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Baroness Cumberlege: I concede my noble friend's tribute to the Scottish system and am grateful to him for the part that he has played in it.

This amendment seeks to add the Mental Health Act Commission to the list of persons the RMO must consult. The commission plays a valuable role in its visits to detained patients. It fulfils admirably the Secretary of State's functions under Section 120 to keep under review the exercise of the powers and the discharge of the duties relating to the detention of patients, or to patients liable to detention.

The commission's remit is limited to detained patients and does not extend to those receiving care in the community. Therefore, it also rules out guardianship orders. We believe this to be right, given the need to make the best use of finite resources. At the moment, when a supervision application is made the patient will be detained in hospital and the commission will be able to review the way in which the procedures operate. But there is no obligation under the Act as it stands to consult the commission, for example before a patient is detained or before detention is renewed. It would be inconsistent to require this when supervised discharge was being considered.

In the light of this, I hope that the noble Baroness will not press the amendment.

Baroness Jay of Paddington I understand precisely what the Minister says about how this amendment will obviously extend the role of the Mental Health Act Commission, but that is precisely what it is intended to do. Perhaps the Minister can help me a little further on how the Department of Health, and indeed those bodies who will be responsible for patients under supervised discharge orders, expect to be able to evaluate appropriately this new form of care if there is no form of central register, or no way of reporting to a body that can monitor and evaluate this type of care at any future stage.

Baroness Cumberlege: Local mental health registers are being established. I believe that it would be up to the Social Services Inspectorate and the National Health Service Executive to monitor very carefully how effective those registers were.

Baroness Jay of Paddington: I am grateful to the Minister for that reply. Obviously, what she says is helpful. I hope that we can return to this at a later stage.

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I will read very carefully what she has had to say. However, given the context of the discussion at Second Reading about the possible need to revise the whole of the mental health legislation, we probably need something more systematic and nationwide in evaluating this new policy if we are to make approaches of this kind to the old Act. In the meantime, I beg leave to withdraw the amendment.

Amendment, by leave, withdrawn.

[Amendments Nos. 27 and 28 not moved.]

Baroness Jay of Paddington moved Amendment No. 29:


Page 3, line 32, after ("supervisor,") insert ("who shall be a Community psychiatric nurse,").

The noble Baroness said: Amendment No. 29 is designed to make specific on the face of the Bill who shall be the supervisor of those subject to supervised discharge orders. We have been told that the supervisor will be the named person who will carry the responsibility for ensuring that the patient receives aftercare services in the community. The named person will, if necessary, make the decision to convey the patient to the place where he resides, is being trained or is receiving treatment. Ultimately, it may be the named person who recommends that the supervised discharge order is revised or lifted. Obviously, this will be an extremely responsible and—one may almost think—exposed position. As I said at Second Reading, my fear, and that of several people to whom I have spoken who will be involved in both recruiting and managing people in the community who are subject to supervised discharge orders, is that if the responsibilities that the supervisor is supposed to have and the lines of management and accountability are not absolutely precise, it may be very difficult to persuade colleagues to take on these roles, particularly in view of the harsh spotlight of unpleasant publicity that can fall on named people in these local positions if something goes wrong.

On Second Reading I asked who would be the supervisor, and the noble and learned Lord, Lord Fraser of Carmyllie, said:


    "The supervisor may well be a social worker. But we think it more likely in fact that he or she will be a community mental health nurse. Most key workers in the care programme approach are such nurses".—[Official Report, 16/3/95; col. 977.]

That would be also be consistent with the Bill being regarded primarily as the health authority measure. Given that, it is surely important, so that the lines of responsibility and management accountability are understood clearly and agreed, that the Bill should specify who will hold that crucial post.

Whether they are named specifically on the face of the Bill, community psychiatric nurses will—if they are asked to take on this new role—carry a new and heavy burden. If the amendment is not accepted, I hope that the Government will acknowledge that the codes of practice will need to identify maximum case loads and the need for particular training in those new

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responsibilities which will almost certainly, as I say, fall upon the community psychiatric nurses who are already severely burdened and under strain. I beg to move.

Earl Russell: I am very much in sympathy with the objectives of the amendment, but I noticed that the noble Baroness said at the end that community psychiatric nurses are over strained and over-worked. There is a question then of the viability of the amendment. The Royal College of Psychiatrists says that in London the average reported case load of community psychiatric nurses is 37, and the range in that is 17 to 62. Do we need more community psychiatric nurses before the amendment is viable? I should be glad to hear the opinion of the noble Baroness on that.

Baroness Jay of Paddington: Perhaps I may respond briefly to the noble Earl. The point that he makes is an extremely good one. I hope that if this person is identified clearly and specifically, as the amendment suggests, the pressure to provide such people with adequate resources and to recruit more CPNs, and to see that they are trained appropriately to take on these additional tasks, will become irresistible.

Baroness Miller of Hendon: All professional members of a patient's care team have a degree of expertise and knowledge of the patient which will make their contribution essential to the patient's support and well-being in the community. In practice, the supervisor, for the purposes of supervised aftercare,will be the key worker identified under the care programme approach. That is at the centre of our policy on the care for mentally ill people in the community, which will apply equally to patients covered by the new provisions.

Most key workers are indeed community psychiatric nurses, who have particular skills and clinical background to enable them to fulfil that role effectively. But that is not always the case and there is no reason why other members of the care team—say the doctor or social worker—should not fulfil that role when it is in the patient's best interests and is more practical. The same flexibility is needed in nominating the supervisor under our new provisions. That should be the professional who is best suited, to the satisfaction of all concerned, with providing the aftercare health services needed, to undertaking the role.

Narrowing that to a single discipline is an unnecessary constraint. I hope that the noble Baroness will agree to withdraw the amendment.

Baroness Jay of Paddington: I accept what the noble Baroness said, but on the other hand if the assignment of authority—if one can call it that—is not made specific and clear, and, as she said, drawn rather narrowly, the opportunities for confusion and the breakdown of relationships, which has been demonstrated so clearly in so many of the reports which have been referred to in earlier amendments this afternoon, will persist.

If the Government feel that the most appropriate person is the community psychiatric nurse, and if the distinction, as we have heard it argued this afternoon, between the supervised discharge order and, for example, guardianship is that that is a health authority

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responsibility, why is it not appropriate to name the community psychiatric nurse as the appropriate person? As I said in response to the noble Earl, Lord Russell, I hope that that person will be supported adequately.

Baroness Miller of Hendon: It will not always be the community psychiatric nurse, sometimes it will be the social worker. We are only codifying what already exists. As the noble Baroness may be aware, we have had a huge increase in the number of CPNs, but we feel that we need the same flexibility to make the care package work successfully. I hope that that explanation will satisfy the noble Baroness.

Baroness Jay of Paddington: I am grateful to the noble Baroness for that reply. In a sense it comes back to the nub of the debate we had this afternoon about what it is that distinguishes the supervised discharge order from other forms of supervision in the community. Again, I refer to guardianship. I shall read what the noble Baroness had to say and may return to this at a later stage. In the meantime, I beg leave to withdraw the amendment.

Amendment, by leave, withdrawn.

[Amendments Nos. 29 to 31 not moved.]


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