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Baroness Cumberlege: My Lords, the care programme approach is intended to do just that--to ensure that when people leave hospital they have a key worker who makes sure they do not get lost in the labyrinth of different services supplied by the National

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Health Service and also by social services. One of the strategies in the policy is to ensure that social services and the health service work more closely together. We accept that some people will need secure accommodation probably for the rest of their lives. But I do not think we should underestimate the enormous progress that has been made, particularly through the new drugs that have become available. We see people now who in the past would have been kept in acute care. They are now holding down jobs, leading a normal life, and in many cases a very happy family life as well.

Lord Strabolgi: My Lords, arising out of what was said by the noble Lord, Lord Campbell of Croy, will the Government pay particular attention in future to the role of the so-called anonymous lay managers? There have been some cases where they have overruled the views of professional doctors and psychiatrists and have let out dangerous mental patients into the community against all advice. Who are they? Why are they allowed to remain anonymous? Why are they allowed to overrule the professionals? Will the Government pay particular attention to this point in future as there have been cases where dangerous mental patients have been allowed back into the community, without adequate supervision, to murder and rape?

Baroness Cumberlege: My Lords, mental health managers are not necessarily people in pinstriped suits who are employed by the health authority. Managers in these terms are often lay people who are brought onto a board. The National Association of Health Authorities and Trusts, the Mental Health Act Commission and the Royal College of Psychiatrists share the noble Lord's concern. They have set up a group specifically to review this role of mental health managers. They will be reporting very soon in the spring.

Baroness Faithfull: My Lords, does my noble friend agree that we have not got to the heart of the matter? We have talked about money; we have talked about beds; we have talked about homelessness; but we have not talked about the best way to treat a schizophrenic. I have had to do this work myself in the community and I have great sympathy with community psychiatric nurses and social workers. If a patient is discharged from hospital and he has to be supervised in the community it is impossible to be with that patient 24 hours a day. One problem--I am sure my noble friend will agree with me--is that some schizophrenics will not take their medication. If they take their medication there are not many problems. But how does a community psychiatric nurse, good though he or she may be, or a social worker, good though he or she may be, make a patient take his medication? The patient may have good accommodation at night but there is always that moment when he has not taken his medication.

We have closed down a number of centres where patients used to be able to go, morning, noon and night. At the centres a nurse would be on duty and food would be supplied. It is also to be regretted that we have closed down the occupation centres. They provided dignity for patients. They could be under supervision--we tried to

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make it not appear to be so--and they could do a job of work. In Oxford I used to be in touch with the Cowley works which would send to us simple jobs which people could do. Cowley would pay the going rate to the patients. In that way patients were supervised throughout the whole day without it appearing that they were being policed. They were provided with dignity.

I do not think we have considered enough how we should deal with schizophrenic patients in the community who will not take their medication. We really should remember the families of schizophrenics. Schizophrenics are an agony to families. I have seen families destroyed because their schizophrenic son has disappeared. They wonder what has happened to him. They do not know. I know it is felt that it is wrong to supervise by laying down lines of supervision, but we have to do that with some patients. The only way to do it is to give them a dignified life. That means giving them somewhere to live where they are supervised, befriended and cared for, where they can work during the day and earn a living, but where they are in care and supervised.

I feel humble in speaking in front of noble Lords who are doctors, but I do not think the doctors have set out for social workers and community workers exactly how such patients should be treated. All the money in the world and all the community care in the world will not make a difference unless we give real thought to what these patients really need and how they can be cared for in a dignified but supervised way.

Baroness Cumberlege: My Lords, I agree with much of what my noble friend has said. Schizophrenia is a quite hard diagnosis to make. We know that it can vary enormously, from those who are extremely ill to those who have bouts of illness from time to time and are easier to manage. The supervision registers which we are putting into place in all health authorities identify those people who may be of particular risk to themselves and to others.

Our second initiative is the new power of supervised discharge under the Mental Health Act which, as I have said, noble Lords passed earlier this year. That enables the re-admission of a patient if they are not complying with the treatment. So there is a much greater grip on the situation. I agree so much with what my noble friend has said about ensuring that people are occupied during the day. One of the difficulties in the past has been when people have been discharged from hospital. Their basic routines, not only of where they sleep, how they eat, how they spend their weekends and whether there are employment opportunities, have been neglected in the past. That is why we want the care programme approach which will address these issues.

As regards families, I share my noble friend's sympathy for the families who take on these very difficult responsibilities. But through the Patient's Charter, which we are putting out in draft form for consultation today, we would involve families in the

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assessment of the patient and also in the discharge arrangements. That is very important because so often it is the family which is left to pick up the pieces.

Lord Archer of Sandwell: My Lords, if I understood the noble Baroness correctly, she said that her department would be reviewing the future of mental health review tribunals separately. Is she aware that that will come as tidings of great joy to those who have to operate the system? Will she ensure that the consideration which she indicated a few moments ago in answer to my noble friend as regards management meetings is undertaken jointly with consideration for the future of the mental health review tribunals? The relationship between the two procedures gives rise to a great deal of confusion.

Baroness Cumberlege: My Lords, at this moment we are not reviewing the tribunals but the mental health managers. We have some difficulty with the tribunals in that they are part of the Mental Health Act. It may be that the 1983 Act will need some sort of revision or review in time. I am very sorry to disappoint the noble and learned Lord, but that is the situation.

Lord Mottistone: My Lords, I very much support what my noble friends Lady Faithfull and Lord Campbell of Croy said. I also congratulate the Government on tackling the problem. Like other noble Lords, I have doubts whether they will be able to do so because I do not believe that there is enough money around in the country let alone in the Department of Health. But let us see how that goes.

When my noble friend was making the Statement she mentioned a number of reports, papers, plans and all kinds of other things. It seemed to me that some of them might be in print and some not. It would be helpful if everything that was mentioned by my noble friend, and not only the charter, was available for us to read as well as the Statement itself. There is a great deal there to be read because we have a great deal of studying to do. We are talking blind from this side of the House. Noble Lords opposite always get their papers in advance, and how lucky they are!

Lord Graham of Edmonton: How wrong you are!

Baroness Cumberlege: My Lords, I do not share my noble friend's pessimism. I believe that in time we shall get this matter right. I recall child abuse 20 years ago when it was a huge issue. By ensuring that we had key workers and a number of other procedures, we have managed now to make progress on that front. There are five documents. There is The Spectrum of Care; there is another document on 24-hour nursed beds, an audit pack on the care programme approach; the draft charter for mental health services; and the application criteria for the mental health Challenge Fund. I shall ensure that they are all in the Library.

Lord Hayhoe: My Lords, reference has been made to mental health managers. While I accept that on occasions mistakes have been made, in these exchanges it would be wrong if some reference were not made to the immense amount of work that they do in a voluntary

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capacity. That has been a duty laid on them by Parliament, who decided that this lay element should make the decisions. In those circumstances, I hope the Minister will agree that it is right that praise should be given to the great service that the vast majority of these managers give to the community. I have a little knowledge of it myself. I believe that the individuals concerned deserve praise rather than condemnation and criticism.

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