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Lord Rees: My Lords, before the Minister sits down, he may recall that I posed this same question both during Committee stage and this evening. With his habitual courtesy I have no doubt that he will wish to answer it. Will he say simply that whatever the size of the majority, whatever the size of the turnout in Scotland and Wales, if there is a "yes" vote the Government will proceed with devolution legislation?

Lord Sewel: My Lords, I thought I had made the Government's position clear by reading out the passage from the manifesto where it says,


Indeed, in this case, in terms of the Government's position, one is enough.

8.15 p.m.

Lord Mackay of Ardbrecknish: My Lords, to sum it up, the Government do not care what the turn-out is. It is not something that bothers them one way or the other. I am sorry that we have not been able to tempt government Ministers away from their narrow briefs into a wider consideration of the question I posed. Not only in relation to this referendum--I accept what is in the Government's manifesto, I have heard it often enough--but also in relation to other referendums, it would be interesting to hear what noble Lords felt about the general proposition in regard to turn-outs and majorities.

I was happy to hear the noble Lord, Lord Howie of Troon, recruited to my view that we need a generic referendum Bill. That is one of the questions which may or may not be addressed in a generic referendum Bill.

Lord Howie of Troon: My Lords, but not tonight.

Lord Mackay of Ardbrecknish: My Lords, I can assure the noble Lord that I have no intention of even beginning it tonight.

The noble Lord, Lord Hooson, asked why fresh rules were required. I commend him to the Marshalled List and to the amendments tabled by the Government. He will there see detailed rules, and they are required because a referendum is quite a new animal. It does not have any legislative provision. It therefore has to ride piggyback, so to speak, on the Representation of the People Act, which is designed for parliamentary and local elections.

If the noble Lord, Lord Hooson, does not see that there is a huge difference between a referendum, which is a one-off question with a one-off answer, and a parliamentary or local government election, where people are electing a government or a local authority to deal across a whole range of issues, then nothing I can say tonight will ever manage to persuade him of that difference. It is self-evident to me that there is a huge difference.

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However, that is not the proposition, though it is related to it. It is because it is different that we ought to address the problem. I am sorry that government Ministers have not even begun to turn their attention to the wider question: if we are to have lots of referendums, what are we going to do--if anything--about turn-out and majority? I have said to the Government before that, if we have lots of referendums and we come to one where there is a low turn-out and only a bare majority of a couple of people, should the Government then say, "We are going to ignore it because people do not feel strongly about it", they will have real trouble from the people who thought that they had won. I remind the noble Lord of all the people who thought that they had won in 1979. They have borne it girning in their souls ever since; ad nauseam, despite the fact that they made the rules. They were the people who told the people of Scotland, "If you want to vote no, you do not have to bother turning out". I gave them an answer to that in my formula. If a formula had been accepted rather than a table, we would have got rid of the cliff edges.

Clearly we are not going to make progress on this matter. I am sorry that the attempts of my noble friends Lord Stanley and Lord Rees failed to persuade the Government to address this proposition in general terms. Does any old turn-out count? Clearly, any old turn-out counts. If only 10 per cent. or 20 per cent. of the people of Wales turn out, the Government will be happy with that.

I will only say that those of us who want a resounding "No" for Scotland and Wales will redouble our efforts to make sure that people realise the significance of their votes and what damage may be done to both our countries. We are not going to make any more progress on this point. I beg leave to withdraw the amendment.

Amendment, by leave, withdrawn.

[Amendment No. 12 not moved.]

Lord Sewel moved Amendment No. 13:


Page 2, line 5, at end insert--
("( ) An order under this section shall be made by statutory instrument.").

On Question, amendment agreed to.

Clause 2 [Referendum in Wales]:

Lord Sewel moved Amendment No. 14:


Page 2, line 6, leave out ("Her Majesty may by Order in Council") and insert ("the Secretary of State may by order").

On Question, amendment agreed to.

[Amendment No. 15 not moved.]

Baroness Farrington of Ribbleton: My Lords, I beg to move that further consideration on Report be now adjourned.

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

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The Homeless: Health Care

8.18 p.m.

Baroness McFarlane of Llandaff rose to ask Her Majesty's Government what steps they are taking to ensure that there is an appropriate level of health care for the homeless.

The noble Baroness said: My Lords, since there will be no right of reply after the Minister has spoken, I should like to take this opportunity to thank all those who have put their names down to speak. The range of their interests represented means that we shall have a profitable review of the subject.

I am sure that your Lordships look forward to hearing my noble friend Lady Emerton making her maiden speech. We have been professional colleagues in nursing over many years and her experience now as chairman of the Brighton Health Care NHS Trust and as a chief officer of St. John Ambulance equip her to speak with authority on the topic we have before us this evening.

I also look forward to hearing the right reverend Prelate the Bishop of Liverpool. I believe that this could be the last time in which he will take part in the proceedings of the House, though we are delighted that he will be with us for the whole of this week reading prayers. I can think of no one more suited to contribute to our proceedings this evening. He has been a prophet to the Church in his defence of the poor and disadvantaged. He has never allowed us to forget our obligation to show a "bias to the poor" and we look forward to hearing him.

The links between homelessness and health are complex. A report from the South Manchester Health Authority in 1993 stated:


    "The causes of homelessness are largely rooted in public housing, employment and income policies. The main route for improving the health of homeless people lies therefore in improving their prospects for housing, work and adequate benefits".

The BMA has stated:


    "Tackling homelessness should be a major priority for social policy on health grounds".

In a Written Answer to the noble Earl, Lord Russell, in 1995 about the poor diet of the homeless, the noble Lord, Lord Lucas, indicated that five government departments, including the Department of Health, were involved in the future of the rough sleepers initiative. It is a complex area.

The present Government have expressed their determination to reform social policies and this Unstarred Question seeks to probe their intention to provide and to integrate health care policies and social policies for homeless people. The Help the Aged and Crisis report, Homeless Truths, published this year, stated:


    "There is no single definition of homelessness. It is defined in different ways by policy makers, service providers, academic researchers, the media and the public and this produces varying estimates of the scale of the problem".

The Royal College of Physicians, in its report, Homelessness and Ill Health, identified three categories of homeless people. The King's Fund report, Health and Homelessness in London, revised these categories to

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reflect the pattern of homelessness in London. The categories it used were, first, statutorily homeless people, defined under the Housing Act 1985; secondly, non-statutorily homeless people, staying in hostels, night shelters and so on; and thirdly, people sleeping rough. Other people use a wider definition: the lack of decent, secure, safe and affordable housing. This includes those whose homelessness is hidden from view. In some authorities teams of nurses are actively engaged in case finding for the homeless. It seems fitting to ask Her Majesty's Government what categories of homeless they intend to recognise in their policies and plans for care.

Lack of an adequate quality of accommodation, exposure to severe weather conditions, poor nutrition and limited access to hygiene facilities predispose to poor health. Specific medical disorders are commonly associated with homelessness; for example, respiratory disorders. Many experience chest and breathing problems, including bronchitis and lung cancer. There is a particular concern over the incidence of tuberculosis, especially drug resistant strains. One study found that homeless men are 50 times more likely to suffer from tuberculosis than the rest of the population. And now there is the relationship between HIV and tuberculosis.

Other types of morbidity commonly found include musculoskeletal disorders, foot problems--few of the homeless lie down to sleep--with chronic oedema, damage to the skin, infection and ulceration. Standing and walking for long periods in ill fitting shoes, alcoholism and poor nutrition lead to peripheral neuropathy, and sleeping in wet footwear leads to "trench foot". Then there are the dermatological disorders and infestations which are increased by lack of access to sanitary facilities. Mental health problems can be the cause and the result of homelessness. I am delighted to know that the noble Baroness, Lady Cox, will be dealing with that subject. I leave it in her capable hands.

There is very little information on the dental health of the homeless in the UK. I was delighted to receive a paper from Daly, which brings together four surveys undertaken in the UK. They indicate that homeless people had almost twice as many missing teeth as the general population and three to five times as many decayed teeth. Old, broken and ill fitting dentures were common and 22 per cent. in one survey reported difficulties with chewing and biting and 16 per cent. reported themselves as in pain at the time they were interviewed.

Homelessness places a significant cost on the health system. Shelter estimates that in two London district health authorities acute admissions of homeless people cost £3 million per year. It has been estimated by the Standing Conference on Public Health that cold housing alone costs the health service £800 million every year. Poor housing is estimated to cost the NHS around £2 billion a year more per annum.

During the early 1990s the previous government took a number of initiatives in making provision for the homeless. They launched the rough sleepers initiative and in 1990 the then government and the Mental Health

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Foundation launched the mentally ill initiative, with £20 million being made available for accommodation and outreach teams. In addition, some 35 primary care schemes for the homeless were centrally funded.

I would ask the Minister to what extent Her Majesty's Government intend to maintain and extend these initiatives and whether they have any new initiatives in mind; for instance, for the young homeless and elderly homeless. Would they be in favour of the policy, which I am told happens in Paris, of sweeping up the homeless, particularly at night?

The provision of health care services is essential. I know that other noble Lords will speak on this topic and so I shall leave it to them. Perhaps I may just touch on the need for dental care and the work going on in Lambeth, Southwark and Lewisham. A full clinical service is maintained at St. Giles and there is a combination of outreach work to hostels and day centres. It is an excellent model. Different models of care--an integrationist model, in which health care is integrated into mainstream health services; specialised schemes to improve access; and separate dedicated services--all have their role.

I have found a tremendous interest in the subject of homelessness. The Churches, the voluntary sector and statutory services seem to work together. There is no want of innovation and creativity. A great deal is being done. I look forward to hearing from the Minister how the Government intend to maintain, shape and fund the necessary services for this vulnerable group in society.

8.27 p.m.

Baroness Cox: My Lords, I believe this evening is an historic occasion in that it is the first time in which three nurses will have spoken in your Lordships' House. I am therefore very happy to thank the noble Baroness, Lady McFarlane, for making this possible and for doing so in the context of a debate on such an important issue which she has introduced so comprehensively.

It is no surprise perhaps that this topic has been chosen for her maiden speech by the noble Baroness, Lady Emerton. It reflects her professional commitment to advocacy on behalf of those who are among the most vulnerable and disadvantaged in our society. That choice is entirely consistent with the great contribution the noble Baroness has made to nursing and to healthcare throughout her professional career. I am sure that we all greatly look forward to hearing her speech.

I shall focus on the needs of those people who suffer from mental health problems and whose predicament is exacerbated by homelessness. Organisations working with and for the mentally ill who are suffering from homelessness, such as the National Schizophrenic Fellowship--NSF--and Mind, indicate and identify a number of interrelated issues which require urgent attention. These are substantiated by several research studies which show strong links between homelessness and mental health problems. For example, various research reports estimate that between 30 and 60 per cent. of homeless people in London have a severe mental illness, such as schizophrenia, manic

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depression or major depression, and similar, although slightly lower, figures have been recorded for the rest of England and Wales. Problems facing people suffering mental illness have been exacerbated by the closure of hospital beds for the mentally ill without adequate alternatives being made available in the community.

Appropriate housing is the most important element in care plans for people with mental illness. A stable home greatly helps social, psychological and physical well-being. Homelessness by contrast is linked to loneliness, isolation, non-compliance with medication, deterioration in physical health, decreased chances of employment and financial insecurity--in fact, a dismal cycle of multiple deprivation. And very disturbingly, as the noble Baroness, Lady McFarlane, indicated, increasing numbers of younger people are found among the homeless. They have difficulty accessing services in the community and cannot be hospitalised when they need care because of bed-blocking caused by shortages. For example, according to the NSF, acute beds in London are now oversubscribed by a terrifying figure of 200 per cent.

Problems are also experienced by patients being discharged from hospitals, including some of the most dependent and vulnerable patients, who may have been in hospital for many years. For them, the hospital may have become their home, indeed their world, their only constellation of personal relationships. The community to which they are discharged can be a very lonely place.

Other problems confront hospitals which are trying to discharge patients who are potentially a danger to themselves and to others and who need a safe, secure environment at least until treatment enables them to face the risks of living a less structured and supervised way of life. The extreme shortage of secure and medium-secure units for those trying to arrange discharges from hospital for these patients is causing a real crisis, especially for those patients for whom section orders expire and who must be found secure or medium-secure accommodation. There is not sufficient accommodation of this type available.

Time permits reference only to one research study: all these issues are underpinned by research. The study to which I refer is the Homeless (Mentally Ill) Initiative undertaken by Craig and colleagues whose findings were published in 1995. They reported on the work of five specialist teams in three of the former regional health authority areas of London. They confirmed between 30 and 50 per cent. prevalence of severe mental illness among users of night shelters, with schizophrenia as the most common diagnosis. They highlighted a number of issues of which I shall indicate just a few. The first was a need for much more psychiatric support for these vulnerable people.

The findings revealed that about one-third of those covered by the survey had lost their accommodation on account of mental illness, usually after they had been admitted to hospital. In two-thirds of resettlement so-called "failures", there had been a deterioration in a person's mental health which had not been identified and treated quickly enough. Therefore, among many recommendations was the need for joint commissioning and planning by health, social and housing agencies.

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I conclude by asking the Minister four questions. I shall fully understand if it is not possible to answer all of them tonight, but I would like to make them available for consideration. First, will the Government fulfil their pre-election promise of a moratorium on psychiatric bed closures at least until adequate and appropriate quality accommodation and support are ensured for those to be discharged? Secondly, will the Minister give an undertaking to promote policies designed to enhance co-ordination and communication between health and social services, the voluntary sector, the police and--very important indeed--the informal carers; and to improve speed of access to services, appropriate referrals, measures to protect vulnerable people from falling through the safety net of care and, in that context, support for those informal carers who play such a crucial role and who are often not recognised and identified with sufficient support?

Thirdly, will the Government consider sympathetically a range of options for different kinds of care for people with mental illness discharged from psychiatric hospitals? For example, will the option of village community-type care, so well established and well proven in this country and in other countries in terms of care effectiveness and cost effectiveness, be included impartially as one possible choice for those being discharged from hospital?

My last question is this. Homelessness is an outcome of the failure of community care in general. NSF believes that £500 million in revenue spending a year would be required to provide appropriate care and support for people with severe mental illness and their carers. Can the Minister give any assurance that appropriate resources will be available for the necessary care of these very vulnerable people?

It has been well said that the extent to which a society is civilised can be judged by the care it provides for its most vulnerable members. The same can be said of governments. One of the challenges facing the Government today is the problem of homelessness in general and of those who are mentally ill in particular, whose problems are exacerbated by homelessness. This debate provides a valuable opportunity for the Government to show how they will rise to these challenges and, if they can, give hope to those who are now suffering from inadequate provisions and encouragement to those who are currently trying to provide that care for the mentally ill with dedication but too often without the resources to do so as effectively as they would wish and as the mentally ill need.

8.36 p.m.

Baroness Emerton: My Lords, it is an honour to be able to address your Lordships' House. I ask for your Lordships' indulgence as I deliver my maiden speech. I first declare an interest in that I am a chairman of a health care trust and a chief officer of St. John Ambulance.

The Patient's Charter states that every individual has a right to receive health care on the basis of their clinical need, not on their ability to pay, their lifestyle or any other factor.

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The various categories of homeless people described by the noble Baroness, Lady McFarlane, frequently experience problems in obtaining appropriate health care due to prejudice against the homeless by health professionals and in particular by many general practitioners who refuse to register the homeless. This leads to a reluctance by the homeless to seek health care until diseases become debilitating or there is a suffering of severe pain. In addition, the homeless tend to be a mobile population and therefore continuity of care presents a problem, especially for those suffering a mental illness, as the noble Baroness, Lady Cox, mentioned.

The health status of people sleeping rough is far worse than that of the general population and research has shown that the average life expectancy of people who sleep rough is only to their mid-forties.

In 1981, Sir Donald Acheson, the Chief Medical Officer at the Department of Health, highlighted the imbalance between the generous provision of acute hospitals and the poor overall quality of primary and community health care, the consequences being that many patients ended up being treated in hospital. As far as the homeless are concerned, 16 years later there is evidence that A&E departments are being used inappropriately. A study published last year into the use of a London teaching hospital A&E department demonstrated that, if all the patients who had inappropriately attended the department had attended a more appropriate general practitioner surgery, a saving of £60,000 would have been achieved. If that was applied across all A&E departments, a substantial saving to the National Health Service could be made.

Frequently, those presenting at an A&E department have an overriding problem of alcohol or substance abuse or mental illness and can be very consuming of staff time in their management. Evidence from a research project in Brighton in 1995 demonstrates clearly an inappropriate use of the department in particular by the street homeless.

Accessibility to appropriate health care provision is, therefore, a paramount need for this group of people. The previous government, following a favourable evaluation of two pilot schemes, part-funded 35 schemes across the country. Health authorities were then asked to consider improving access by homeless people to primary health care. In Sussex, 1.1 per cent. of the total population is homeless--that is, 3,453--and of these 1,792 are in Brighton and Hove. This is approximately 50 per cent. of the Sussex homeless population. In the 1991 census, there were 66 people sleeping rough, giving Brighton the highest rate of street homeless per capita in the UK.

I visited one of the pilot schemes situated in Brighton, called First Base, where approximately 160 homeless attend daily for a range of services, including health care. This is a well integrated scheme which meets the needs of both street homeless and those in bed and breakfast accommodation, many suffering from physical or mental illness. The health care provision is made by a nurse practitioner and a nurse who attend the centre on a regular sessional basis. It is quite evident that the relationship between the homeless and the nurses, while

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professional, is very informal and demonstrates mutual trust. There is also a general practitioner attached to the centre who attends on a sessional basis, but it is the nurse to whom the majority of homeless relate. It is, therefore, the role of the nurse practitioner which has proved to be very useful in filling the gap for homeless people who are not registered with a general practitioner.

An evaluation showed very high levels of patient satisfaction where nurse consultation for minor injuries were introduced: 86 per cent. of patients required no doctor contact at all. With the proper education for nurse practitioners, providing knowledge, skill base and competences to the appropriate standard, there is no reason why evidence-based practice cannot be delivered to a very high standard. The United Kingdom central council has through its policy scope of practice facilitated the development of extended roles and this has been supported by the Royal College of Nursing in programmes of preparation among many other colleges across the country. An increase in nurse practitioners would be a cost-effective route to the provision of appropriate health care for the homeless--and I would ask the Minister to consider this.

The centre I visited recently could, I believe, deliver a more cost-effective and efficient service to the homeless if the nurse prescribing legislation had been such as to allow the nurse practitioner prescribing rights. A review chaired by the noble Baroness, Lady Cumberlege, and the subsequent publication of the report Neighbourhood Nursing--A Focus for Care in 1986, recommended that community nurses be permitted to prescribe from a specified nursing formulary. This was followed by a Private Member's Bill which received Royal Assent in 1992. The statutory instruments allow district nurses and health visitors in specific pilot projects to prescribe from a limited formulary. There is now a nurse prescribing pilot scheme in each English NHS region and two in Scotland. The previous Government's White Paper, Primary Care: Delivering the Future, published in December 1996 announced that nurse prescribing would be extended throughout the country from May 1998.

It is evident that with the rapid growth of practice innovations, highly trained nurses who are specialists in a variety of areas are equipped to know and deliver the most appropriate and clinically effective treatment for their patients. This is particularly true of nurse practitioners treating homeless people. They could well benefit by inclusion in the nurse prescribing group. The Royal College of Nursing is pressing for legislation which would be sufficiently flexible to allow nurses who hold specialist qualifications and have appropriate skills and competences to be considered eligible for prescribing rights. Safeguards, checks and balances would be easy to implement as registered nurses now have to comply with the United Kingdom central council post-registration education project requirements for regular updating.

The formulary is currently restricted to a range of products based around the provision of nursing care involving treatment of wounds, minor injuries and some

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fungal infections. These alone would allow nurses to give appropriate care effectively to the homeless without the involvement of a doctor.

There is an obvious need for education of health professionals to break down the barriers of prejudice and marginalisation of homeless people and, where possible, to include homeless people in contributing to the planning of the provision of services most appropriate to them. This is not easy and in my experience of involving people with learning difficulties in the planning of services for themselves, it requires patience and understanding--but in the long term it is very worth while. Likewise, homeless people know the type of service they would respond to and can provide a useful contribution to its planning.

In planning services, one must not forget the importance of inter-agency working, and this should include the voluntary sector, which currently provides many services for the homeless. In particular, in my role in St. John Ambulance, I have been involved with the recent launch of a mobile unit pilot scheme in Manchester which provides first aid and primary health care during the evenings for the homeless. Volunteer nurses and volunteers specially trained provide these services. It is hoped to expand the project to two further centres this year. The volunteers provide a non-bureaucratic, easily accessible service, but they have the knowledge and skill to be able to refer clients to appropriate agencies if necessary. Funding of these schemes is, however, difficult for voluntary organisations and development is limited by the availability of funds.

The health care needs of the homeless is an area of need which requires government guidance and support to ensure that homeless people receive health care on the basis of their clinical need as stated in the Patient's Charter.

8.46 p.m.

Lord Pearson of Rannoch: My Lords, it is a great honour to follow the maiden speech of the noble Baroness, Lady Emerton, and thus to have the privilege of congratulating her and of welcoming her on behalf of the whole House. Her long and distinguished career in St. John Ambulance where, among her other executive duties she leads that great organisation's excellent care in the community programme, together with her experience in regional health care, make her unusually qualified to participate in this debate this evening, as we have heard. I understand that the noble Baroness's career began early when she achieved the distinction of being awarded the Grand Prior certificate before she was 16 when she was a cadet. I feel sure that all noble Lords who have heard her this evening will agree that she has achieved a similar success with her maiden speech and that they will join me in hoping that we shall hear her speak again very soon.

I propose to concentrate my own few words tonight on the concern that a growing number of mentally handicapped people may be becoming homeless. I use the

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words "mentally handicapped" instead of the more usual expression "people with learning disabilities" because I wish to distinguish between mental handicap and mental illness, which has been so admirably dealt with by my noble friend Lady Cox.

I would submit that a mentally handicapped person who is homeless is most unlikely to enjoy an adequate level of health care. Before I go any further, I should declare an interest as the father of a mentally handicapped daughter, and as Honorary President of the National Society for Mentally Handicapped People in Residential Care, known for short as RESCARE.

Perhaps the most disturbing evidence that increasing numbers of mentally handicapped people may be becoming homeless came from the Department of Health itself last year. In its evaluation report on residential care provision, it admitted that there is already a shortfall of some 25,000 residential places for people with a mental handicap, and it predicted increased demand over the next two decades. This is not surprising because many of the parents who are still looking after their mentally handicapped children are not getting any younger and are now very worried about what will happen to those children when they die. There is therefore a growing shortage of residential provision, and community care is, alas, increasingly unable to cope.

There are other worrying developments: one of these is that when people are discharged from long-stay hospitals into community care, their former friends and contacts in their hospital are often being encouraged not to stay in touch with them. I gather the theory is that this will spare them from carrying with them into community care what their social workers and others imagine may be the stigma of having been in a hospital. But of course it means that those who used to care for them and know about them may lose touch with them completely. The fear is that some of them, perhaps many of them, may now be ending up homeless.

Another disturbing report appeared in The Times on 23rd June this year, to the effect that some GPs may be dropping people with a mental handicap from their lists. If this is happening, it would seem to lend support for the retention of centralised hospital services with the kind of village communities which RESCARE favours. In those circumstances, many of us were very encouraged by the pre-election indications from the Labour Party that it would impose a moratorium on further closures of long-stay hospitals for people with a mental handicap and on the sale of the sites in question. But now that the Minister's party is in government, I am not quite sure what its new policy may be. Perhaps its mind is not yet made up.

The Minister may be aware that my noble friends Lady Cox and Lord Renton and I did our best over several years to persuade the previous government to halt these closures until it was really safe to proceed with them, and we failed. We failed also to get the previous government to encourage residential and village communities for mentally handicapped people as one of the choices which should be available to them and to their families. Indeed, a number of long-stay

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hospitals would be eminently suitable for conversion into residential communities, but such evolution appears to be resisted in the Department of Health and by local services, although there is a huge demand for the lifestyle and care which they provide.

To be specific, I can give the examples of St. Ebba's Hospital, Epsom, and Offerton House, Stockport, where reputable public companies have offered to finance, develop and run such communities. Those projects are strongly supported locally and by the relevant parents' and relatives' organisations, and yet they are being resisted by the local health authorities. If pursued, those projects must also provide invaluable pilot studies of how old style long-stay hospitals can be converted into something modern and useful. So I very much hope that the new Government will take a fresh look at the case for village communities for mentally handicapped people--my noble friend Lady Cox mentioned mentally ill people. That case was succinctly set out by my noble friend in her publication Made to Care in April 1995, the conclusions of which, as far as I know, have never been seriously challenged. Briefly, these are that village communities can provide a much richer and more fulfilling life for some people with a mental handicap, with better on-site medical care than can sometimes be provided under community care. And of course well run village communities remove the danger of homelessness entirely. RESCARE's national survey continues to show that at least half the families of mentally handicapped people want village communities as an option for their relatives. And, finally, although we were not supposed to say so under the previous government, our communities provide all this very much more cheaply than can community care.

This does not mean that our support for village communities is driven largely by considerations of cost. But, as my noble friend Lady Cox repeatedly asked the previous government, if village communities are care effective, and they are, if many of the people concerned desperately want them, and they do, and if they are also cost-effective, why do we not encourage them? Why instead do we resist their development? At the very least, we would hope that the new Government might end the ambiguity pursued by the previous government and put village communities firmly and clearly back on the list of provision which local authorities are encouraged by the Government to support. No one is asking for a monopoly, but the evidence is now overwhelming that village communities should be part of that provision.

If I may, after this debate I shall present the Minister with a free copy of Made to Care. It has an excellent one-page summary on the back, and I very much hope that she may find time to read at least that. Perhaps she, or her appropriate colleague in government, might also find time to meet my noble friends and I, so that we can dispel any doubts she may have about the common sense and compassion of what we propose.

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