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Lord Dubs: This has been a full debate. I deal first with a number of specific points that are not to do with the main thrust of the debate: disability. The noble Lord, Lord Cope, asked about the number of possible ministerial posts and why Amendment No. 36 made provision for the Secretary of State to increase the number beyond 10. The answer is that throughout the summer we have been consulting widely with all the parties on this question. The wording of the amendment therefore reflects the view of the parties in Northern Ireland simply to leave open the possibility that there may be a wish to have more than 10 posts. But that is something for the future. The noble Lord, Lord Cope, also asked about subsection (3) in Amendment No. 36. What it means is that all departments must have a Minister but that no Minister should be in charge of more than one department. Put that way, the noble Lord may say that it is rather simple. I know that the noble Lord is keen on clear English, as I am. I concede that its wording is a little more complex than the way I have put it.

I turn to the main focus of the debate initiated by my noble friend Lord Morris of Manchester. I pay tribute to his lifelong dedication to the cause of the disabled and the very effective way in which he has achieved enormous gains for disabled people over many years. That is not to say that other noble Lords who have

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contributed to the debate have not also shown a high level of commitment to the needs of the disabled, including the noble Lord, Lord Rix. My noble friend Lord Morris referred to Monica Wilson. I have met Monica Wilson on a number of occasions and know her fairly well. She is a doughty and effective campaigner for the needs of the disabled. She puts the case with enormous strength and sensitivity and such is the force and persuasiveness of her arguments that it is not easy to disagree with her.

This debate has covered a good deal of the ground which is probably more appropriate to Part VI of the Bill to which we shall come later. That part of the Bill deals with these matters in detail. I do not say that in any way to diminish the importance of the points that have been made but simply to point out that we are bound to return to this matter in Part VI which is subject to government and other amendments. However, they are so far down the list that, apart from one or two, they are not necessarily before the Committee this evening in any way that we can discern. I do not belittle the arguments that have been put, but I shall reflect upon them between now and when we come to the appropriate part of the Bill when these matters will be before the Committee.

I say to my noble friend Lord Morris that the Government do not believe that their proposals which appear in the agreement will result in any diminution in the importance of addressing the needs of disabled people. In response to the noble Lord, Lord Rix, we do not wish to anticipate a more detailed debate on Clauses 58 and 59. I shall be happy then to address a number of the points in detail. The Government have tabled a significant number of amendments to those clauses and associated schedules to meet some of the concerns that have been expressed. I say most emphatically that disability will be treated on an equal basis as other equality concerns. There is absolutely no question of establishing a hierarchy of equality.

My noble friend Lord Fitt made reference to a consultation period which ended in July. The Government have reflected upon it and provided a number of reassurances and amendments. But we continue to believe in the merits of a single equality commission. No doubt other noble Lords will wish to discuss that further when the Committee turns its attention to Part VI. However, as to the amendments before us this evening, whatever the strength of the argument that has been put, I suggest to the Committee that these are considerations for the Assembly rather than this particular Bill. The First Minister and Deputy First Minister are charged with devising a structure of departments appropriate to the needs of Northern Ireland. It is better to leave it to them than to suggest that they can do that except in one respect when we want a particular department. I do not want to belittle the concerns that have been expressed about disabled people because I share many if not all those concerns, but I believe that the method that has been devised is the most appropriate way forward and we should leave the structure of Northern Ireland departments to the First Minister and Deputy First Minister and let the Assembly pronounce upon it. Further, I believe that they will be

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sensitive to the concerns that have been expressed today and--who knows--may even adopt some of the suggestions that have been made, but essentially that is a matter for them and not us.

Lord Morris of Manchester: There will be an opportunity later, as my noble friend the Minister said, to return to this still sadly neglected policy area. For that reason, and so that representatives of Northern Ireland's disabled people can reflect on the Minister's response to me, I shall not be pressing Amendments Nos. 38 and 39 tonight. Meanwhile, I must point out that my amendments as a whole were drafted to facilitate a debate on Disability Action's concerns about the Bill as now drafted and, as your Lordships heard, my main purpose was both to draw attention to those concerns and the undoubted cogency with which they are argued by the disabled people of Northern Ireland.

On Question, amendment agreed to.

7.45 p.m.

Clause 15 [Northern Ireland Ministers]:

The Deputy Chairman of Committees (Lord Strabolgi): Before I call Amendment No. 37, I should point out that I cannot call Amendment No. 38, although I appreciate that the noble Lord has already spoken to it.

Lord Dubs moved Amendment No. 37:

Page 8, line 1, leave out subsections (1) to (3) and insert--
("(1) Where--
(a) an Assembly is elected under section 24 or (Extraordinary elections);
(b) a determination under section (Ministerial offices)(1) takes effect;
(c) a resolution which causes one or more Ministerial offices to become vacant is passed under section 23(2);
(d) the period of exclusion imposed by such a resolution comes to an end; or
(e) such other circumstances obtain as may be specified in standing orders,
all Northern Ireland Ministers shall cease to hold office and the Ministerial offices shall be filled by applying subsections (4) to (9) within a period so specified.").

On Question, amendment agreed to.

[Amendments No. 38 and 39 not moved.]

Lord Dubs moved Amendments Nos. 40 to 44:

Page 8, line 17, leave out from beginning to ("shall") in line 23 and insert--
("(6) If--
(a) the nominating officer does not exercise the power conferred by subsection (4) within a period specified in standing orders; or
(b) the nominated person does not take up the selected Ministerial office within that period,
that power").
Page 8, line 26, leave out ("to") and insert ("and").
Page 8, line 31, leave out ("are") and insert ("were").
Page 8, line 32, at end insert ("on the day on which the Assembly first met following its election").

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Page 9, line 5, after ("vacant") insert ("otherwise than by virtue of subsection (1), the nominating officer of the party on whose behalf the previous incumbent was nominated may nominate a person to hold the office who is a member of the party and of the Assembly.
(13A) If--
(a) the nominating officer does not exercise the power conferred by subsection (13) within a period specified in standing orders; or
(b) the nominated person does not take up the office within that period,").

The noble Lord said: I beg to move Amendments Nos. 40 to 44 en bloc.

On Question, amendments agreed to.

Baroness Farrington of Ribbleton: My Lords, I beg to move that the House do now resume. I suggest that the Committee stage begin again not before 8.50 p.m.

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

House resumed.

Mental Health Legislation

7.49 p.m.

The Lord Bishop of Lincoln rose to ask Her Majesty's Government what plans they have to amend current mental health legislation in order to facilitate positive intervention to assist the mentally ill living in the community.

The right reverend Prelate said: My Lords, my Question touches on one of the most excluded and neglected groups in our society. I am delighted that the noble Lord, Lord Laming, has chosen to make his maiden speech as part of this short debate.

The care of mentally ill people is a topic which allows for nothing but realism and compassion. Realism is necessary because I am aware of the shortage of resources in mental health provision. Compassion is essential because the condition of life of some with mental illness falls far short of what they would desire for themselves.

The particular reason why I speak tonight is the case of Christopher Edwards, a young man killed by a fellow inmate in Chelmsford Prison in November 1994. At the outset I pay warm and heartfelt tribute to Christopher's parents who have campaigned tirelessly for justice on behalf of mentally disordered offenders.

Christopher was mentally ill. He was killed by a schizophrenic called Richard Linford. I do not want to become involved in the question of the responsibility for the events which led up to his murder. That matter has been dealt with at length in the inquiry chaired by Keiran Coonan, QC, and which reported in June this year. There are still questions which arise from that inquiry but they are under discussion by Members from another place.

My own concern is twofold. First, how can the mentally ill, who have little or no insight into their condition, be helped by the medical and social services?

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Secondly, how can mentally disordered offenders be diverted from prison, and if they do end up in prison, how can they best be helped?

The inquiry into Christopher Edwards' death found that the mental condition of both young men deteriorated because they did not recognise the need to take the medication prescribed for them, and that both of them should have been sent not to prison but to hospital. I am aware that sufficient powers already exist under mental health legislation to intervene where an individual's health or safety, or the safety of others, is at risk. The safeguards exist if they are properly used.

I am also aware that the Health Secretary has indicated that he wishes to see a system of care for the mentally ill which provides both security and support for all who need it. He has set in train a review of the Mental Health Act in order to reflect the opportunities and limits of modern therapies and drugs. I want to support his initiative wholeheartedly. But what I want to do, equally, is to encourage a thorough examination of this very difficult question of intervention and to encourage schemes of diversion away from prison.

A recognised symptom of mental illness is failure to be aware of your own condition. It is indefensible, then, to expect the mentally ill to seek and accept treatment and to hold them responsible for their condition if they do not. We do not treat people unaware of their physical condition after a car accident in that way; we take them to hospital. Of course, there are civil liberties involved, but the present system of minimum intervention aimed at protecting civil liberty has here cost one man his life and condemned another to many years in Rampton. Equally, it has condemned many other mentally ill people to self-harm, imprisonment, misery and sometimes suicide.

I recognise that the use of new medications can play a big part in encouraging and maintaining compliance with medication. But where a patient lacks insight into his or her condition and is resistant to or non-compliant with treatment and medication, there may ultimately be no option but to consider compulsory treatment. I believe that that should be a last resort and that it should always be provided in a hospital or equivalent clinical setting.

There must always be full and proper safeguards for the rights and dignity of the patient, and any treatment must be accompanied by full and ongoing monitoring of the individual's physical and mental condition.

I believe that problems in community care often stem from a lack of understanding of the complex needs of patients with a mental illness and their families. What is needed is the engagement of both individual and family in the entire process of the illness from the first signs of its onset to the establishment of a comprehensive individual care plan to meet their needs.

I turn to my second concern. No one can believe that prisons are suitable places for the treatment of severe mental illness. The Home Office, in a 1991 study, spoke of custodial remand as a method of obtaining help for mentally disordered offenders being "inhumane, expensive and ineffective". As I have said, the

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1983 Mental Health Act allows court diversion by remanding in hospital rather than in prison, but court diversion schemes vary throughout the country and there was no scheme existing at Colchester Magistrates' Court when Christopher Edwards was apprehended. No one seems to know how many schemes exist. Some are run by social services, others by health authorities or the Probation Service.

There is an urgent need for a comprehensive review of those schemes and for guidelines to be drawn up for their use. Just as important is the need to deal with the severe pressure on secure hospital beds. I am told that the number of patients who have to be compulsorily detained in hospital has trebled since 1980. Many authorities cannot staff 24-hour crisis teams. Many police surgeons do not have Section 12 training. Only 21 per cent. of all health care officers and nursing grades employed in prisons are registered mental nurses. All that has to be set against a current prison population where some 20,000 sentenced prisoners and 8,300 remand prisoners have some kind of mental disorder--psychosis, neurosis, personality disorder, substance misuse or addiction.

I shall not say more, save that I believe that the inability to find a more understanding, humane and just approach for mentally-disordered offenders has been one of the most conspicuous failings of both government and society over many years. I see these people when I visit prisons as part of my work as bishop to prisons and we hear of cases in the Board for Social Responsibility where we try to think through issues of community care.

I hope and pray that this Government's decision to conduct a comprehensive review of the Mental Health Act will be self-critical, thorough and compassionate. No one should underestimate the difficulties of achieving the integration of services, but if a set of core values, central to a decent quality of life for both users and carers, can be recognised and accepted, a significant step will have been taken to reduce the misery of the mentally ill and to assist and support all those who care for them.

8 p.m.

Lord Judd: My Lords, I am sure we are all immensely grateful to the right reverend Prelate the Bishop of Lincoln for having introduced the subject today. I am also sure that we all look forward with great warmth to the maiden speech of the noble Lord, Lord Laming.

As a complete layman, I wish to underline a few of the points made by the right reverend Prelate. First, it is a time when, rightly, we face the need in penal policy to be much clearer about the distinction between right and wrong and to protect society. In particular, the most disadvantaged members of society are often asked to carry a disproportionately large burden in coping with delinquency and social disorder. It is, as we heard again in the House today, a time when we are determined not to be sentimental about the need for honest punishment on occasions. What has always concerned me is the degree to which our prisons are overcrowded with

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people who should not be in prison. I believe that the remarks of the right reverend Prelate underline the point which must concern all of us who consider the issue: the complex and thin dividing lines between criminal behaviour and mental disturbance. We cannot overemphasise the point, or encourage governments too much to endeavour always to make that distinction, and to ensure that the appropriate support is being given to people who need it.

During my 13 years some time ago as a Member of another place, there were within my constituency areas of acute deprivation. What troubled me then was that when there was a case of clear mental disturbance, it frequently put unimaginable burdens on families with limited resources to cope with them. The consequence was often breakdown among other members of the family because of their inability to cope and the absence of resources for support.

I worried at that time as regards my constituency. In my present work as president of the YMCA in England, I have seen the issue presented again in the overwhelming challenge of homelessness, not least among the young. We are often encouraged to attempt to consider the issue simply in terms of finding homes; but, on many occasions, the homelessness is the symptom of a deeper problem. With regard to drug addiction and those who work with drug addicts, again mental illness is often the origin of the problem and not simply a consequence.

If we accept the complexity of the interrelationship between those different dimensions and the thin dividing lines which I suggest exist between criminality and mental inadequacy or mental disturbance, it becomes clear, as the right reverend Prelate emphasised, that above all we need an integrated approach. We need flexibility. We need imagination. We have to avoid over-specialisation and over-fragmentation. The tremendous challenge is to ensure that adequate information is available to families and those who are looking for the right place and seek the right support. There is tremendous need for dynamic exchange of information between the different agencies working in this area.

I emphasise that I speak very much as a layman in these matters. However, I have been thrown up against the issue in various areas of my life. When the Government are considering commendably so rigorously and afresh many of these issues, we should urge them in every possible way to take the need for flexibility, imagination, integration and co-operation as one of the most important priorities in the whole approach.

8.2 p.m.

Lord Laming: My Lords, when I turned my mind to the contribution that I might make to this debate I recalled the words of Sir Walter Scott when he said:

    "Respect was mingled with surprise".
I am sure it will be understood when I say that my respect for your Lordships' House is surpassed by my surprise at being here! Because of that I planned a long

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apprenticeship but, in the event, could not resist a comment on the important Question so well posed by the right reverend Prelate the Bishop of Lincoln.

However, before doing so, perhaps I may thank your Lordships for the warmth of welcome; and thank the officials for their unfailing help. I fear I may need that help for some time to come. I hope that it will not be thought presumptuous if I congratulate the noble Lord, Lord Hunt, on his appointment in the Government. The noble Lord, Lord Hunt, had a very distinguished career in the National Health Service before joining your Lordships' House and I wish him continued success.

I began my career in the Probation Service. I mention that only because in those years I was well used to visiting penal establishments of all kinds. However, when later I had to work in a large, geographically isolated, Victorian mental hospital it had a profound effect upon me. The patients lived in large wards. They had few, if any, possessions, little or no personal space, no privacy and were often disturbed by the disruptive behaviour of others. It would be an exaggeration to say that their lives were confined to the perimeter of the hospital. Rather, their horizons did not extend beyond the ward in which they lived, and they had few rights. And what was even worse, over and above the effect of their illness, was the disabling influence of what became known as "institutionalisation" which created enforced dependency on the institution.

I am pleased to report that that institution, and many like it, are now closed. Because of new medications, and improved medical and social care, many thousands of people now have entirely new life opportunities and are being successfully cared for in the community, to everyone's benefit. If treatment in hospital is needed it is, as with other health matters, for a relatively short duration. The tragedy is that the services that were designed to replace the old institutions were often seriously underfunded. Furthermore, success depended on good inter-agency co-operation, which was all too often missing, and the services which existed, displayed in many instances an unrealistic degree of optimism about the ability of rootless people, who had been greatly affected by their illness, to live ordered lives.

As has been indicated, the current legislation dates back to 1959. Therefore, it is timely to consider a review to ensure that the law reflects changes in practice and meets new needs. I have no doubt that the review team, which the Government have established, will have in mind the following. First, mental health problems are very common and varied. They can be experienced by anyone at any time. They are a major reason for absence from work and they result in heavy demands being made upon local medical services. However the good news, and this must be emphasised, is that with the correct treatment most patients recover well and usually without admission to hospital.

Secondly, there exist already many examples of good practice based upon successful teamwork between the key agencies. We know already what works and what are the ingredients of a comprehensive, reliable and effective mental health service. We can build on that strong foundation.

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However--it goes to the heart of the Question posed by the right reverend Prelate--it must be acknowledged that in general the services have not properly addressed the complex and special needs of a small minority of patients who have been seriously damaged by their illness and who are potentially a danger to themselves and others. Often those patients lead casual life styles and cannot be relied upon to know when their mental health is deteriorating.

The tragedies which have occurred--and all too many have occurred--have often been because the services have expected these patients to be capable of leading more structured lives and to be aware of their own needs. In future the legislation and practice must ensure that those people do not fall through the net. In my view this requires specialist outreach teams, operating where the patients live, maintaining regular and frequent contact and making absolutely sure that essential medication is being taken. This requires the proper use of authority. Without this, some patients may be a serious danger to themselves and others, and the public will rightly lose confidence in the Government's policy.

The Government are to be congratulated on giving a much higher priority to mental health services. The safety and well-being of the community depends upon people with mental health problems receiving appropriate and effective treatment. For some that must include a realistic assessment of risk. Over and beyond that, I feel sure that your Lordships will want to be satisfied that those who experience mental health problems are treated with dignity and enjoy good standards of care.

8.10 p.m.

Lord Mottistone: My Lords, it is my great privilege to congratulate the noble Lord, Lord Laming, on behalf of this House as a whole and on behalf of your Lordships present in particular, on a splendid maiden speech, made within the time limit and one which was not too controversial. I hope we shall hear him many more times in the future.

It was my honour, when I was Lord Lieutenant of the Isle of Wight, to have had quite a lot to do with the Probation Service, in which the noble Lord started his career. I have the highest regard for them in their work. I entirely agree with much of what he had to say. I would also like to thank the right reverend Prelate the Bishop of Lincoln for introducing this Question and for his remarks.

It is splendid to see the Minister concerned listening to our debate. In my experience, it is very rare for Ministers to come and listen to debates in this House and I hope he stays to the end. I say that particularly because I am advised in what I say by SANE, of which I have the great honour to be the chairman. SANE is an acronym for Schizophrenia, A National Emergency. It was not just plucked out of the air, but was the title of a series of articles by Marjorie Wallace, who is now our chief executive. She has been telling me how much the Minister Mr. Boateng is working towards some sort of a solution to the problems which we are airing today.

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I believe that the care in the community idea was splendid. Indeed much of what the noble Lord, Lord Laming, had to say about the old asylums is very true. I saw it in the one we had on the Isle of Wight. There was definitely a good reason for the last Government taking the initiative that they did. However, they never had enough money to do it properly. It is also true to say that they did not give enough attention to the fact that some mentally ill people, some of the time, would need more accommodation than could be provided for them by care in the community. That is the nub of the problem. We have lost 50,000 beds during the past 15 years. They may have been the wrong beds in the old asylums, but the beds were needed. I really do not know how we will get them back. It will be a very difficult problem.

Furthermore, I believe that there are not enough people to look after the mentally ill. The British Isles has a population of around 60 million. If out of that number one in 200 suffers from some sort of mental illness at some stage in his or her life, then we must have people to care for up to 300,000, though not all of them all of the time. Even if it is 100,000 mentally ill people I am not sure that there are enough people with the aptitude and the ability to look after them. We have a real problem, which I am sure the Minister, Mr. Boateng, will do his best to try to solve, and I wish him all the best.

8.15 p.m.

Lord Thurlow: My Lords, I can only endorse what previous speakers have already said on most of the points. When the right reverend Prelate the Bishop of Lincoln told me he was going to focus on this very difficult problem of mentally ill offenders it rang a bell in my mind, because my own son came into this class. It was many years ago and luckily he was never convicted. When it came to court, he was sent to hospital. I regret to say that, although I did not make any criticism at the time, the police had no conception of how to handle this kind of case: that of a known schizophrenic who had committed a serious offence but who had already been in and out of hospital and had a well-documented record. It is, and has been for many years, clear that the police and those concerned in the courts--solicitors, magistrates, prison staff--all need far greater exposure to education and training.

The problem of offenders is only one small segment of the enormous problem that the present Government are showing every sign of tackling with great determination. I believe that by the due process and care they have adopted in assembling recommendations from every quarter, we are at last to get something much nearer the kind of framework we require for above all solving the problem of co-ordination between authorities. The Griffiths Report made clear at the time that there were grave dangers unless there was a single agency to bring together health, social services, housing and so on. This is the glaring need. We want not only a single national policy accepted by all in the field, but also single district agencies, perhaps coterminous with either health authorities or counties, which would have full authority. They would have staff drawn from the

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local authorities, the health services and all concerned, so that there could at last be a properly co-ordinated tackling of the problems.

This is the key to the future and I hope and believe that, out of the Government's review of mental health legislation, this will emerge.

8.29 p.m.

Lord McNair: My Lords, I apologise to the right reverend Prelate and to the House for being absent at the beginning of the debate, but I am not completely bereft of knowledge of his remarks. I hope he does not mind, but I telephoned his office this morning and the person who answered was kind enough to read to me the first and last paragraphs of his speech. I am grateful that he has opened up this important subject for discussion.

I entered this debate with some trepidation, but my locus for doing so is that I am one of three vice chairmen of the All-Party Mental Health Group. Thinking about the tragedy which lies behind today's debate, it occurs to me that there are certainly some procedures which should be put in place which might go a long way towards preventing similar situations from happening in the future.

What is needed to start with is a much greater clarity of thought in investigating these tragedies once they have occurred. At present, the immediate reaction of the public, media and politicians is to ignore the real background of the situation and simply to look at it from a crime and disorder viewpoint. Because of the fear that such occurrences trigger in our minds, we shut down our analytical faculties and fail to look at the whole time track of the individual who has committed the violent act. This fear is one of inexplicable, indeed of somewhat senseless, violence with no rhyme or reason to it, we feel. But is it?

There are two pictures we need to examine, not one. Yes, the individual does have a history of mental illness, but he, or she, also has a history of psychiatric treatment and this is where we should direct our attention. There are two questions which we and the police should always ask when one of these tragic incidents occurs. First, was he violent before he had psychiatric treatment; and, secondly, was he on one of the drugs known to cause violent and destructive behaviour?

As soon as an incident takes place, there should be an inquiry into the personal drug history before, during and after treatment. It is sometimes said that the problem occurred "because he was not taking his drugs". This begs another very important question: was the individual experiencing the withdrawal symptoms commonly associated with some anti-depressants and anti-psychotics? So far as I know, there are no long-term outcome studies of the drugs and certainly no understanding of the biochemical mechanisms and their effects involved in the withdrawal process.

I think that the kindest thing we can do for those suffering from behavioural and emotional problems is to make sure that we treat them in all respects as we ourselves would like to be treated under similar circumstances. In other words, we should provide a

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quiet environment where they are treated in a kindly manner which maintains their self-respect and does not do anything to make it more difficult for them to recover.

I do suggest that the solution is not to provide more and better of the same, but to re-examine the philosophical and medical basis of the treatments currently being provided. Would it not be better to step back and look at the problem as a whole; to admit that what we are doing at the moment is not working very well and to look for a different approach?

It has been said that the ethnic minorities are under served by the mental health service. But this is a somewhat two-edged sword. For many, such attention as they do receive sadly reflects their experience in other areas of society. Excessive doses of drugs and the exorbitant use of ECT have been all too frequent occurrences. Members of the ethnic minorities, particularly from the Afro-Caribbean community, may have mixed feelings about calls to provide them with increased levels of service unless this is seen to be culturally appropriate and sensitive.

My main hope is that we shall look carefully at alternatives to current treatment modalities. For example, it is now well known that an important, possibly the most important, factor in understanding eating disorders is a simple zinc deficiency. And this, multiplied across many other similar examples, does, of course, have a bearing on the question of the cost of mental health services. It also introduces comprehensibility to the whole question of mental disorder and gives sufferers and their families the chance to take responsibility for solving their problems.

It is interesting that this debate should have been initiated by one of your Lordships from the Bishops' Benches. Any sensible approach to the affliction of mental illness requires that we regard the human being holistically; that is, as spirit, mind and body.

8.25 p.m.

The Lord Bishop of Ely: My Lords, I, too, thank my right reverend friend for initiating this debate. I should like publicly to acknowledge his 15 year concern for the prison services. It is an outstanding record. I also congratulate the noble Lord, Lord Laming, if I may do so without presumption, on his maiden speech. He brings a wealth of experience to the subject from his knowledge of the probation and social services. I hope that he will have many other occasions on which to address this House, preferably with more than four minutes at his disposal.

I share the concern of my right reverend friend for the tragic, senseless and needless death of Mr. Christopher Edwards. I warmly support all that he said on the subject and I look forward to hearing the Minister's reply.

Is the Minister aware of the great satisfaction which exists in this country as a result of the Written Answer given by the Secretary of State for Health in another place on 31st July this year? The Answer will have given satisfaction to many people who courageously cope with suffering from mental illnesses, to those who care for them and to the professionals who work among

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them in conditions of considerable deprivation. It was very bold of the Secretary of State to speak of the inadequacy of the present provision, to demand and look for a dramatic change for the better and to announce a root and branch review of the Mental Health Act 1983. I reiterate that it is most welcome indeed. Making mental health a priority in our nation has been a stated aim in the health policy of this Government. It is most welcome and enormously appropriate.

The most alarming part of my right reverend friend's speech was the statistic showing a 300 per cent. increase in the number of people compulsorily detained in hospital since 1980. That figure was provided by SANE and illustrates a very serious issue. It is vastly out of proportion to the increase in the number of people with mental illnesses. What conceivable reasons can there be for a 300 per cent. increase during those years? Is it related to the increase in the number of drug-related mental illnesses in our population? Is it related to failures to prevent relapse; failures in the aftercare of those who move out into the community; or failure of the community to understand the needs of those who are coping with illnesses in the community?

I wish to emphasise the great need to attend to public education in mental health and their awareness of the nature of mental illness. I warmly support the five year campaign launched last week by the Royal College of Psychiatrists to de-stigmatise mental illness. So far as I am aware, mental illness is the only form of illness where the attitude of the general public makes a significant difference to the outcome. Therefore, it is vital that the general public are more fully appraised of the significance of what can now be done for those who suffer from mental illnesses and the importance of attitudes in the community to the outcome.

The Secretary of State for Health said that care in the community has failed. I understand what lies behind that statement. It is an understandable soundbite, even though it may have caused some distress and misunderstanding to the many who are courageously coping in the community. However, I am inclined to say, as of another subject when Christianity was claimed to have failed, the problem was not that it had failed but simply that it had not been tried.

8.30 p.m.

Lord Rowallan: My Lords, I too would like to thank the right reverend Prelate the Lord Bishop of Lincoln for raising this very important issue. It is interesting that the case he raised was one that very much concerned me when I introduced the Mental Health (Amendment) Bill in this House earlier this year. As a result of that I was asked to be a director of SANE, and I declare that as an interest.

Care in the community is the subject and I think it might almost be called care in crisis. Ask anyone in the street today, flung out of an in-care hostel or the psychiatric wing of a hospital because of a shortage of beds, "Where is care in the community?" and he will answer, "Wherever I can find somewhere to sleep; a cardboard box; a park bench; a railway arch".

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That is a terrible indictment of our modern society. The choice for them, all too often, is sleeping rough, committing a crime and going to prison or committing suicide. Forty per cent. decide to sleep rough. One in three suffers from mental illness; others are in prison; and one in seven commits suicide--some choice, some care!

Even Frank Dobson, the Secretary of State for Health, said that care in the community had failed a substantial number of mentally-ill people and I am delighted that this Government have decided to give a root-and-branch review of mental health law because it is now accepted that the Mental Health Act 1983 no longer serves the best interests of sufferers, their families, carers or the general public. We must have 24-hour crisis teams. We really need sheltered accommodation for the mentally ill, in the same way as the old folks have it, so that they can get their drugs and so that there may be a doctor looking after them, or whatever, all under the one roof. We must have more acute hospital beds. Without the backstop of hospital beds community care will never regain public confidence.

The saga of tragedies is revealed in the independent inquiry into homicides by mentally ill people which the Government instigated in 1994 and which revealed fault lines in a system in chaos. SANE surveyed 23 recent inquiries and found a clear-cut pattern of fault. All but one blamed the breakdown of communications. Nearly all revealed the lack of effective risk assessment; poor recording and keeping of case notes. There was a failure to listen to the experiences of family and sufferer. In some cases life and death decisions were made by people without qualifications. Within the mental health service patients' welfare is often shuffled around like a crazy game of pass-the-parcel from one authority to another--more importantly, from health care to social services.

When lives are lost in such circumstances, we are told that no one is to blame. But is not the system to blame? Is that not what we have to sort out? I am so glad that this Government seem to recognise the need for revolution in mental health care. Those of us who have been warning about the desperate situation for so long have lived to see the acceptance that community care has not been the Holy Grail of mental health. There is a long way to go. To make good intentions work we need to attract back doctors and nurses who have been demoralised, to build up centres of excellence for assessment and diagnosis and to impose sanctions on authorities which fall short of national standards, especially in providing the right number of available beds.

However, the Government must tackle the two most controversial and thorny problems. The first is the issue of compulsory treatment in the community and the second is the involvement of families and carers, the country's most wasted resource.

8.33 p.m.

Lord Clement-Jones: My Lords, I should like to join with other noble Lords in congratulating the right reverend Prelate the Lord Bishop of Lincoln on

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initiating this debate. I should also like to congratulate the noble Lord, Lord Laming, on his extremely cogent and well-informed maiden speech.

Although the review of the Mental Health Act was only recently announced, I hope that tonight the Minister will be able to give us a clear indication of the principles which he believes the review team will follow and the issues that they will tackle. However, let me, first, say that we on these Benches welcome much in the Government's approach to mental health. We welcome the fact that one of the first two National Health Service frameworks to be drawn up will be for mental health. We also welcome a commitment to more 24-hour nursing care. We welcome the concept of assertive outreach. We welcome the partnership-in-action approach, designed to break down barriers between health authorities, social services and other providers.

Finally, we welcome the commitment to a disability rights commission, which will cover people with mental health problems. I look forward to seeing that in the Queen's Speech. However, we do not welcome some of the punitive language that has been used by Ministers. The safety-plus approach adopted by the department must not mean treating mental patients as criminals. Furthermore, we do not welcome blanket statements by Ministers that care in the community has failed. The implementation of care in the community has undoubtedly failed in many cases, but the philosophy of care in the community has not failed and we must not return to the bad old days of thinking that every mental patient needs locking up in an institution.

With proper regular care and supervision, many patients can take their place in the community without danger to the public, but more resources are needed to provide for more effective care and supervision. We have been tantalised with reports of further substantial resources being made available for mental health services. I very much hope that the Minister tonight will confirm this and explain where it will be directed.

Turning to the Mental Health Act review itself, there is no doubt that it needs updating to reflect the care-in-the-community approach. Currently it is extremely orientated to institutional treatment. In addition, it needs to reflect the needs and concerns of carers. We believe that there may be a case for some form of compulsory treatment in the community, but this must only be as a last resort. Assertive outreach must not become aggressive outreach; otherwise it will fail.

As a number of organisations have pointed out, there should also be a right to care and treatment for those suffering from mental health problems. This should underpin the new legislation. We also hope that the review team will look at the issue of discharge, as highlighted by SANE. It was accepted by the previous government that the powers of lay managers to discharge without reference to the responsible medical officer should be abolished. We also believe that the legal regime for mentally disordered offenders should be re-examined, as was so graphically described by the right reverend Prelate.

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The review also needs to look at how those considered to have untreatable personality or psychopathic disorders are dealt with. Currently they appear to fall outside the Act. The issue of confidentiality also needs to be addressed. Information must be shareable in appropriate circumstances. At the end of the day, however, I hope that the review team and the Government will also recognise, both from the legal and the clinical perspectives, that public education is vital. I cannot say this better than did the right reverend Prelate the Lord Bishop of Ely in his remarks: for treatment to be truly effective we need the full confidence and understanding of the community--and only public education can do that.

8.39 p.m.

Earl Howe: My Lords, in considering the nub of this Motion--that is to say, the question of what might be done to amend current mental health legislation-- I confess to starting from a basic belief. That belief is that the broad direction, the broad aim of mental health policy over the past 35 years, which has been to humanise care of the mentally ill and as far as possible to normalise their lives, has been the right one, both ethically and clinically.

Most people with mental health needs can and do lead satisfying lives in the community, given the right kind of support. In fact, being part of a normal community is the best kind of therapy for the majority of those with a mental illness. In recent years we have seen the closure of the large long-stay psychiatric hospitals, and in their place has been the provision of community services and appropriate accommodation.

In any transition as fundamental as that we can point to a balance sheet of losses and gains, but it cannot be stated too emphatically that in the recent development of care in the community the gains far, far outweigh the losses. I recently had the pleasure of visiting a mental health trust in the right reverend Prelate's diocese; namely the South Lincolnshire Community and Mental Health Services Trust. Anyone who wants to gain an understanding of what care in the community means, particularly in an extended rural area, would do well to pay a visit to the Stamford Resource Centre. The centre was opened recently as the base of operations for home treatment service for mental health patients living in the locality.

The service is provided by a 24-hour on-call team, who will assess and treat patients in their own homes, either routinely or in response to requests for crisis intervention. The primary aims at Stamford are to provide a speedy service, to tailor the type of care to the specific needs of the individual patient and as far as possible to minimise any stay in hospital. The local verdict on the service, from GPs as well as patients, has been overwhelmingly positive, but it is not just a matter of putting in place a workable system in a particular area. Much depends, too, on the professionalism of the individuals running it.

The key to the home treatment service is for the team to get in early while the patient retains some measure of judgment and persuade the individual that he or she

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needs treatment. The key to that is to gain the trust of the patient and to establish a relationship which ensures that if treatment is needed, whether medication or a trip to hospital, persuasion rather than coercion will bring about the desired result. Indeed, if there is one thing which separates success from failure in community mental healthcare, it is that engagement with the patient, the exercise in communication which leads a patient to accept his or her condition and the treatment needed to tackle it. With mental illness, it is not enough to ask ourselves what patients need. We also have to ask what they want, and attempt to provide it, if care in the community is to succeed.

That is why I am cautious about any proposal which would allow clinicians to exercise on patients a power of compulsion broader or more severe than the powers already afforded to them under the Mental Health Act. Once you introduce such a power, you run the risk that the relationship of trust between patients and medical staff will break down, you risk stigmatising mental illness more than it is stigmatised already and you will also run into major logistical difficulties. How in practice could we envisage community psychiatric nurses forcibly treating people in their own homes?

I very much welcome the Government's intention to review the provisions of current mental health legislation. Among other areas, I think we need to look carefully at creating a better interface between mental healthcare and the criminal justice system for conditions such as psycopathy. But I firmly believe that delivering better care to the vast majority of mental health patients is not a matter of amending an Act of Parliament; it is first and foremost a question of resources.

8.41 p.m.

Lord Hunt of Kings Heath: My Lords, I too should like to thank the right reverend Prelate the Bishop of Lincoln for raising this important issue and for his very important work in this area over many years. I should also like to say how much I welcome the maiden speech of the noble Lord, Lord Laming. His intervention was as authoritative as one would expect from someone who has given such distinguished service as chief inspector in the Department of Health.

A number of noble Lords have raised concerns about aspects of our mental health services. These concerns have served to illustrate the failures of care in the community. Service provision has been too patchy and, as the noble Lord, Lord Mottistone, pointed out, insufficient resources have been made available to provide the care and support services to which mentally ill people need to have access if they are to live as independently as is practicable. That is better for both them and for the wider public.

Let me say straight away that improving services for those who suffer from mental illness is one of this Government's key priorities. My honourable friend Paul Boateng, who is the Minister with responsibility for mental health policy, has made this very clear. The details of our new policies, which are aimed at providing safe, sound and supportive services for this most

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vulnerable group of people, will be announced soon, together with details of a substantial financial package to resource real improvements in both health and social services.

So far as concerns improving standards, we are determined to remove the appalling regional variations in services for those who suffer from mental illness. That is why we are developing, as a matter of urgency, a Mental Health National Service Framework.

This framework will set challenging evidence-based national standards that both health authorities and local authorities will have to meet. It will drive up standards so that people with mental health problems will receive the service they need, regardless of who they are or where they live.

An important element in our strategy for better mental health services will be a completely revised legislative framework. My right honourable friend Frank Dobson announced in July that there would be a root and branch review of mental health legislation. As the right reverend Prelate the Bishop of Ely suggested, review of the Mental Health Act 1983 is long overdue.

Our new policy must be underpinned by modern and robust legislation that not only reflects modern patterns of care and treatment but also supports the robust policies which we are putting in place to ensure high quality services and that a proper balance is struck between the rights of individuals and the interests of the wider public on the few occasions where these can sometimes seem to conflict.

There is no doubt that the current Mental Health Act, many of the provisions of which date from the 1950s, reflects a bygone age. It is almost entirely about hospital-based treatment for those who are deemed to be in need of detention. Modern patterns of treatment and care, particularly the growing realisation of the importance of social care interventions, mean that legislation that is largely about hospital-based treatment is now out of date. Modern legislation must recognise the growing importance of life outside institutional settings for those who are mentally ill.

However, we do not pretend that revising mental health legislation is something that is easy or something that lends itself to quick solutions. There are highly complex issues involved and it is most important that we get the various balances that have to be struck exactly right. As a first step, therefore, we have established a small group of experts to consider the scope of the changes that are necessary. The chair, Professor Genevra Richardson, is an acknowledged expert in this field. The group has been tasked with advising Ministers on legislation to cover the whole field of mental health service provision in the setting of the modern policy context which we have established to improve the quality of mental health services. It will report to Ministers in April next year with firm recommendations which can form the basis of wider consultation on a completely revised legal framework which will reflect modern patterns of care and treatment and which will support our new, safe, sound and supportive approach to the provision of mental health services.

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There have been great changes in medication and in our growing understanding of the importance of social care interventions that have enabled more and more people with mental health problems to live more fulfilling and independent lives within supportive neighbourhoods, a point forcefully put by the noble Lord, Lord Laming, and referred to by the noble Earl, Lord Howe, who discussed the examples of good practice to be found throughout the country. This approach to treatment is proven to result in a better outcome when based on proper support--in turn based on proper assessment. This points up the important role that local social services authorities have to play in delivering comprehensive mental health services. All too often in the past patients have been discharged from in-patient treatment with insufficient attention being paid to their social care needs.

There is a large range of effective social care interventions, ranging from highly specialist rehabilitative day care and specialist supported housing to just having someone to help with the smaller problems of everyday life, such as shopping or paying the bills. Most importantly, effective social care provision can go a long way to preventing future crises and therefore to minimising unnecessary passages through the revolving door of care between hospital and home.

The noble Lord, Lord Laming, spoke of the need to ensure that the seams between service providers, and particularly between those providing health and social care, must be strongly sewn if those who are rootless or who for other reasons such as homelessness are hard to engage are not to fall through the net of care. This point was also mentioned by the noble Lord, Lord Thurlow. I hope noble Lords will agree with me that the focus that we are now putting on partnership working will help to ensure that proper, robust and positive support, which must include better assertive outreach, will go a long way to ensuring that this most vulnerable group of people receive the help they need.

The right reverend Prelate the Bishop of Lincoln specifically raised the tragic case of Christopher Edwards who was killed while sharing a cell with Richard Linford. The case was discussed also by the noble Lords, Lord McNair and Lord Rowallan. It was a very disturbing case. Many of the recommendations contained in the inquiry report have already been implemented by the agencies concerned and joint action plans have been made for follow-up action. As a result of their experiences, the parents of Christopher Edwards want to ensure that all the lessons are learnt from this and indeed other inquiries. They have launched a petition for improvements to Care in the Community and to the treatment of mentally disordered offenders. I am aware of that petition and of the significant issues which it raises. Many of those will be addressed in the forthcoming strategy on mental health.

Perhaps I may deal now with some of those issues. They were referred to by the right reverend Prelate the Bishop of Lincoln, my noble friend Lord Judd and the noble Lord, Lord Thurlow. We accept fully that there should be a sufficient number of secure places and

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recognise in particular the need to ensure that services engage effectively and speedily with those who for one reason or another might ordinarily resist help altogether.

The Government recognise that there is an urgent need to improve the quality and effectiveness of healthcare services in prisons, both to reduce the level of morbidity among prisoners and the risk of mental health problems becoming chronic or acute when prisoners are released back into the wider community. Unrecognised or untreated mental disorder increases risk to family members and the wider public and is likely to exacerbate problems of social exclusion.

The majority of prisoners identified as having a mental disorder can be managed appropriately within the prison setting in the same way as the majority of people in the general population with mental disorder are treated by primary care and community mental health services. The Government are now considering the recommendations in the HM Inspector of Prisons report that the responsibility for prison service healthcare be transferred to the NHS. The prison service and the NHS Executive have set up a working group to advise the Secretary of State and Home Office Ministers on the options for improving prison healthcare.

The noble Lord, Lord Mottistone, raised the issue of resources and beds and the noble Lord, Lord Rowallan, referred also to beds. My right honourable friend Frank Dobson has already given an indication of our proposals for mental health services. There will be a greater focus on crisis intervention, a growth in the number of acute beds and greater support within the community for hostels and other kinds of supported accommodation. He has indicated also that there will be a substantial financial package to underpin the new vision. But I am afraid that your Lordships will have to wait a little longer before we can reveal the details.

We are only too aware of the failure of services in the past to deliver to those who need them the right range of treatment and care. That is particularly important for people who are black or from an ethnic minority who we know have not been well served, as the noble Lord, Lord McNair, pointed out. Black and ethnic minority users are over-represented in the proportion of their numbers under sections of the Mental Health Act and in psychiatric in-patient beds. We know also that they are not always deemed suitable for the range of non-drug treatments which are in such high demand. That cannot be allowed to continue. I am aware that my honourable friend Paul Boateng has urged those leading the work on the National Health Service framework to take account of that.

But if there is a responsibility on the NHS and local government to deliver quality services to provide for individual care plans, so there is also an increasing responsibility on individual patients to comply with their care programmes. The right reverend Prelate the Bishop of Lincoln and my noble friend Lord Judd rightly pinpointed that important issue.

Just as compliance with treatment can be required for those who are detained in hospital, so we must now consider the need for similar measures for those living outside hospital. For some--and it is a very small

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minority of mentally ill people--that will mean that compliance with the treatment programme can no longer be optional.

Perhaps I may allay a fear put forward by the noble Lord, Lord Clement-Jones, and the noble Earl, Lord Howe. We are not talking about forcibly administering treatment over the individual's kitchen table. Any new arrangements must involve compliance within an appropriate clinical setting. And of course, just as there are currently safeguards built into the current legislation governing detention in hospital, so too must there be safeguards when it comes to any requirements to comply with treatment programmes for those who are living in the community.

We do not underestimate the complexity of such arrangements and it is one of the key issues on which we shall look to the expert group for advice. But one thing is certain: as modern treatment and care arrangements quite rightly enable more people who are mentally ill to live in their own homes or in homely settings, we can no longer duck the issue of making certain that the care plans that enable this desirable improvement are adhered to. We must strive to achieve balance between the rights of individual patients and the understandable expectations of the wider public.

The expert group does not have an easy task before it. It will set the direction for completely new legislation that will underpin mental health services for the next millennium. But its work only begins the process. Once we have received its report there will follow a wide round of consultation.

Finally, I hope I have made it plain that not only do we recognise the need for modern robust services to deliver safe, sound and supportive services for mentally ill people, but we recognise too the need to support them within a legal framework that reflects the changes in patterns of care and treatment; and that through the inclusive approach that has characterised our whole approach to policy development in this absolutely crucial area we have taken steps to revise the law quickly and efficiently but, above all, thoroughly.

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