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9.47 p.m.

Lord Swinfen: My Lords, it is an honour to follow the noble Baroness, Lady Young of Old Scone, with her detailed knowledge of this subject. I must admit that my knowledge of the issues surrounding mental health is minimal. As the House knows, I normally speak on issues to do with physical disability. However, the Bill should be welcomed from all quarters of the House as an honest attempt to raise this issue and to produce a possible solution.

I have a strong feeling that when the Minister responds to the debate, the answer is likely to be a lemon--not necessarily because she believes it but because the Treasury has got its sticky hands around her throat. And that is enough to drive anyone mad.

The noble Lord, Lord Sainsbury, pointed out that 95 per cent. of people with a severe mental illness are cared for in the community. I agree that in most cases that is probably the best place for them; as near normality as possible. I have a feeling that madness breeds on madness. Like other diseases of an infectious nature, I am sure that people who have a severe mental illness are not helped by being cooped up at the same time with others with slightly different mental illnesses.

Mental health patients, even those in the community, go through crises from time to time and need more intensive care. I may be wrong, but I do not see in Clause 1 of the Bill provision for respite care. I may have misread it. In that case, I apologise to my noble friend. However, I feel that the Bill could be improved by making specific provision for respite care. That is where immediate short-term help can be given to those from the community who are going through a crisis. The help is not just for them; it is for their family and their carers at the same time.

If those who care for the mentally ill in the community are not given proper support, they themselves will become ill--possibly mentally, but more likely physically. That in itself will cost the community more than giving them and the person with the mental illness the appropriate support when required. Not only will there be additional costs in trying

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to restore that individual to health but there will be loss of service to the community because often they will not be able to continue in work and there will be a loss of tax to the nation because they will stop earning and not pay tax. There could also well be the additional burden of social security payments.

Clause 2 of the Bill deals with the question of single-sex accommodation, which, as the House will know, is part of the Patient's Charter and is therefore recognised by the present Government, as it was by the previous government. I know that it will take time to bring in single sex accommodation everywhere, but it is of course desirable because a mental illness may possibly have started--I am not a skilled psychiatrist and I may be talking through my hat--by the individual having been sexually abused or raped at an earlier time. That goes for men as well as for women.

There is also the fact of religious concerns. In some communities women have to make certain that they are not seen by any male other than members of their own family. Being in a mixed ward, going to and from the bathroom under these circumstances, could have a deleterious effect on their health. In one extremely strict Moslem sect a woman may not even shake hands with a male who is not her father, her husband or her son. Every other male is off limits even for the purpose of shaking hands. That makes it extremely difficult for her. In looking after people with mental illness, we must also ensure not only that they do not suffer any form of sexual harassment when in hospital but that they do not suffer racial abuse or abuse on grounds of their sexual orientation.

We should support the Bill but I feel that we may need to improve it as it makes its way through the House.

9.54 p.m.

Lord Alderdice: My Lords, I would first like to thank the noble Lord, Lord Rowallan, for bringing this Bill before your Lordships' House and also to declare an interest. I am a consultant psychiatrist and psychotherapist working in Northern Ireland. I say that not only to declare an interest, but also to say something about the background that I come from. It is one of commitment to working with people in the community. When establishing a service in psychotherapy, I chose to move out of an acute hospital trust to work in a community trust. I work in Northern Ireland, where health and social services have been integrated since the early 1970s and where so many of the problems that were so eloquently spoken about by other noble Lords in that sense at least do not apply. I am a psychotherapist and have spent a good deal of my interest and time working with people, not using medications particularly, sometimes working with patients with severe psychosis, but with very limited use of medication. I say that because it is important that noble Lords understand that background, since some of the things I shall say will be at odds with some of what other noble Lords have said.

Let us go back a little in history. It is perhaps rather striking that we are speaking about these issues of community care--and, particularly in relation to this

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Bill, about in-patient care--so shortly after the death of Enoch Powell. He was a man with whom I disagreed on almost every issue. Yet in 1961 it was he, as Minister of Health, who spoke about the big mental hospitals being places that we should move towards closing down, moving people into the community, which was much the best place. On that issue, if on almost nothing else, including Northern Ireland, I very much agreed with him.

That possibility arose for a number of reasons. In the 1950s there had been developments in psychological terms and also in the production of pharmaceutical preparations which made the discharge of patients into the community a more realistic possibility. There was also a change of philosophy which helped people to accept into the community those whom they had wanted to banish away. For a number of years, slowly, much too slowly, there was a gradual move towards community care.

Then two things happened which combined to speed up the development of such care and, more importantly, the closure of the mental hospitals. One was the more radical attempt to develop community care which said, "Let us close down as many of these hospitals as possible". There was also concern about public expenditure by a Conservative Government which realised that when people are put into the community it is much more difficult to measure whether one is producing adequate services for them. There was also the excuse of closing beds and wards to enable people to go out into the community. The result was that many people, particularly on this side of the water, went out into the community with a lack of preparation.

For various historical and other reasons the case of Northern Ireland was much less a problem of that kind. Very considerable preparations were made and a whole range of services of the kind referred to by noble Lords have been provided. Yet I believe that within all this what sometimes was forgotten was that there are patients who need in-patient care for a period of time. There are also others who need a variety of other kinds of care, such as 24-hour nursed beds, out in group homes, and all kinds of other things.

But it would be very wrong of us indeed to pretend to ourselves, as people often have in the past, that there is not a need for people to be looked after for sometimes prolonged periods of time and, in other cases, shorter periods, in acute in-patient psychiatric facilities.

I know that the move towards community care was very important. I will never forget being called at three o'clock one morning to see an elderly lady with a medical problem in a psychiatric hospital where I was working as a junior psychiatrist. She was in her 80s. She had been in the hospital for over 50 years. She had been admitted with moral imbecility: she had had a child out of wedlock. That was sufficient for her to be admitted. That experience on its own, never mind the many others, convinced me that many people had been incarcerated in mental hospitals who did not need to be there. On the other hand, more recently, I have become increasingly convinced that there are many people who are being denied adequate in-patient psychiatric care. Many go

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into hospital and find places without adequate staff, who themselves are feeling inadequately supported in their work.

One only needs to look at the statistics, which can lie in all sorts of ways. There are bed-occupancy rates well in excess of 100 per cent. Psychiatric staff are leaving hand over fist and 14 per cent. of consultant posts are vacant, with hundreds of psychiatrists leaving the service as soon as they can, because they find themselves working in an environment which is stressful, unpleasant and, frankly, untherapeutic and indeed, sometimes, anti-therapeutic. The percentage of patients admitted on orders has increased by 300 per cent. since 1980. That has created an environment of fear, tension and enormous difficulty for patients and staff alike.

It is self-delusion to suggest that the resolution of that problem will come with the integration of health and social services and the provision of many more community facilities. It will not. Of course, things could be done to help and, yes, some of those in in-patient care could be provided for in 24-hour nurse-staffed units, if those units were adequately staffed. However, we should not pretend to ourselves that there are not those who need such care and who at present are not receiving it.

If I could make two amendments to the Bill, the first would be to expand Clause 1 and to ensure that it related not only to in-patient but also to other residential facilities. I do not think that that would detract from the Bill; I think that it would strengthen it.

Secondly, while considerable care is taken in Clause 2 to speak about the separation of the sexes, there is absolutely nothing about young people who find themselves entering in-patient psychiatric care with adults. Adolescents or those in their early 20s frequently enter in-patient care having been sexually abused, but they find themselves on wards with those who are, or have been, abusers. We are not necessarily talking about massive numbers of people. That is one of the reasons why separate facilities have not been provided, but that should not lead us to the very attitude that we deprecate in our predecessors who turned their eyes away and who put out of sight the most disturbed. If we say to ourselves that the solution to the problem is merely to provide community care and to provide it at its best, we are averting our eyes from some of the most disturbed people with the most difficult of problems. We should not put such people into places where we would not, and could not, work. Increasingly, staff are finding that they cannot work in such places and are leaving the service.

A serious input of resources is inevitably required. However, community care is not necessarily a cheaper option, because many of those who can be cared for in that way require intensive domiciliary arrangements. That is not necessarily the cheapest option. We have done that in my trust, particularly with patients with dementia. It has been markedly successful, but there is then the problem of resources and of being able to fulfil one's financial requirements.

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It is sometimes suggested that we do not need more strategies. It is only a few days since we had the Turnberg Report, which referred to mental health services in London. It recommended that we address the situation of mental health services because that is the service that is under the most pressure in London. It was said that we need a mental health strategy for London, but what did the Secretary of State for Health say? He said that he accepted the whole of the Turnberg Report and its recommendations.

We have to face the fact that some of the perfectly legitimate arguments that have been put forward tonight by noble Lords are based on two difficulties. First, they have argued a case that has already been made. The case for moving to better community services is made. I fear that we sometimes forget that there is also a case to be made for in-patient care. The other problem is providing the resources for all that care. Those on the Benches opposite have a fundamental problem there because, having accepted the spending limits of the previous administration, they find themselves not easily in a position to provide the necessary resources either for community care or for in-patient care.

The suggestion that the way to improve community services is to rob even more resources from hard-pressed in-patient care will lead to a shortage of trained staff. An extraordinarily high level of expertise and commitment is needed to work in such facilities, particularly if you take a psychological approach rather than one dependent on medications alone. I fear that those who do have to be in-patients--the young, the middle-aged, the elderly, men, women, whoever--will increasingly find themselves in a kind of custodial care that is a shame to us and the community at this time.

I support the Bill, not because I want to see less community care or because I want to see more people receiving in-patient care, but because I want those who require care to be properly catered for. I want staff to work in situations in which they can survive during their professional lives rather than simply opt out and leave it to juniors and agency nurses. I want better community care, but I am honest enough to say that it will require resources. Robbing Peter to pay Paul will not better the community health of our nation one whit. I ask noble Lords to support the Bill not only at this stage but at the next stages. If one or two minor amendments are made, as I believe they must be, the Bill can be improved and can proceed. But let us not commit the most dreadful mistake of all and make the ideal for which we all strive the enemy of the good which we can achieve by the passage of a Bill of this kind.

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