being discharged into the community before they are ready to accept the responsibility of life in the community, resulting in frequent, short-term re-admissions to hospital. If the Bill is to be effective, immediate hospital admission when needed must be safeguarded. Incidents like that of the patient who telephoned for help on a Monday and was told that a community psychiatric nurse would see him the following Thursday simply are not good enough. That is like ringing the fire service on Monday and that service telling you it will arrive on Thursday. It is desperately important that people who ask for assistance should be given it immediately.

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According to the Royal College of Nursing, only one in five people diagnosed as having schizophrenia has access to a community psychiatric nurse. The number of community psychiatric nurses must obviously be increased if patients are to receive adequate support. Perhaps the most disturbing aspect of the Bill is that the only extra costs envisaged by the Government are the costs for mental health review tribunals. But even those costs do not include the cost of the extra time spent by psychiatrists and social workers on preparing reports. If this Bill is to improve the position of the mentally inadequate people in our society there will be many other additional costs involved in providing the right background. For example, I cannot see how the Bill's provisions can possibly work without a 24-hour emergency service provided by a multi-disciplinary team.

I do not know whether the Minister is aware of the West Birmingham home treatment service which covers an inner city population of 200,000 people. It is open 24 hours a day, seven days a week, and has reduced hospital admissions by 50 per cent. and produced a saving of 25 per cent. in the cost of the service. One of the most important matters is to make certain that people who are out in the community are given the right conditions in which to live. It can never be acceptable that some of these people are put into bed and breakfast accommodation.

I believe, therefore, that if there is to be any possibility that the Bill will improve the services available to patients, the Government must withdraw the statement in the financial memorandum that it should give rise to no additional costs for the health authority or local authority. That cannot be true. The scheme will not work unless we fund it.

4.19 p.m.

Lord Thurlow: My Lords, I welcome the Bill. I support its broad objectives. I thank the noble Baroness for her very clear exposition.

While I welcome the Bill, like previous speakers I have strong reservations. The new legal framework can be very helpful in improving the level of care in the community, but the question is how it will work in practice. As the noble Baroness, Lady Robson, said, there are considerable doubts as to whether the resources will be available to make it work properly.

I shall not go into the question of whether guardianship could be a sufficient means of dealing with this difficult problem. The fact remains that for a considerable number of years guardianship has not proved to be sufficient. Therefore, from the point of view of the lay public the introduction of this new legal framework is welcome.

All the experts, professionals, agree that there is a critical issue: that of the trust between the responsible professionals and the patients. There is a real danger that unless the provisions of the Bill are handled with great sensitivity that trust, not only between the individual patient and those seeking to help him or her but also

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more widely among those suffering from mental ill health, may be undermined as a result of the prevailing impression.

I recognise, as will your Lordships, that there is sensitive and effective handling by the responsible authorities of difficult cases requiring sectioning. However, the mentally ill who will be the subject of supervision are very difficult people. Suspicion is one of the basic symptoms of schizophrenia. Suspicion is easily translated into violence, and when that escalates and becomes a matter for constraint the situation becomes very painful and difficult.

As the noble Baroness, Lady Robson, indicated, a factor to be considered is the pressure on CPNs and social workers. We were glad to hear from the noble Baroness that the number of CPNs has increased considerably; but from what a small base. When community care was introduced, the army of CPNs was pathetic. Therefore, as Griffiths observed in his great report, the need is very much greater than can be met by the present resources.

Community care has proved satisfactory in some areas. West Birmingham has been mentioned. However, all responsible people concerned agree that it has been patchy. That is inevitable in the development of a new system which has been running for only a limited period of time. However, Griffiths indicated that the closure of the big hospitals would inevitably lead to greater requirements for resources because care in the community is more expensive. It requires more resources. Although resources have been increased—the noble Baroness quoted the figure of 49 per cent. in real terms—and that is welcome, the need runs ahead of provision. Therefore, we look forward to a progressive increase as the years go by. Public perception is that in relative terms the amount allocated within the health service to the mental health sector has fallen.

The noble Baroness mentioned the leakage of funds saved in the closure of mental hospitals into other budgets within local authorities. That is a statistical quagmire. It is probably impossible for anyone to sort out what goes on in that way, but there is a general impression that, in view of the great constraints under which so many local authorities are operating, that leakage has been at the expense of mental health funds.

I should like to mention one point that the Law Society has emphasised. That is the crisis in inner city mental health services, particularly the high throughput and rapid discharge of detained patients. That creates a serious problem of high bed-occupancy, leaving no space in many cases for informal admissions. That is a very serious matter because we all prefer patients to go into hospital informally rather than under section.

I echo the appeals made by the noble Baronesses who have spoken from this side of the House for a continued increase in resources while admitting and acknowledging that an increase has already taken place.

4.28 p.m.

Lord Campbell of Croy: My Lords, I should like to thank my noble friend Lady Cumberlege for outlining so clearly the purpose and the proposals in the Bill.

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Last November I was pleased to see included in the Queen's Speech a measure to provide for people with a serious mental disorder to be cared for under supervision when not in hospital. That seemed a quick response to disturbing incidents, including murders by schizophrenics in particular. In the Clunis case the subsequent inquiry produced recommendations for sensible action and changes.

While I applaud the intention, therefore, there are disadvantages in instant legislation. First, one cannot avoid disturbing the present law and procedures without having had a general review. Secondly, the time for consultation with the medical professions and organisations involved and concerned has been very short. The Bill has been given an early place in our parliamentary programme; and I welcome that. But it must have been in draft, and possibly in print, over a month ago and that is only a short time after the announcement in the middle of November. Some of the objections and reservations voiced by interested organisations may well have arisen because of the short time between the announcement in mid-November and the presentation of the Bill. The present law to be changed and supplemented is contained in the 1983 Act for England and Wales, and the equivalent 1984 Act for Scotland. The Bill is sensibly divided neatly into two for that reason.

The Bill's proposals are before us at a critical time—previous speakers have already referred to this—in the new system of care in the community which has not yet settled down, with differing results so far in various parts of the country.

As some noble Lords will know, for nearly 30 years I have been advocating in both Houses of Parliament that there should be more care in the community for disabled people, (both physically and mentally disabled) in suitable conditions rather than keeping them in institutions as long-term patients. I welcomed the Griffiths Report and the decision to launch the system in the 1990 Act. However, adopting the system has not been simple or straightforward. Where the mentally ill are concerned, the intention has been clear and admirable. No one should be discharged from hospital until full and proper arrangements have been made for that individual in the community. In practice I am sure that many of us know of cases where that simply has not happened. We are in the early stages, and one hopes that the situation will improve.

Furthermore, with mental illness, hospital beds will be needed at short notice for patients who have had relapses or failed to take their prescribed medication. We must remember that care in the community has been made possible largely because of the advances in medicine and in knowledge over the past 40 years, and in the drugs and treatment possible. Sufferers from mental illness can now live fairly normal lives in the community provided that they are not too bad and that there are arrangements for them to be returned quickly to hospital when necessary. However, if sufferers from mental illness cease to take assistance—medication and treatment—then the situation can change dramatically and in some cases their ability to cope with ordinary life recedes.

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The cases which have had great publicity in the past three years involved schizophrenics, violence, danger to the public, and danger to the sufferer himself in the case of the London Zoo incident. The schizophrenics who are violent form a small proportion of the whole. They can usually be identified by the medical profession and I suggest that they must be the people for whom this Bill is primarily designed. There is a delicate balance to be achieved between protecting the public and patients themselves on the one hand, and preserving civil liberties on the other. Depriving a person of freedom by detaining in hospital, or forcing treatment against someone's apparent will, are controversial matters which will doubtless be raised later in the debate.

I speak with no medical qualifications, but from experience. As some noble Lords know, and I remind them, a close member of my family has been suffering from schizophrenia for the past 30 years. Also for part of that period I was for four years (when in another place) Secretary of State responsible for health. I have been closely associated with the National Schizophrenia Fellowship since it was established 25 years ago; and I am the patron of the National Schizophrenia Fellowship (Scotland). Therefore I am close to the problems and have been for some time.

I strongly support the principle that the consent and co-operation of a sufferer from mental illness should be sought and obtained if possible. At the same time, the minimum powers of compulsion necessary should be available in the patients' best interests. A characteristic of schizophrenics is that they hear voices. Often those voices seem commanding, and to be obeyed. The voices usually propose unpredictable actions, or foolish ones such as, "Stop taking the medication", or "Disappear into the blue without telling anyone and go missing for days". In those circumstances the schizophrenics are probably not violent, but they need special care and supervision.

Of course, compulsion must be used only on suitable occasions and with care. We are all well aware of the gross misuse of psychiatric diagnoses and detentions by totalitarian regimes, especially in the former Soviet Union, to keep political opponents, or as they thought dissidents, in custody or out of the way. In a democracy, however, that should not be possible and the safety of the public and of the individual require some powers of restraint.

Perhaps I may make some comments regarding Scotland. Because the law and system are different, the Bill proposes community care orders—an alternative arrangement for Scotland. I must tell your Lordships that those proposals have met with some disappointment among the organisations concerned north of the Border. The present indefinite leave of absence from the hospital which has worked extremely well is now to be reduced to one year. Some of us have known that leave of absence from hospital without time limit might be challenged legally. That has not happened so far. As it is an accepted system, operating well in Scotland, we had hoped that the Bill might make a simple change in the legislation and remove the possibility of a legal challenge.

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In Scotland the mental illness system includes arrangements for guardianship but that has been very little used. I understand that it is considerably used for mental handicap—for people with learning disabilities—north and south of the Border. That disability is not a subject for this Bill. However, I believe that the guardianship arrangements have special application in that field.

Two weeks ago I wrote to my noble and learned friend, who will reply, about the points which have arisen among the organisations concerned in Scotland. He has already sent me a full reply. I quickly add that I shall not dilate on any of the points now. However, as my noble friend Lady Cumberlege stated, unlimited leave of absence seems illogical. Sheriff Younger pointed that out. Its great merit is that it works and has been accepted in Scotland by almost everyone concerned. I think that in other walks of life there are similar situations.

The intentions behind the Bill are sound, in my opinion. The difficulties arise from the details of the changes and the new procedures proposed. I hope that the Government will continue their discussions, especially north of the Border, with the organisations most concerned and first, explain more fully what they propose and how the procedures suggested will operate in practice; secondly, listen and be prepared, if necessary, to make amendments.

4.40 p.m.

Lord Carmichael of Kelvingrove: My Lords, first, I wish to congratulate my noble friend Lady Jay on the competent way in which she spoke about the Bill and her attitude to it. There is a long list of speakers today not just for the Bill but for the other measures and I shall endeavour to outline some of the points on the Bill which relate to Scotland and which have been raised with me by outside organisations. I hope that I shall be able to spend more time on the Bill when we reach the Committee stage, proposing well-documented amendments after receiving information. I apologise to the Minister and the House; I have never before left a debate halfway through, but unfortunately I must leave early. It is quite unavoidable, I must be in Scotland at a reasonable time this evening and I hope that the House will forgive me. I shall, of course, carefully read the speeches when Hansard is published.

We must all thank the Scottish Office for its efforts to involve the many statutory and non-statutory bodies in Scotland in consultations before the Bill was published. However, that does not mean that the views of the statutory and non-statutory bodies have been met to anything like the extent that we would have liked. I read with care the consultation document issued by St. Andrew's House last December and must admit that I found it pretty hard going. Perhaps that had less to do with the paper and much more to do with my learning curve. As I read on, I began to understand a little more and with the help of many agencies I am just beginning to grasp some of the Bill's proposals.

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It is a pity that the clauses relating to Scotland could not have been incorporated into a revised Mental Health (Scotland) Bill rather than the way we have had them presented to us in a UK Bill. I am pleased that the noble Lord, Lord Campbell of Croy, took exactly the same attitude to the Bill. I have no desire and I am sure he has none to make a narrow nationalist point, but I feel that the Bill is a clumsy way of legislating for Scotland and the rest of the United Kingdom in a measure which is so mixed and difficult to access for the layman. There are two Bills dealing with two separate spheres all in one volume and I do not believe that that makes for good legislation.

It is generally accepted, and has been accepted in all the speeches that we have heard so far that, where possible and where beneficial to the patient, as many people as the services can cope with should be treated in the community. However, there are problems, many of which have been mentioned today, to which we must find solutions. I hope that some of the amendments which I intend to put down at Committee stage will elicit information from the Minister.

I am informed by professionals that there is not always easy or indeed any proper co-operation between all the agencies which should or need to be involved in dealing with individuals who have mental difficulties. A specific staff member should always be responsible for regular contact with the patient and have full awareness of and liaise with all the other professional agencies involved.

Another point which I wish to emphasise is that I am told there is no easy method of co-ordinating information across the agencies which deal with the patient in the community. Sufficient weight is not always given to the experience of families and friends of the patient. After all, they see him much more often than anyone in the hospital and they also see the patient in different moods. They should be consulted much more widely than they seem to be. It is even difficult for the professionals—whether it be the nurse, social worker or the psychiatrist—to judge, because they only see the patient for short periods. Relatives and friends, however, live with the patient for long periods.

I am indebted to numerous agencies in Scotland and to individuals for their help in briefing me for this debate. It would probably be helpful if I outlined some areas of unease on which I shall try to put down amendments at Committee stage in order to obtain clarification. I hope that the Government will take the opportunity to consider the amendments and go halfway or even further towards meeting the desires and views of most of the professionals in Scotland.

We will need definitions of those to whom the Bill will apply. Obviously, it includes patients with serious mental health problems, but what about those with serious learning disabilities which affect their performance? Sometimes they are treated as though they have a mental problem, whereas it is a specific type of mental disability. That causes anxiety in Scotland.

Then there is the question of leave of absence with which I shall deal at some length at the Committee stage. Is this a serious problem in Scotland? We do not really know whether it is. I do not know that any serious

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research has been done on it and, if it is not a serious problem, why should we change the legislation? Again, the Minister will be able to tell us about that in winding up.

I return to a question on which I was trying to obtain elucidation earlier. Is the psychiatrist the best person to take the leading role? Obviously, he will play an important part, but should he take a leading role in the long-term supervision of a patient? He will have a vital input, but surely the social work department will be in much closer and more continuous contact with the patient and should have at least an equal voice in helping to make decisions, playing an important role in any assessment of the patient. I am not trying to reduce the role of the psychiatrist who, as well as being the senior professional, has a leading role. Knowing the medical profession, I believe that he will make the real decisions, but it would take a strong-willed psychiatric nurse to bypass him.

The other point raised concerns compulsory treatment of a patient who returns to hospital for assessment which is dealt with under Clause 35. The wording of the clause suggests that the patient who is re-admitted for assessment is "detained". We would like the wording clarified, because it may very well mean that a patient who has been detained may be given medication, whether or not he wants it. In other words, he could be given medication against his will. I should like to know whether the patient has any right to appeal against recall to hospital. What is the process by which he is recalled?

We on this side of the House and the Scottish people to whom I have spoken believe that the Government have genuinely tried to deal with the situation. Care in the community is something which we all feel is right in the proper circumstances. We believe that it is good, but the Minister will not be surprised that those professionals and specialists are asking for clarification on a large number of issues within the field of mental health. I hope that in Committee we shall be able to help by getting answers from the Minister on some of the points that I have very briefly tried to outline.

4.50 p.m.

The Earl of Mar and Kellie: My Lords, I should like to thank the noble Baroness the Minister for introducing this Bill. I also apologise to the whole House. I sincerely hope to be present at the end of this debate, but I may need to leave early to return to Scotland.

We are discussing mental health. This is a forgotten area and, regrettably, one that is probably still taboo. I suspect that most families would prefer that their relatives were bad rather than mad. We are considering compulsory measures of care for those who have been labelled as psychotic or schizophrenic, or as having aggravated learning difficulties. Here I must declare an interest. During my social work career I was, in England, a duly authorised officer and, in Scotland, a mental health officer. That was some time ago, but I speak as a former practitioner.

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Mental health patients often do not realise that they are ill, and therefore they sometimes do not take their medication. That prevents them from functioning normally in the community. I regard this as a very important point and I shall return to it. I thank my noble friend Lady Robson of Kiddington for introducing the Bill from our side and for mentioning that I shall be dealing only with Part II, relating to Scotland. This Bill amends and alters the Mental Health (Scotland) Act 1984, and, like other noble Lords, I wish that this were the "Mental Health (Community Care Order) (Scotland) Bill", so that we could be discussing that on its own.

Clause 4 extends the range of compulsory measures in the treatment of people who are either mentally ill or suffer from aggravated learning disabilities. The range of these measures is: Section 18 hospital orders; Section 37 guardianship orders; and restriction orders where the Secretary of State determines when a patient will be released, rather than the consultant. There are also fairly extensive leave of absence arrangements. Among this range of measures are two new mental health orders; namely, the supervision and treatment order, coming in through the Criminal Justice (Scotland) Bill that is currently in another place, and the community care orders that we are discussing at the moment.

Clause 5 deals with those who are absent without leave. It lengthens the period before they cease to be detained from 28 days to six months. That is probably too long. Clause 6 deals with the leave of absence arrangements and restricts the period to one year, which is probably too limited.

Most patients in Scotland are informal patients. We have 30,000 admissions, of whom 3,000 are normally on compulsory measures. Significantly, there are approximately 100 patients in Scotland who have been on leave of absence for more than one year and are therefore prescribed candidates for community care orders.

The Bill lays down the criteria for the community care order patient—that is, that he or she should be mentally disordered, requiring treatment but not requiring detention, with some risk to his or her own health or safety; or someone who is likely to generate the need for the protection of other people. These are not the same criteria as for a Section 18 hospital order, as there is no requirement for detention and no power of treatment. Obviously, acute psychiatric patients will remain in hospital, which is an unnatural environment. Mental health implies the ability to live in the community.

There is some logic in this statutory halfway house provision. The expected route to getting onto a community care order would be that the patient would be admitted to hospital under either a Section 18 compulsory admission or possibly a Section 24 emergency admission, and would come into hospital for assessment and treatment. The consultant psychiatrist would apply to the sheriff for a community care order after consulting the social work department, a community mental nurse, some voluntary agencies, the carer and the patient. The consultant psychiatrist is

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required to draw up a community care plan which will distinctly need a care worker, as was mentioned by the noble Lord, Lord Carmichael.

What exactly will these people do? I suggest that the social workers will not only produce a social circumstance report but will also make arrangements for accommodation for an occupational programme, probably in daycare or in a sheltered workshop. They will make travel arrangements; arrange an income with the Department of Social Security; provide counselling; and may do things such as advising the school to which the patient's child goes as to what is happening. The community mental nurse would be dealing with medication and monitoring the patient's mental health, and of course providing counselling.

The carer is perhaps the most critical person in this whole sphere. This person may be a parent, a spouse, a relative or even a neighbour. The carer is the person who, frankly, has the burden of care. Then, of course, the patient must also consent to being placed on the order. The sheriff will make the community care order but cannot make such an order unless there is a satisfactory community care plan that is ready to implement. It seems to me that the quality of the community care plan ends up being a burden on the sheriff to decide. Ironically, the patient may be on leave of absence from hospital while the community care plan is being prepared.

So the patient is released to the community care team. I suggest that a busy community care team might be able to handle up to 15 patients, and probably fewer in a very rural area. The team must be able to respond today, usually on a call from the carer, and not just make routine visits. We are dealing with people who would otherwise be revolving door patients. If the patient deteriorates, then readmission can follow, and the consultant psychiatrist will arrange for the person to be brought back into the hospital for a new period of reassessment at seven days, whereas normally emergency admissions are only 72 hours.

If, as a result of the reassessment period, the person is found to be rapidly restabilised, then the patient will go back out into the community and the community care order will continue. Otherwise, a new Section 18 admission will be taken from the sheriff court. The community care order will last six months. It can be renewed by the consultant psychiatrist, first for six months and then subsequently for 12 months. But I note that renewals are not subject to judicial scrutiny by the sheriff. They are, however, notified to the Mental Welfare Commission for Scotland. A community care patient will take his or her medication voluntarily, whereas patients on leave of absence will be liable to compulsory treatment because they are still subject to a Section 18 hospital order.

While the legislative arrangements are properly ordered in the Bill, there is more to a community care order than passing a Bill about it. Community care plans require the co-operation of social work departments, housing, health board staff, voluntary agencies and carers—and the use of their funds. The House will be well aware that Scottish local authorities are to be

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reorganised in 1996 when we move from 12 social work authorities to 32. So I fear that this Bill may be introduced into an atmosphere of organisational chaos.

I also wonder whether the consultant psychiatrist should be making the community care application, as he will be committing other agencies' funds and personnel. Also, in Schedule 2 (page 39, line 27) dealing with offences, I am a little worried by the part which reads:

    "(2A) It shall be an offence for any individual to ill-treat or wilfully neglect a patient in respect of whom a community care order is for the time being in force."

Does this failure to provide after-care services, which may occur, come under this Bill? If so, who is going to end up in the dock? As it is, Section 8 of the Mental Health (Scotland) Act, dealing with after-care services, is already regarded as being underfunded. Community care orders will cost more than the community-based budget but, of course, less than the hospital budget. As the community care team seems liable to prosecution for failing to provide after-care services in extremis, it seems to me that they should be making a joint community care application rather than the more hospital-based consultant psychiatrist. These resource implications are, of course, the crux of any community care proposals. Hospital care is expensive but all the patients are together and easily administered. Care in the community is cheaper but more difficult to carry out effectively, especially on a shoestring budget.

I am also worried by the wording of new Section 35A (on page 17) in Part II, which says that the responsible medical officer may make application to the sheriff for an order,

    "providing that the patient shall, instead of continuing to be liable to be so detained, be subject to the conditions specified in the order, being conditions imposed with a view to ensuring that he receives—

    (a) medical treatment; and (b) after-care services provided for him under section 8 of this Act."

I am worried about the possible implications of that. If community care order patients are given statutory access to health and social work services, it seems to me this would lead to a rescheduling of priorities and a denial of services to others, unless the budget can be expanded.

To conclude, provisions of a community care order are in fact weaker than the provisions in respect of leave of absence. There are no powers of treatment in a community care order and of course leave of absence is to be restricted to one year. I wonder whether psychiatrists will rush to use them in view of that. I think we shall see the psychiatrists holding on for a full year before implementing them. However, community care orders may bring compulsory measures and after-care services to the most vulnerable among the currently informal patients, and this may be a bonus.

Finally, Scotland needs an overhaul of all mental health provisions, in the light of increasing community care provision, not just additions and amendments. I look forward to a new mental health Bill for Scotland being introduced.

5.3 p.m.

Baroness Seccombe: My Lords, I thank my noble friend Lady Cumberlege for, as always, spelling out so

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clearly the proposed legislation. I welcome this Bill. I feel that the proposals provide for the care of people in the best sense of the word. The Bill proposes extra care for the patient who is in need of medical care, and care for the general public who can suffer if the proper supervision is not present.

When my children were small and I was thankful for my good fortune that they had both good mental and physical health, I went with many others on a regular basis on a Saturday afternoon to a nearby hospital, where long-term patients lived. My job was to help in the hospital shop and canteen, providing refreshments to the families who came every week to spend three or four hours with their relatives. I found it a very humbling and worthwhile experience. The dedication and love of these people was demonstrated; some making long and difficult journeys to visit their relatives on a weekly basis. Without any medical knowledge, it appeared to me that many of the patients were responsible and capable people who could have lived a normal life outside. It was therefore very heartwarming when I heard that more suitable accommodation had been found. The hospital was an old Victorian institution and care in the community, if organised properly, seemed to be a much happier and more sensible answer.

Many of those patients are now living useful lives in independent accommodation but of course there will always be a need for more structured and constant supervision for the few suffering from severe mental illness. We have all read the tragic circumstances of certain recent cases. Although care in the community is working well in the majority of cases, it is essential that for that minority the provisions are strengthened where people have been detained under the Mental Health Act 1983. This minority of people are those who need special and extra support on discharge from hospital.

So I welcome the proposals for supervised discharge. Patients should agree with their carer to a treatment plan. It should be detailed and should specify requirements, if necessary, such as residence and attendances for medical treatment. As everyone who has been ill appreciates, even with general medication the need to continue a course of treatment may still be there after the initial symptoms have been relieved. In the case of mental illness this may be even more vital. Failure to make use of the facilities available can cause many problems, and it is this issue and not only the alleged lack of facilities for mentally ill people which has needed addressing.

In a compassionate society such as ours, it is essential that those suffering from mental illness have access to all the services that they need. For some, that may mean a period as an inpatient in hospital or in receipt of continuing care in the community. Financing the right treatment has been a priority for the NHS, with a 40 per cent. increase in funding. The number of consultant psychiatrists and community health nurses has risen dramatically. Local authorities are also providing places for people with mental illness, to help meet the social rather than the health needs involved. This is very important in the care of an ageing population. There is a perception that the number of beds has decreased over the last decade, but in fact it has been fairly constant at

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around 80,000. It is the closure of the large institutions, such as the one where I worked, which leads us to that belief. But of course there is now a whole range of options, from the more highly supervised larger units to the smaller homes. I should like to pay tribute to the thousands of volunteers who, with pump priming from the Government, participate in the care of mentally ill people. I refer to the Samaritans and SANE in particular, who have put forward many initiatives in this field.

Finally, I should like to pay tribute to the families of mentally ill people, often suffering themselves from the stress of caring for their sick relatives. I believe that we should all welcome this Bill as it strives to improve the quality of life for the patient while maintaining the confidence of the public that the safety of us all is paramount.

5.8 p.m.

The Earl of Longford: My Lords, I am an unrepentant feminist even though I am not always politically correct. I assume that women possess certain qualities not possessed by men, and of course there is the other aspect of that—that men may possess qualities not possessed by women. At any rate, today we have a debate in which the first three speakers, all highly qualified and eloquent, were women and now I find myself speaking between two ladies who are also eloquent and highly qualified; and so I will offer a rather diffident contribution.

I am encouraged by my noble leader in this matter, Lady Jay, who referred to the Matthew Trust report, Victims of Care. I remember that during the war, Mr. Duff Cooper, then Minister of Information, suggested that when people talked in a rather defeatist way, they should be asked: are you a paid or unpaid agent of Hitler? I suppose I might be asked whether I am a paid or unpaid agent for the Matthew Trust in these days when everybody has to declare an interest. I am not a paid or unpaid agent of the Matthew Trust but I am a great admirer of its work and of Peter Thompson, its founder and inspirer, who, as I have said before now, has done more for mental health than anyone I know of in our time.

Perhaps I may dwell for a moment on the report, Victims of Care. No one could read it without realising that there are great deficiencies in our arrangements for the most difficult cases. I do not know whether it is possible to enumerate these cases statistically, but there are a number of our fellow human beings who present difficult problems. I am glad to find that one of the Ministers in the Department of Health has written to Mr. Thompson saying that he found the report thought provoking. I hope that the noble Baroness, Lady Cumberlege, has also found it thought provoking. Reading the report one realises that there are great deficiencies. The question then arises: what do we propose to do about it? People in their different ways, many of them highly expert, have tried to cope with the problem, but it will always remain one of the most difficult in the world with which politicians will have to cope.

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These people are problems. They are problems for society. The press regard some of them as dangerous. They are problems for those who love them and they are problems for themselves. They must be supervised and helped. Those two problems are at the centre of what the Government are trying to do. When we come to the Committee stage we shall no doubt have a lot of detailed proposals to consider. I am looking at the broad issue in my few remarks today.

On a previous occasion I mentioned someone who was referred to me by the Matthew Trust. He is a young man, now aged 28, who when he was 16 was diagnosed as schizophrenic. Now, 12 years later, he has been in and out of trouble—not very bad trouble but in and out of trouble. He is going to provide a very great problem for all concerned, not least himself.

How do we propose to tackle such problems? Resources are an important part of the solution. I hope that the Government are not committing themselves to the idea that they cannot or will not provide any more resources. The idea that a new and better service can be provided without more resources is absurd.

Perhaps I may offer an analogy from the prison area. I am in touch with someone who, I was told by the Minister with responsibility for prisons, was to be treated in a certain prison. However, he has not yet received any treatment. The excellent governor concerned pointed out that when the prisoner arrived there were 14 other prisoners in the same category arriving on the same day and there was one psychologist to make the initial assessment. Without more resources, nothing of any consequence will happen in this area.

But resources are not everything. With so many experts present I hardly need to say that most of the public do not realise quite how shortsighted it is to say that these mentally ill people ought to make use of the existing services. It is all very well to talk like that. There must be a few noble Lords present—I cannot see any of them today—who have pensioner bus passes.

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