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I support those parts of the amendments that relate to the demand for an assessment of proper needs and the duty to respond appropriately. I am surprised that so far the name of Marjorie Wallace has not come up in our debates. The campaigning journalist and founder, chief executive and now, I think, president of Sane has pointed out over and over again the cases that come to her of people who sought help and could not get it. That has happened on innumerable occasions.

I think of the tragic case in the East London and The City Mental Health Trust two or three years ago, a case with which the noble Baroness, Lady Meacher, will be familiar. One that really came home to me was the sad case of Andrew Robinson, the vicar’s son in Devon, who committed homicide against another Robinson, an occupational therapist from a different family. I have seen the letters from his desperate parents, over a period of weeks and days before he was seen by the psychiatrist, to the director of social services, to the psychiatrist, to the psychiatric social worker, to the occupational therapist—and he was not seen. The outcome was that he was admitted into hospital in the most appalling state of psychotic illness, and he murdered while in the unit. It is worth remembering, when we are talking about detention, that a significant proportion of homicides sadly occur inside psychiatric units. Such cases bring home to you the need for these amendments, I scratched my head and thought, “Oh dear, obligatory services—the Government won’t like that”. But then I thought that we do that all the time for people with physical health problems. The example that springs most readily to mind is the obligatory two-week response for cancer waits. Now, if a GP suspects that someone has cancer, he has a hotline to the hospital and he can demand that that person is seen within two weeks. I think the Minister will accept that on the whole there has been a remarkable response by services in delivering that target. There are glitches, but on the whole it has been a success. It can be done, and it would immeasurably improve the confidence of caring families and individuals to know that they had a right to ask for help when they felt that things were going wrong. I support the amendments.

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Baroness Finlay of Llandaff: I shall intervene briefly to support these amendments, particularly Amendment No. 7, which outlines comprehensive assessment in a comprehensive way. I understand that the Government have been looking at comprehensive assessment, and that Warwick University has been working with them on it. Amendment No. 7 should not come as any surprise at all to the Government. It is holistic; it looks at a person’s need from the perspective of health and social care. It addresses the tragic situation we hear about only too often, of people wanting help and being turned away.

Earl Howe: We have heard some compelling speeches in this debate. The noble Baroness, Lady Wilkins, and the noble Lord, Lord Williamson, are to be applauded for all that they said in support of their respective amendments. In a policy context it is always problematic to talk in terms of a completely demand-led service available as a right to whoever asks for it. That appears to be the effect of the noble Baroness’s amendment, and I suspect the Minister is likely to balk at it. In his shoes, I probably would as well. Even if I cannot support her amendment quite as worded, however, I am definitely with the noble Baroness in spirit. I am also definitely with the noble Lord, whose amendment seems to me to have the edge over that of the noble Baroness.

There are several things that both the noble Lord and the noble Baroness said that bear underlining. The first is that all too often the only reason that someone ends up being subject to powers of compulsion under the Mental Health Act is the lack of available outreach or early intervention services appropriate to their needs at an earlier stage. I was staggered to see the figure from Rethink that 50 per cent of people subject to compulsory treatment have previously asked for help and been turned away. That chimed in with the story that the noble Baroness, Lady Murphy, told us, and it is a terrible indictment of the way mental health services are configured.

If anyone supposes that it can be better or more cost-effective to treat someone as an in-patient under conditions of coercion than to provide treatment to the person informally when they are much less severely ill, I will be amazed. Time after time, though, that is what the service ends up doing to people. The Sainsbury Centre for Mental Health has put the total cost of mental illness to the economy at over £77 billion a year. A figure like that is a salutary reminder that an approach to mental health that adopted a much broader and more imaginative model for assessing cost-effectiveness could well prove highly beneficial.

Like the noble Baroness, I think straight away of the proposals put forward by the noble Lord, Lord Layard, who, as she said, has argued persuasively that a substantial investment in talking therapies for those with depression would repay itself in savings of incapacity benefit. I hope that the Government will give that idea the support it deserves and take it forward. That is only one example of the savings that could undoubtedly be made across the piece, if only we were able to deal earlier and better with mental illness and get people who are ill back into employment.

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Therefore, I hope that the Minister will listen carefully to his noble friend and to the noble Lord who, as I am sure he agrees, know a thing or two about disability matters. They are absolutely right to move our attention away from issues to do with detention and compulsion and on to issues to do with better and more timely service delivery, which are the things that really matter to the vast majority of service users.

7 pm

Baroness Neuberger: I, too, support in principle the amendments of the noble Baroness, Lady Wilkins, and the noble Lord, Lord Williamson. Like the noble Earl, Lord Howe, I am delighted that for a few minutes we have been taken away from issues of compulsion to talk about what mental health services should be like and, indeed, what entitlements patients should have. My noble friend Lord Carlile was right to say that we should be thinking of a very basic Bill of Rights, as it were, for patients who use mental health services. We should be thinking about a right to assessment, support and treatment.

The noble Baroness, Lady Murphy, was right to remind us of the work of Marjorie Wallace of Sane, and, indeed, of the work of other organisations, but particularly that of Marjorie Wallace, who has reminded us time and again of people who have told her organisation that they could not get anywhere. Neither individual patients nor their families or carers who have asked for help can get a response from the services. We need to look at what the services are doing.

I speak from experience. I am sure that the noble Baronesses, Lady Meacher and Lady Murphy, have had the same experience as I have of the mental health services. I refer to chairing a mental health service trust in central London. The reason that on the whole people get such a poor response is that bed occupancy is so high that the services are struggling to provide for people who are compulsorily detained. Trials, experiments or, indeed, the introduction of a new service such as assertive outreach, which the noble Baroness, Lady Murphy, mentioned, have shown that it is possible to get bed occupancy down in the compulsory services by going for assessment, support and treatment but not necessarily for compulsion. You can make the services much more responsive. There is a lesson for us to learn from that. That is why the insistence on assessment, particularly in the amendments of the noble Lord, Lord Williamson, and the noble Baroness, Lady Meacher, is so important.

When assertive outreach was piloted in three London trusts I was still chief executive of the King’s Fund. We piloted the measure jointly with the Sainsbury Centre for Mental Health in three areas with Department of Health funding. I believe that the Minister was party to that on the first occasion that he held his present ministerial office. The pilot was so dramatically successful that assertive outreach was put into the national service framework before the assessment and evaluation of that project were fully completed. That is unusual but I think that it tells you that there is

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another way of doing things. During these two days of debate we have said time and again that there are ways of thinking differently and of encouraging people to use services. We should not drive them away by the threat of compulsion but allow them to engage with services and feel that they are being offered fair assessment, support and treatment. I say to those Members of the Committee who are not aware how it works that assertive outreach is a rather imaginative process. Often it involves doing a deal with patients. Patients agree to take their medication, having had a full assessment. They engage with the treatment and are compliant. In exchange they often get the support that they have asked for, which on the whole our services are very poor at providing. Sometimes patients get access to housing. Often they say that they want access to employment. We rarely manage that but often we manage to secure daytime occupation. The evidence thus far suggests that such patients have a better quality of life. That experience, in so far as we have had it—it is now in the NSF—should indicate to us by practical example that going for assessment, support and treatment is a better way in than a system that is based on compulsion. I hope that the Minister will take that very seriously because it seems to me that we could reduce the need for compulsion if we were serious about assessment, support and treatment.

If we went down this path, we would follow the recommendations of the Joint Committee on the 2004 Bill. We would accord with the Government’s own national service framework—a framework which is at the moment somewhat in danger because the services themselves are having money stripped out of them. Mental health services are losing money to the acute sector due to deficits. That should give us real cause for concern when what we want to see is a system that encourages assessment and voluntary treatment. Other Members of the Committee have said that Rethink’s evidence that 50 per cent of people who are treated compulsorily asked for help but did not get it is a disgrace. It is indeed a disgrace but we also need to recognise that when people ask for and receive treatment voluntarily, the evidence shows that it tends to be much more successful. The Healthcare Commission has told us that some 51 per cent of mental health service users have no access to crisis care out of hours. Yet, if you want a system of assessment, support and treatment that people will engage with voluntarily, you have to have access to crisis care. That fits with the model that the national service framework has given us.

The noble Baroness, Lady Meacher, talked at length about the cost of mental illness and particularly of depression. About 40 per cent of people in receipt of incapacity benefit have a mental health problem. The economic costs are huge. I shall not go through all that but we have developed very good ways of supporting people with an alternative to care in an acute ward under compulsion. I refer to the Drayton Park alternative to in-patient care for women and the American idea, which we hope to establish in Britain, of the Times Square hotel of supported housing. Those measures have almost always been funded under charitable or short-term project

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funding. My noble friend Lord Carlile is right to say that mental health services are still the Cinderella services of our health service. Often but not always you can easily raise money for hospices. You can raise money for cancer and multiple sclerosis. However, it is incredibly difficult to raise money for mental health services. This is an area where we should give patients rights, which need to be backed up with money. Money should not be stripped out of the system. The Government will loathe our saying that this will cost. It will cost in the early stages although in the longer term it may save money. Many of us would argue that it would save money in the longer term. We should have a charter of rights that gives people the right to assessment, support and treatment. That will need funding but not from the compulsory side of the sector. I should like to see this Government have a Bill of Rights that takes on board the principles behind the two amendments that we are debating and which is not just lip service to patients’ rights but shows that we really mean it.

Lord Hunt of Kings Heath: This has been a good debate. I say right at the beginning that I have no disagreement whatever with how noble Lords have expressed their comments about the need to develop services. It seems to me that the one thing on which the House is united in our debates on mental health is our belief in the importance of mental health services and our wish to strengthen them. We wish, as noble Lords have suggested, to have early intervention and to see that the tragedy of the million people with mental health problems who are on incapacity benefit is put to an end. We are all united in wishing to see that happen.

I rather wish that noble Lords might have given the Government a little credit for some of the developments in the last few years. The noble Baroness, Lady Neuberger, by pointing to crisis intervention teams and so on, has illustrated some of the improvements. The noble Earl, Lord Howe, put his finger on the real question: is this amendment the right way of fulfilling our desire to improve services, access, rights and so on? That is the point on which I disagree with noble Lords. I disagree for two reasons. First, the public’s rights on assessment and service provision are already covered in general legislation. Secondly, while I know that noble Lords here tonight would wish to prioritise mental health services above all other services—for I suspect that that is the implication of what they are saying—we also have to look at the impact of identifying simply mental health services and putting strict duties on to local providers, when similar duties will not be placed—

Baroness Meacher: We were only asking for equal treatment of mental health alongside physical disability. I do not think any of us indicated that we wanted a greater priority for mental health.

Lord Hunt of Kings Heath: I fully understand that. What I am trying to say is that such an amendment to the Bill would, by its very nature, have the effect of forcing the health service and local government to

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give absolute priority to those services. There would be no similar duty in other areas of the health service. That is my point.

I shall mention the legislation that we believe covers the responsibilities. Under the National Health Service and Community Care Act 1990, it is already the case that a person who appears to a local authority to be in need of care services is to receive an assessment of that need. The Secretary of State already has a duty, in the National Health Service Act 1977, to promote a comprehensive health service designed to secure improvement in the physical and mental health of people and in the prevention and diagnosis of illness. There are similar provisions in relation to Wales. Those are significant and important duties. Moreover, a process of inspection and regulation has also been established. We have the Commission for Social Care Inspection and the Healthcare Commission.

Wherever the needs of a person being assessed for community care services are such that an assessment is also required from a health professional, the local authority is required to request a contribution to their assessment from the appropriate NHS body and to take into account the health services that are to be provided as a result. There is a statutory responsibility for NHS and local authority bodies to co-operate. Under the existing arrangements, community care assessments already provide the elements that make up the definition of “treatment and support” in subsection (10) of the amendment in the name of the noble Baroness, Lady Wilkins. That is current good practice. Therefore, the legislation itself meets many of the objectives which noble Lords wish to see in generic provisions that apply to health and community care generally.

7.15 pm

Surely one should also acknowledge the huge improvement that has taken place in mental health services over the past few years. Of course it is not perfect and much more needs to be done, but surely we should acknowledge the enhancements such as the whole purpose of the National Service Framework for Mental Health and the guidance given to the health service. There has been extra investment. The noble Baroness, Lady Neuberger, has referred to early intervention teams, crisis resolution teams and assertive outreach teams.

We face many more challenges, and we want to do everything we can to improve the performance of the mental health service. We want to ensure that patients know their rights and that the gaps in provision which noble Lords have mentioned will be met. However, given the existing statutory framework and the problem of singling out mental health provision as Amendment No. 55 suggests—for we see a real problem there—surely the emphasis has to be on the work of the care commissions and on monitoring performance management. That government role goes hand-in-hand with the legislative changes we are proposing. We will do everything we can to ensure that the current improvements continue.

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Baroness Neuberger: I am so sorry to interrupt the Minister, but when he says that the Government will do everything they can to continue the improvements in the mental health services, does that include the money currently being removed from mental health services to plug gaps in acute services?

Lord Hunt of Kings Heath: A great many switches in resources are taking place. To single out mental health and to suggest that all the money is being taken from mental health services is, if I may say so, a rather gross exaggeration. The health service clearly has to live within its means. That is why we are requiring it not to be in deficit at the end of this financial year. It involves some difficult decisions that affect not just mental health services but others as well. I invite the noble Baroness to accept that we are in the middle of the largest increase in NHS funding in our lifetime and that mental health services have benefited as a result.

Baroness Wilkins: I am most grateful to all noble Lords who have taken part in the debate and given their support to both the Rolls-Royce and the Mini of these two amendments. I am obviously disappointed by the Minister’s response. The extension of compulsion that the Bill will enact will, as the Royal College of Psychiatrists has pointed out, further diminish the resources that go into mental health care services and make the need for a charter of rights even more important, as the noble Lord, Lord Carlile, pointed out. This is one opportunity in a generation. I would like to reflect on the debate. For the moment, I beg leave to withdraw the amendment.

Amendment, by leave, withdrawn.

Lord Hunt of Kings Heath: I beg to move that the House do now resume and that the Committee stage begin again not before 8.20 pm.

Moved accordingly, and, on Question, Motion agreed to.

House resumed.

Anti-social Behaviour Orders: Youth Justice Board Report

7.20 pm

Baroness Stern asked Her Majesty’s Government what action they will take in response to the report by the Youth Justice Board, published on 2 November 2006, on research into anti-social behaviour orders given to young people between January 2004 and January 2005.

The noble Baroness said: My Lords, I thank so many noble Lords for deciding to speak to this Question for Short Debate. I know that a number of Members of this House have been concerned for some time about the effects of anti-social behaviour legislation on young people. In particular, we have been concerned that very disadvantaged children and young people with serious problems would be given enforcement rather than help. We have had anxieties

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about a disproportionate use of such measures on young black people. We have feared that families that need stability and support are instead facing eviction from their homes. We have seen evidence from reports and Parliamentary Questions that troubled and troubling children are being pushed towards the criminal justice system inappropriately.

We hear that those responsible for young people in trouble, the youth offending teams, are marginal to the activities of those in the police and local authorities who deal with anti-social behaviour, although we do not know whether this has improved as a result of the guidance that came out in March 2005. We have heard that the conditions imposed on some young people have been unrealistic and impossible to comply with. We have said before in this House that naming and shaming can put children and their families in danger. We have been concerned about aspects of the legal regime that contain injustice.

In our debates, we have repeatedly asked for more evidence and for some facts on what is actually happening. We have, therefore, all been awaiting with interest this report from the Youth Justice Board. We now have it, and sadly it confirms our worst anxieties. I remind the House that we are talking here about children. There is a wider issue about anti-social behaviour legislation in general and what happens to adults, which is not the subject of today’s debate, although a recent report from the National Audit Office suggests that the whole policy gives cause for concern. Those of us who are concerned about the impact of this policy on children care enormously about the quality of life in high crime areas. We have great sympathy with those who have to live in the same streets as disturbed and uncontrollable children. In our view, the anti-social behaviour legislation is a poor and unjust substitute for a properly resourced policy on family and child care and support for neighbourhood initiatives by local authorities.

This independent report, commissioned by the Youth Justice Board, the first such report, looked at ASBOs issued to young people aged under 18 in 10 areas of England and Wales between January 2004 and January 2005. The report finds that the children who are given these orders are among the most disadvantaged of our children. They have suffered family breakdown and previous abuse, bereavement and loss. They also tend to live in high crime neighbourhoods where there is very little for them to do. Some 22 per cent of the children in the sample were from black or other ethnic minority groups. One quarter of them were in special schooling of some sort. One mother of two children on ASBOs explained that they had reacted badly,

“to deaths in the family and witnessing a murder”.

One mother of a son on an ASBO described to the researchers their family’s experience of violent racism, which had forced them out of their home. One grandmother talked of her grandson who had been neglected and physically abused before he came to live with her.

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