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Noble Lords: Yes!

The Earl of Longford: My Lords, there are apparently one or two present. Perhaps some of them—I am sure only one or two—lose their bus passes occasionally, as I am inclined to. In that case I hope that they do not go to the local post office. At my post office, which is a few hundred yards from where I live, one is put through a very awkward cross-examination if one loses one's bus pass. I was told, "We must be sure that you live here where you say, just a few yards down the road. Do you have your passport on you?" I said, "I'm sorry. I don't carry it with me". I was then asked, "What about your birth certificate?" I said, "I don't have that either". The next question was, "Your driving licence, perhaps?" I replied, "I'm sorry. I don't drive". I was told, "Go away and come back when you are better equipped", or words to that effect. Luckily, one can outsmart those people because we have a lovely post office here. Any Peer who knows his way about this building can get a new bus pass by presenting himself at the post office. That is the privilege of Members of the House and of the House of Commons. However, the ordinary mentally ill person, confronted with that kind

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of treatment, as he is likely to be, will not go near a post office again. Therefore, there must be a lot of extra help—beyond what appears to be duty—if those people are to benefit.

Resources are not everything. Even good intentions are not everything. There must be skill and understanding in those who seek to serve mentally ill people. The Matthew Trust makes a big point of more training. I do not say that there should be more training for all local government officers but social services workers should have more training—perhaps a year's more training—and there should be a much greater number of psychiatric community nurses. Without that kind of provision, throwing money at the problem will not make as much difference as one would wish.

Many other points will be raised by subsequent speakers in the debate. I just want to back up what has been said from our own Front Bench, and said much better than I could wish to say it.

5.16 p.m.

Baroness Macleod of Borve: My Lords, we are discussing the lives of the most vulnerable members of our society and a Bill which we hope will be of help to them. I thank the Minister for the way in which she so cogently presented the Bill. To me, it is very complicated. I had looked upon it as going repeatedly over the same point but probably to those who drafted the Bill it was done with expert knowledge. The Minister has helped us on our way.

I thank also the noble Earl, Lord Mar and Kellie, who gave us an insight into what it is to help the people for whom he has been responsible. The noble Earl's name always appears before mine on the list of speakers. Perhaps the typewriter has become stuck. I have followed the noble Earl on the last three occasions I have made speeches on the welfare of other people. Very few people have done more than the noble Earl for the welfare of other people.

Many people, both inside and outside the Chamber, have knowledge of those who have left psychiatric hospitals. We know that it is the after-care which will shape their lives. Today, we are dealing with men and women who have suffered from mental disorders which include schizophrenia, severe mental impairment, psychopathic disorder or mental impairment. I sincerely wish that we could offer much more help to those who suffer from depression. There are far too many people who are homeless and deeply lonely. Such people are often unemployed. They rarely get offers of the care which the Bill envisages for those who have been in hospital. It is estimated that there are 2,000 mentally ill patients in London alone without accommodation. I have the honour of being president of the Cherry Tree Housing Association which helps those who are in Napsbury hospital in Hertfordshire.

We started the association some time ago because we were worried about the welfare of the patients going out into the community. We began a plan which, unfortunately, is very rarely used in the rest of the country. The plan consists of medical and nursing staff who get together and choose six men and women who

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are expected to like living together. Through our auspices those people are put into a flat within the hospital boundaries. They are able to see their doctor, nursing staff or whoever they want. They are put there for six months to see if they can live together.

People have to be on the verge of going out into the community. After they have spent six months in one of the two flats—there are 12 people at a time involved—we have borrowed, begged and perhaps stolen and had homes built for the same group in some of the 12 boroughs in which we have a catchment area. We now have 18 homes administered by the Cherry Tree Association. The ex-patients who are still on licence live in the homes and go out to work as normal people. They are paid for their work and are therefore able to pay rent for the homes in which they live. Usually one person in the home acts as housekeeper and cook while the others go out to work. It is a home for people who have had no key of their own for very many years.

The scheme has worked amazingly well. I am very proud that the most recent home, built from knocking down two very old houses, was named after me. That is how we have dealt with the matter at Napsbury. Beds are being closed in that area. It is vitally important that beds should be available when needed by any of the people in the homes or those who have gone out into the community. They may have to return at almost a moment's notice. Some of the illnesses from which they suffer can take control again very rapidly and the patient has to be restored to hospital.

Not enough people care for ex-patients. There are not enough people in the community to care. Although we have been told by the Minister that no more money will be needed, I say that it will. We need more people like the noble Earl, Lord Mar and Kellie, who will undertake to look after people who are on the verge of being totally cured of a very serious illness.

Those who go out from the hospital are lucky if they have relatives to go to. If they have not—we have been told by the noble Baroness, Lady Jay, about the guardians who came into existence after the 1983 Act—I wish that the guardians were more fully used. I have also heard of foster homes where perhaps one ex-nurse will take in, and look after, one patient, very often for the rest of their lives. I know of one case of a schizophrenic who is so much better because she is being looked after by an ex-nurse who sees to her medication.

Two billion pounds is spent on services for the mentally ill —a vast budget. One would have thought that it covered people who work in this field both inside and outside the hospitals. But money is always very difficult to come by. We look to the Minister to help us to come by more for the working of the Bill.

As I have tried to say, it is people in the community who are vital in looking after these ex-patients whether in the voluntary sector, as the noble Baroness, Lady Seccombe, said, or as carers who are very often part of the local authority. They are the people who will care for these patients. We owe them our thanks for all that they do.

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To my knowledge, which is fairly extensive, but perhaps not as great as that of other noble Lords, voluntary helpers will come forward and help to look after people either inside or outside hospital. I say to the Minister that to my knowledge it is young people between 16 and 22 years of age who will help to look after the psychiatric and mentally disordered patients, more so perhaps than middle-aged people who may believe, "There but for the grace of God go I". I hope that the Bill will do more than has been done in the past for people who have psychiatric disorders.

5.27 p.m.

Lord Ennals: My Lords, I believe that the noble Baroness, Lady Macleod, has every reason to be proud that the most recent of these homes has been named after her. The long period of work which she has done in this field is admired by all. It is typical of the tremendous amount of voluntary work that is going on throughout the country in one way or another.

I was ruminating as I heard the noble Baroness, Lady Cumberlege, presenting the Bill and the speech of my noble friend Lady Jay of Paddington. I thought how privileged we are in this House to have two women of such ability to lead us in our debates. But I then had another thought which is not against my former thought. Many noble Lords begin by saying something like, "Ladies and gentlemen"—as one does when making a speech—"I welcome this Bill". I cannot welcome this Bill at all. I would like to do so. If a penny farthing is added to it I would welcome it to the extent of the penny farthing. I believe it is a difficult Bill which will create more problems than it resolves.

I had the honour to be president of the mental health charity MIND. I have been associated with its work for 25 years including four years working on its staff and another four years as its chairman. I have watched its work. MIND is the National Association for Mental Health. I have seen its campaigns and its work for a better life for those diagnosed as being mentally ill. I have seen a great deal of the work of its 240 local associations. It is a major provider of services and, through its information, legal and campaigning work, it promotes respect for the rights and dignity of those who are diagnosed as mentally ill.

When I was Secretary of State for Social Services, having concluded that the 1959 Act was too old and that it needed to be revised, I had the privilege of starting the long process of consultation which, as far as I was concerned, would end in a White Paper putting forward new ideas for a new Mental Health Act. When I then found myself sitting on the wrong side of the House—I am not expecting to sit on the wrong side of the House for very much longer—I later had the privilege of serving on the Special Select Committee which considered the 1983 Mental Health Act. We benefited greatly from the meetings that were held in advance to clear away some of the misunderstandings and to ensure that the committee was more aware of some of the complications of such a Bill than might otherwise have been the case.

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I believe that experience has shown that those who, in earlier times, might have spent long periods of their lives incarcerated in long-term hospitals can, and do, live full and valuable lives in the community. To that extent, I very much agree with the Minister that the situation has improved. Parts of the country have good community care services, which provide essentials such as crisis services, long-term support and a choice of treatments and where people with mental health difficulties are listened to and are fully involved in the decisions that are taken about their care and treatment. I should like to repeat that because I believe that we simply cannot act on behalf of other people. We should act only following proper consultation with those whose lives are as real as ours and whose views need to be listened to carefully.

It is clear that short-term hospital admission can be avoided, freeing resources to end what the Audit Commission characterised as a "vicious circle" of inadequate community care services, leading to hospital admission. The commission's report shows that, despite the rhetoric of community care, over two-thirds of the spending on mental health is still on hospitals. Community services are inadequately funded—and under the Bill not a penny is provided to help with that.

Together with most organisations that are involved with mental health care, MIND believes that the problem is that there are not enough good community care services of the type that people need and want. In my view, crisis services come at the top of the list. When people are stuck and they do not know where to go or where they will sleep, and when all of a sudden things are crushing them, they need some help. MIND has argued that the Government should set national minimum standards for community care which would prevent the provision of such services being the geographical lottery that it is at the moment. The Government should promote the entitlement of psychiatric patients to the services that they need. I repeat that such patients have an "entitlement".

The Bill does not offer any new resources. It does not place any new duties on authorities to provide essential community care services—nor does it lay down standards of service provision. Instead, it proposes that patients who are discharged into the community can be forced to accept the services that they are offered through health and social services authorities imposing requirements of residence, attendance for medical treatment, work or training, and by giving "supervisors" the power to "take and convey" a patient to their residence, treatment, work or training place. I find the power to "take and convey" a patient from one place to another (when that may well be against his will) to be very intimidating.

MIND fears that the framework proposed in the Bill will undermine the very things that are required for good community care: good therapeutic relationships, trust between patients and carers and, as I have already said, patient involvement in decision-making, and that the coercive measures undermine fundamental human rights. MIND's concerns are shared by organisations such as the Royal College of Nursing, the Community Psychiatric Nurses Association, the Mental After Care

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Association, the Mental Health Foundation, the Law Society, Liberty, the UK Advocacy Network and Survivors Speak Out.

I have had letters from many psychiatrists—in fact, I have had more letters from psychiatrists than from any other group in the period leading up to this debate—who are now running successful community services and who are worried that the Bill will undermine, if not destroy, the services that they are providing. Perhaps I may give one example. I refer to a letter that I have received from Dr. E. V. Edmunds, who is a consultant psychiatrist in Rugby. The letter states:

    "Over the past five years or so we have developed for Rugby District, which has a population of about 90,000, a mental health service which is community based and involves different disciplines working together. We actively involve both the service users themselves and their carers in planning their treatment and management, and have tried to focus on building a therapeutic and trusting relationship with our service users, some of whom have had a long history of contact with the psychiatric services which have not always been to their satisfaction.

    I believe this approach has had good results. Some of my patients who have suffered from very severe mental disorders have made good recoveries and have been able to return to full time work and education. A number have returned to complete degree courses and one has completed teacher training and has gained employment".

The letter continues:

    "I am ... very concerned that the additional compulsory powers will have the opposite effect from that which is intended"—

I stress the use of the word "intended" because I am sure that the Minister does not intend to do otherwise. The letter concludes:

    "and I think that it would be very difficult for me to continue with the style of working that I feel is most effective. It is difficult to build up trusting relationships when the patient/user perceives that all of the power rests with the psychiatrist. I would instead prefer that greater attention should be paid to the provision of community care services which are suited to individual needs and the communities that are served".

I was also interested in the comments made by the Royal College of Nursing, which refers to the Bill as offering,

    "false reassurance to patients and the public".

Those are the words of an organisation which all of us in this House respect including, I am sure, the Minister. It points out that the Bill fails to provide mentally ill people with the full range of services that they need; threatens to offer little more than a method of compelling patients to take harmful neuroleptic medication; fails to provide sufficient resources and training, particularly for community psychiatric nurses, to implement the proposals; and will reinforce existing discrimination in mental health services against patients from minority ethnic communities. We must watch that point carefully.

Indeed, the RCN developed that point later, stating that it,

    "fears that far from addressing discrimination in mental health services against patients from black and minority ethnic communities, the Bill will only serve to reinforce it. Patients from black and minority ethnic groups are already over-represented in the use of powers under existing mental health legislation. They are more likely to be treated with neuroleptic drugs and to be given higher doses than white patients. It is likely that 80 per cent. of the new supervision orders will apply to this group of patients and the discrimination will therefore continue".

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I have another useful quotation from the Mental Health and Disability Sub-Committee of the Law Society for which I have great respect. I spoke at one of its conferences a year or so ago. It says that the Law Society:

    "considers that the case has not been made for more extensive powers of compulsion over people with mental health problems, whether they are being treated in hospital or in the community. In the Committee's view, the existing powers and provisions of the 1983 Act have never been properly used because of insufficient understanding of the extent of those powers, nor fully implemented because of the lack of adequate resources devoted to the care of mentally ill people".

My last quotation comes from the BMA which I know does not always command the Minister's respect. It deals, as did the noble Baroness, Lady Macleod, with guardianship. We must look at that carefully as the Bill proceeds. The BMA said:

    "The Government recognises that there may be scope for extending the use of guardianship and amendments could be made to the provisions on guardianship in the Mental Health Act 1983 to meet the need to tighten up and improve the care provided in the community for severely disordered people".

I shall say no more except to ask the Minister a question. Bearing in mind all the organisations to which I have referred and which have such sharp criticisms of the Bill's contents, when she replies will she tell me with some precision what organisations the Government consulted before they brought the Bill to the House?

5.41 p.m.

Lord Mottistone: My Lords, it is always a pleasure to follow the noble Lord, Lord Ennals, although on one point alone I disagree with him, and that is his keen support for MIND. I have found the members of MIND useful and easy to work with out in the country, but the enthusiasm for civil liberties at the centre of MIND does nothing but harm, rather than good, to the cause of mentally ill people. It is sad that that should be so. He made an admirable speech with quotations from all sorts of other people. It is a pity therefore that I find it difficult always to pay the respect that I should to the noble Lord's speeches when he is doing one of his "MIND jobs".

I thank my noble friend the Minister for so clearly introducing what I believe to be a most welcome Bill. It is supported in principle by the National Schizophrenia Fellowship which advises me on these matters, as I expect your Lordships know, and by SANE of which I am chairman. With the excessively rapid reduction in the number of hospital beds for the mentally ill over recent years—I emphasise excessively rapid—there have been several well-publicised cases of persons with schizophrenia who have not had sufficient care in the community—some with disastrous results. We all know of them, and indeed some noble Lords have given examples.

However there have been several cases, not so very different, which have come to my notice from time to time where the people most affected were the sufferer and his or her family. I had a friend in the Navy. He was a close friend in the early days, and I am talking about 55 years ago or more. He was invalided out of the Navy in the late 1950s or early 1960s. He was mentally

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ill. He lived a satisfactory life during the 1960s, cared for by his family and his GP. In the late 1960s, by which time I had moved away, he had to go to a mental hospital because of something that he did. I really cannot remember what it was. He spent a bit of time there, and was discharged in due course. None of the procedures about which we are talking today was around. To cut a long story short, before long he murdered his second wife. He is now in a mental hospital again. If something like the proposed system had been in existence 30 years ago, it is possible that the lady would have survived. I do not believe, as I think my noble friend Lord Campbell implied, that the legislation is being rushed through. I believe that the legislation is overdue.

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