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Lord Campbell of Croy: My Lords, perhaps my noble friend will give way, because I think he has misunderstood me. I was saying that I was delighted when the Government announced last November that they were going to produce the Bill in this Session. I said that there were disadvantages when preparations had to be made quickly. There was just a short period for consultation. I certainly welcomed the fact that the Bill was coming. Some of the problems that have been raised about organisations outside Parliament have arisen because of the short time in which the Bill has been brought forward. I am certainly not suggesting that it is being rushed.
Lord Mottistone: My Lords, I understand what my noble friend is saying. However, it is not something that should be dismissed, because of the difficulties that will unquestionably arise. The National Schizophrenia Fellowship estimates from its long experience that sufferers from schizophrenia will always need a great deal of help if they are to have reasonable lives in the community. About 30 per cent. will need support between lapses, in hospital it is hoped. An additional 50 per cent. will need varying degrees of care indefinitely from their families and statutory bodies. Within that 80 per cent. of schizophrenia sufferers, there will be a small minorityestimated at about 3,000 people which will reject care or which will never be offered it.
The Bill should be especially helpful to that minority which so often causes most anguish to the public. I hope, however, that the Bill will also provide some better care for the larger number of sufferers.
Although I accept that there might be legal difficulties in adding compulsory medication for mentally ill persons in the community where that is needed, the Bill would be much more useful for the sufferers and the public if a measure of compulsory medication had been included within it. It would also be more helpful and give a clear understanding to health and local authorities of the probable commitments required by the Bill if the explanatory note admitted that, properly implemented, it is bound to cost more and to need more manpower, as most noble Lords have already said.
One other criticism that must be made is that the Bill's wording seems to take particular care to limit the involvement of the nearest relatives. It is true that some schizophrenia sufferers feel passionately, some of the
With the aid of the National Schizophrenia Fellowship, I shall be spelling out my doubts about the Bill when we have our preliminary discussions on its detail next Wednesday. In that connection, having heard our noble friends from Scotland, I believe that there are significant differences between Parts I and II and, more importantly, between the types of amendment relating to Scotland and those relating to England and Wales. Will my noble and learned friend Lord Fraser consider having two separate preliminary meetings next Wednesday in order to discuss Parts I and II independently? That will allow more time for each subject. I understand that we shall have approximately two hours for discussion. It could be the case that, from the point of view of the Scots, that time could be absorbed by the English and Welsh or vice versa. That would be unfortunate if, in the event, the detail is different. Perhaps my noble and learned friend will consider that proposal and give an indication in his reply tonight.
Lord Desai: My Lords, my noble friend Lady Jay gave the analogy of the Dangerous Dogs Act in respect of which a small number of well publicised problems led to reaction in terms of legislation. I wish to use the analogy of car pollution. We know that only approximately 10 per cent. of cars cause most of the pollution but we feel obliged to legislate for all cars.
My belief about the problem, on which I am not a specialist, is that a few mentally ill patients have been discharged from hospital, perhaps too soon, and pushed from pillar to postas Mr. Clunis claimedfrom one person to another in an unco-ordinated fashion. The problem requires not legislation but a rethinking of the treatment.
It may be, for example, that the problem within the NHS is that since the introduction of care in the community and the purchase of provider arrangements there has been a fragmentation of treatment. I direct the Minister to an article in the latest issue of the Health Services Journal about incentives and mental illness. It points out that among the three main purchasers in the mental illness field the health authorities, the local authorities and the funded GPsthere are conflicting incentives about what to recommend and what to opt for.
Therefore, it is not surprising that, while health authorities wish to minimise long stay care in hospitals local authorities, when they are landed with the care of someone, must find the resources for it. And not only
Many noble Lords mentioned human rights. Perhaps I may re-emphasise what was said by my noble friend Lord Ennals. Many patients from ethnic minorities, in particular the Afro-Caribbean, are disproportionately represented among the mentally ill. There is a problem and it may be that classification in a certain category is thought by the patient to be not a medical judgment but a judgment biased by racism. That may not be the case but conflict might arise.
In such a case, the person has a right to refuse medication. It may be said that the person is right and the doctor is wrong, but there has been a great deal of controversy in this area. A great deal of literature has been published about schizophrenia and people disagree about its nature, symptoms, causes and cures. There is no single philosophy and no single belief about the medication that should be used. It is likely that the patient, or someone related to the patient, may object to medication and may have good grounds to do so. In that case, we must look most carefully at the problem of forced medication.
In that respect, I wish to comment about the problem of language. Many people of ethnic minorities may not know English sufficiently well to be able to articulate their objections or desires, let alone the fact that they have religious objections to certain kinds of medication. All those problems must be considered carefully when we deal with the issue of civil liberties.
There is a problem but I am not sure that this Bill is the solution. However, if we identify the problem we might, with a great deal of goodwill and consultation, be able to find a solution which is similar to these proposals but not exactly these.
Earl Haig: My Lords, I too thank my noble friend Lady Cumberlege for introducing the Bill so clearly. The debate has been most interesting and the noble Lord, Lord Desai, made some valuable and interesting points. Ideas have moved on since we debated these matters in 1989. Those debates took place in a non-party-political atmosphere. All noble Lords on all
The Bill addresses the difficult issue of discharge from hospital and, where necessary, the return to hospital. I support the Bill because it will increase the possibility of the mentally ill leading a reasonably normal life in the world outside. Many people will continue to suffer for the rest of their lives but, given supervised after-care and proper medical treatment, there will be less chance of their having to return to hospital and having to endure appalling suffering in loneliness and squalor.
I feel diffident about entering into discussions about the advantages and disadvantages of the detailed proposals. I do so, perhaps, having a relative who suffered from schizophrenia but who has been successfully treated. I know that many people in the medical world, supported by people such as the noble Lord, Lord Ennals, who know what they are talking about, are lukewarm about the Bill.
The serious need for after-care supervision concerns a relatively small number of vulnerable patients, many of whom have bad home lives and many of whom are so ill that they cannot cope with the smallest problem. It is in those situations, where patients are being released into the community, that there is a special requirement for social workers, and in such situations more psychiatric care and medical help is needed to administer medicines and offer counselling.
It is among that section of the community that there are patients who may be a danger either to themselves or to others. Those cases present grave anxieties to relatives and friends. Their difficulties can be overcome only by generous spending and good co-operation between the Departments of Health and the Environment and local authorities, in particular as regards the provision of accommodation.
A recent report commissioned by the Department of Health stated that there are an estimated 2,000 mentally ill people in London alone without any accommodation. In the words of a member of the City and Hackney Community Services:
To keep down the costs of looking after the mentally ill in the community would be counter-productive. If the authorities are starved of funds, there will be a danger of regression and rehospitalisation. I ask the Minister who is to reply whether the statement in the Explanatory and Financial Memorandum that the Bill will mean no additional costs for health or local authorities is made in the context of financial savings made through the closure of hospitals.
There is a danger that with inadequate community care resources, the money will be targeted on the individuals who have previously been detained in hospital. That course may be at the expense of other severely ill people who have been voluntary patients who do not need orders, but who need community support.
The Bill will give health authorities, medical practitioners and psychiatric nurses greater control over patients. I speak with a little experience of those matters and I believe that much depends on the trust which a patient has in the doctor. Only gradually do patients grow to accept and come to terms with their illness. Where there is greater insight, surely there will be a greater keenness to take medicine. I do not mean to imply that on some occasions it may be necessary to enforce the taking of medication.
Concern has been expressed about the powers given to supervisors south of the Border. Those powers are not given to their Scottish equivalentthe after-care officersas regards taking and conveying a patient. In Scotland a special medical officer may, with the consent of the patient's after-care officer, direct the patient to attend. In either case, there is an element of compulsion and I believe that there are occasions when that may be needed.
Much will depend on close co-operation and consultation between the patient and the psychiatrist concerned. There must be a system to enable a patient to go back to hospital for short periods when necessary. A flexible approach is vital. In many cases, a successful improvement will depend on the quality of the home where members of a family are involved in congenial surroundings.
Some of your Lordships are concerned about the lack of powers to treat. The Bill should spell out that the psychiatric nurse or other professional should have the right to say to the patient that he must take the medicine prescribed. There is a hollow ring in the words that he cannot be required to take medication. Those words remove the main purpose of the Bill. Should recall to a hospital be necessary, there will be a need for swift action. In Scotland there is a question as to how long the process of reassessment will take. There is uncertainty as to who initiates the reassessment. On that point, the Bill is far from definite. It contains only a somewhat vague mention of those who are concerned with the patient's medical treatment.
My noble friend Lord Campbell of Croy and the noble Earl, Lord Mar and Kellie, have referred to Scotland. In many ways community care orders fall into line with current Scottish regulations, but under the new proposals the present Scottish system of discharge on a more or less permanent basis monitored by the Mental Health Commission will be changed.
The Bill restricts the period of leave of absence so that there will now be an indefinite threat of return to hospital. That is not in the interests of the morale of patients who, until now, have been given the freedom to continue their treatments under minimum duress. As my noble friend said, the National Schizophrenia Fellowship (Scotland) has expressed opposition to that part of the Bill because it curtails a valuable long-term option that has been widely used in Scotland and which has allowed patients to live successfully in the community.
The community care orders should be backed up by a greater awareness of psychiatry among GPs and the local police who may be required to face dangerous situations. Much depends on the availability of expertise in local communities to meet emergencies. Doctor Finlay was no doubt adequate in his day, but in these complex times, a quick, expert response may be needed.
The Bill may not do all that is needed but it points in the right direction. With proper funding, I believe that it will help to resolve some of the difficulties which have arisen in relation to care of the mentally ill.
Lord Milverton: My Lords, this has been a very interesting debate. I am grateful to the Minister for her clear explanation of the Bill. In this Bill, the Government are being practical in a very good and sensible way, as they have been with other legislation concerned with health. They have realised the weaknesses which have emerged since the introduction of that very worthwhile principle of community care. They have seen the missing pieces and the breaks that there have been, which have meant that the high hopes for community care have not been realised.
I realise that it is important to have mental patients brought back into the community. When I was at theological college, the principal thought that it would be a good idea to take us students to a hospital where there were mental patients. I can well remember how it really shocked me. It made me think. Other students told me that I turned pale and they thought that I was going to pass out.
In my first living, I remember visiting a parishioner who had to go to a mental hospital as a patient. That made me realise the need for improved care and how many ordinary lay people needed help in order to help them. Even a priest needs that help.
As my noble friend Lady Macleod saidand I firmly believe thispeople in the community need to be helped so that they can help the professionals, the carers and the wonderful voluntary workers who have the necessary experience and understanding. I know that I need help to help those people. That may sound odd coming from a priest who is trying to help all the time. However, those people need specific help. Indeed, because one is a priest it does not meanHey presto!one has the ability to help in the way that one would like in all situations. I believe that to be important.
As I am sure is the case with most noble Lords, I can remember being in the community and seeing mental patients who had been sent back into the community. I refer to people who are, somehow or other, ill in that way. One notices that some people seem afraid and shy about having to be in their presence. Yes, we need help to assist professionals and others.
In fact, I can remember my father-in-law who, bless him, died some years ago. He was not at all well during his last years. I can recall when my wife Mary and myself took him out and when he came to see us at the rectory. However, I remember especially taking him to a tea place in Corsham which was near my parishes. It stuck in our mindsand indeed, it still doeshow the
There are people in the community who need to be helped in that respect. Of course, there are those to whom helping comes naturally, but there are also others who find it awkward and who are rather shy about such matters and need to be helped. As one speaker said, invariably it is the young who can lead; indeed, they are marvellous in every way and in all things. They can, perhaps, give the lead to others. I remember asking some young people in one parish whether they would visit some old people. Those people were not mentally ill, but they were old and more or less housebound. The response was, "Yes".
I cannot agree with the noble Lord, Lord Ennals. Like my noble friend Lord Mottistone, if it is decided that a mental patient should be returned to hospital for some further treatment, I cannot see how the Bill in any way infringes that person's liberty. I believe that we are really going mad about the word "liberty" in every way. The Bill is aimed at trying to help such people. If one is trying to help someone, does that mean that you are taking away that person's liberty? Indeed, that is crazy because one could more or less say that about anything being done for someone. One can always say that his or her liberty is being taken away. I do not understand that point of view. If we have the welfare and care of such people in mind, as, I believe, the Bill has, one is not taking such liberty away. One is simply trying to help. If it means that such people need to go back to hospital, how can one say that their liberty is lost?
The noble Lord, Lord Desai, spoke about discrimination. I also find that argument difficult to understand. If some ethnic person cannot understand English very well, can it be said that the Bill is in some way discriminatory? I still find that hard to believe. In the practical sense, I believe that the Government have been bold enough to realise that there were some deficiencies in the community care programme and that such deficiencies needed to be put right. Is that wrong? No, of course it is not. Too many people in this world are afraid to acknowledge that, in their great principles and theories, which were put into effect, were some things that they did not foresee. One of the weaknesses in the present world is not being able to face such facts.
On the whole, I believe that the Bill is good groundwork for great improvement. I do not believe that the proposals have been irrationally thought through; indeed, I believe that great care and attention has been given to the legislation. I hope that the Bill will have a blessed way and that it will be accepted. No doubt some people will want to make amendments to it; but let those amendments be good, and good enough to improve the legislation and be part of the Bill.
I believe that Her Majesty's Government can be praised. I do not believe that they have brought the legislation forward in any hurried or ill thought out way. Indeed, perhaps I should try to make amends in that respect. I do not believe that the Government have acted in that way. They wanted to improve and make even better what basically has been, was, and is very good in the whole field of the National Health Service. As a
Lord Rea: My Lords, the role of a "winder-up" should be to gather up and emphasise the points in the debate which back up his case and, perhaps, to counter those which detract from it. There has hardly been a speech this afternoon which has not made a valid point on one side or the other. My overall impression is that the majority of noble Lords agree with our view that the Bill is only really a stopgap or, rather more crudely, a rather sluggish response to several recent tragic occurrences. At best, it is of marginal value and at worst it is a backward step which may be counter-productive or discriminatory. Above all, many speakers have said that other measures need to be taken to improve the care of the mentally ill in the community to diminish the likelihood of further tragic cases, that the current mental Health Act 1983, if properly used, could well serve the purposes of the present Bill and that the latter is probably unnecessary.
The other improvements which are required in community care will have financial cost implications which, according to the face of the Bill, this legislation will not have. Like my noble friend, I find that most extraordinary. If the Bill works, it surely must have cost implications. Alternatively, if it does not have cost implications and is much used, then other patients will suffer as the noble Earl, Lord Mar and Kellie, said.
I believe that all of us in this House acceptindeed, even the National Schizophrenia Fellowship does sothat, if properly resourced and administered, community care of all but the most acutely disturbed and mentally-ill patients is a humane and constructive policy. But, as so many speakers have said, the system is not working wellcertainly not in inner-cities in England and Wales. I am not so sure about Scotland. In fact, I am not even sure whether the Bill is necessary in Scotland because I believe things are working better there.
In inner cities community care has been getting worse, not better, since the National Health Service and Community Care Act of 1991. Pressure on resources in the community in the inner cities, whether run by social services or community health providers, has been greatly increased recently. A contribution to this has been the diminishing number of acute psychiatric in-patient beds and also lack of emergency centres which now hardly exist at all, as my noble friend Lord Ennals pointed out. So great is the shortage that in some mental hospitals bed occupancy has reached 200 per cent. That does not mean to say that there is double the proper number of patients in those wards but, with a full ward, doctors have had to refuse admission to the equivalent of another "wardfull" of acutely ill patients and have directed them elsewhere. One result is that there is a growth industry in private psychiatric hospitals on the periphery of London and, I imagine, other cities too.
If there is great pressure on beds, then, as so many psychiatrist colleagues have told meincluding Professor Anthony Clarethe mental health threshold for deciding when a patient is fit to be discharged is lowered, and unstable people are sent into the community often before adequate arrangements for follow-up have been made. Theoretically the supervision orders created by this Bill should ensure that these arrangements will be made, but I am concerned that the procedure may be too bureaucratic to be used often and that the resources in the community required to fulfil the supervision orders will not be strengthened at all by the Bill.
My noble friend and other noble Lords have pointed out that guardianship orders are similar in effect to the proposed orders in the Bill. They are available under the current Act, but have not been used very often for mentally disturbed patients. Social services play a central role in guardianship orders but they have often been reluctant to use them partly because of lack of resources but also, it should be added, because of a lack of power in guardianship orders to require treatment. That is also a feature of the current order in this Bill.
Compulsory medical treatment is a sensitive area. Ideally medical treatment should not imply medication alone but a whole programme of rehabilitation, occupational therapy, housing and financial assistance, in the way that MIND calls for, as has been described by my noble friend Lord Ennals. As he has also pointed out, those measures have been called for by a whole range of other organisations in the community.
I return to guardianship. Sir Louis Blom-Cooper and his fellow committee of inquiry members in The Falling Shadowthat title is taken from T.S. Eliot's poem "The Hollow Men"describe the background of the Robinson case in Torbay where an occupational therapist, Georgina Robinson (no relation) was murdered. This report describes a period when Andrew Robinsonthe schizophrenic in the casewas under a guardianship order. Although a guardianship order cannot compel treatment against a patient's will, any more than the current Bill can, Andrew Robinson agreed to medication during the period of the guardianship, even though there was no compulsion to do so. After the guardianship order, and the containment it offered, was lifted, his medical treatment became less adequate and eventually lapsed with a severe deterioration in his condition. His father wrote a letter to the nurse involved in the case, asking for him to come. That was four months after the guardianship order had finished. On 8th March 1993 the Reverend Peter Robinson wrote to John Camus, the nurse, stating,
In summary, we think that Clause 1 of the Bill adds a bureaucratic procedure to the 1983 Act whose effect could have been achieved very much more simply by strengthening the existing provisions for guardianship. This has the advantage that a guardianship order can be made while the patient is still in the community and is not restricted to those about to be discharged from hospital, as this Bill requires. We have no great quarrels with Clauses 2 and 3 which tighten the provisions for absence without leave and prolong leave of absence. But, again, I believe that there are resource implications there which are not addressed.
In a well informed brief the Scottish Association for Mental Health stated its concerns. These are not too different from those of many English bodies and point to deficiencies in mental health services which are not being addressed by the present Bill, in particular the lack of co-operation and communication between different agencies and the,
Like Sir Louis Blom-Cooper in The Falling Shadow, the association suggests that in Scotland, as well as in England and Wales, the time may have come to consider whether the current Mental Health Act, which sees hospitals as the main centres for treatment of seriously ill people, should be replaced by a new Act which recognises that more and more people are, and will continue to be, treated in the community. The current 1983 Act was seven years in gestation. The next Act may not take so long to develop but I suggest that the time is now overdue for the Government to initiate moves towards a new community-based mental health Act so that in a year or so, when we are sitting on the other side of the House, some groundwork will already have been done.
While I am full of admiration for the quality of the two recent reports based on inquiries into particular tragic cases, they are really a form of worst case analysis. What is needed before the legislation is changed is soundly and widely based research on the working of the present Act. The Government should initiate such a research programme as a matter of urgency.
We have, however, got this Bill in front of us. The noble Lord, Lord Milverton, has said that undoubtedly there will be amendments. There will be amendments, and they will be good amendments for a not very good Bill. We hope that they will make it better.
The Minister of State, Scottish Office (Lord Fraser of Carmyllie): My Lords, I am indebted to all those who have contributed to this important debate on this Bill this afternoon. Some of those who have spoken have revealed that they have, possibly, rather unfortunate circumstances and intimate personal knowledge of some of the problems that can arise with the mentally ill. Others, such as my noble friends Lady Macleod and Lady Seccombe, have revealed their intense effort in the voluntary organisations supporting those who are mentally ill. There have also been valuable contributions by those who have spoken for a
I believe that it would be fair, with one honourable exception, to characterise the views expressed today as welcoming the Bill although clearly a number of detailed reservations were expressed which will undoubtedly be explored as we move to the Committee stage of the Bill. However, I say to the noble Baroness, Lady Jay, that to characterise the introduction of the Bill as a reaction to tabloid opinion was unfair, particularly as my noble friend who opened the debate indicated that the report of the Royal College of Psychiatrists in 1993, with its suggestion of community supervision orders, was an important precursor to what we have introduced.
There were some questions about whether the Bill was welcomed beyond your Lordships' House. It has been broadly welcomed and the public believe it to be appropriate. A number of professional organisations, not least the British Medical Association, have written to the Secretary of State welcoming the Bill while, I accept, at the same time adding the reservations expressed by the noble Lord, Lord Rea, and others that it may be desirable to have a broader review of the mental health legislation.
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