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Lord Ennals: My Lords, I am grateful to the Minister for giving way. I asked specifically that the Government should tell us, in view of the number of organisations that I listed which I know have strong and fundamental criticisms of the legislation, which organisations were consulted in the preparation of the Bill.
Lord Fraser of Carmyllie: My Lords, there was an extensive list. I have just given an example. I am reluctant to try to pick out one organisation and say that it offered wholesale or fulsome support. As I said, the BMA welcomed the Bill but qualified that welcome by saying that it would like to see a further review of mental health legislation. It is difficult to separate those organisations as he would like me to, but a full range of professional bodies and voluntary organisations concerned with mental health issues and patient organisations were consulted.
Lord Fraser of Carmyllie: My Lords, if the noble Lord wishes I shall try to draw together a list of those who were consulted. However, one cannot assume that their reactions to what is provided for in the Bill fall clearly into categories of either black or white.
One area of reservation was whether there were sufficient resources for the care of those who are mentally ill. Health authority spending on mental illness services has increased by some 40 per cent. since 1979. Local authority spending has increased by some 171 per cent., and the mental illness specific grant supporting local authority expenditure will be £66 million in the year 1995-96, with the Government committed to continuing that grant through to the end of 1997-98. That funding has supported something like 1,000 new projects helping about 100,000 mentally ill people. Without wishing to appear boastful, in Scotland in the
There are undoubtedly pressures and costs in the care of the mentally ill. However, with the exception of what I shall have to say about tribunals in answer to a question from the noble Baroness, Lady Robson, we do not believe that there will be a significant extra cost. There should not be. One of the important features of the legislation which possibly has not come out as clearly as it might, is that psychiatrists have indicated that they would like to see what is done already in an informal way given a legal framework. One of the features of the Bill is to provide just that.
The noble Earl, Lord Longford, was concerned that there might be a gap in care. I acknowledge that services do not reach all those who need them. That is not entirely a failure of the services because, as has been indicated in the course of the debate, a number of those who are mentally ill are very reluctant to accept help. We believe and hope that the new supervision arrangements will go some way to help them because it will be more difficult for them to lose touch with the services that are being provided.
As regards the training of key workers, in firmly standing by a care programme approach we have included a commitment to improve the training of key workers in their duties under that approach in the 10-point plan. A number of specific initiatives aimed at both NHS and social services staff are already under way.
In the same area of resources I was asked by the noble Lord, Lord Thurlow, whether there were enough acute beds. Leaving aside London, there is no evidence to suggest that there is a general shortage of acute beds. The pressures in London are acknowledged. However, the recent report to which the noble Lord referred found that those could often be alleviated by increasing community provision or improved bed management strategies. The task force identified the need for more acute beds in a few inner London districts. Those district health authorities have agreed action plans to bring about the required increase in provision.
Similarly, in answer to my noble friend Lady Macleod, it is fully accepted that it is important to have in-patient beds readily available in a crisis. It is important that there should be proper integration between hospital and community services. That again was emphasised in the report which I have just mentioned. Action plans are now in force to increase the number of acute beds.
I can tell my noble friend Lord Haig that the importance of suitable housing is emphasised in that report. At present the Department of Health is considering with the Department of the Environment the action that is needed to ensure that local authorities fulfil their responsibilities for housing the mentally ill and others with special needs.
More generally, the noble Lord, Lord Desai, asked whether we really need this legislation. The short answer to that question is yes. Fundamental and identifiable action is needed to allay a degree of public concern and to provide the proper legal framework to support patients and to guide professionals.
However,and I was interested that the noble Baroness, Lady Jay, focused on this pointwe would not wish to introduce a set of arrangements which, because they necessarily contained within them a degree of coercion or compulsion would thereby damage therapeutic relationships. That would clearly be very unsatisfactory. Ultimately, the effectiveness of the treatment and care given under the provisions of the Bill will depend on the co-operation of the patient. That is why the principle of consulting the patient is so firmly enshrined. We believe that with the patients whose needs the Bill addresses a measure of legal backing is nevertheless justified, but we do not see that as undermining the principle that treatment relies primarily on co-operation. We would certainly not wish to damage that relationship.
Nor, I can tell my noble friend Lord Mottistone, would we wish to see relationships with patients' nearest relatives harmed. We would certainly wish to see them involved, but my noble friend will appreciate that if we are to deal with individuals appropriately their agreement should be secured before their relatives are informed unless the nearest relative is also recognised as the patient's informal carer on a day-to-day basis.
The noble Baroness, Lady Jay, asked whether the supervisor would normally be a social worker. The answer is that that supervisor may well be a social worker. But we think it more likely in fact that he or she will be a community mental health nurse. Most key workers in the care programme approach are such nurses. We anticipate that that would be the position.
Baroness Jay of Paddington: My Lords, I thank the Minister for giving way. I am grateful to him for expanding on that point. I am grateful, too, that he mentioned earlier that there would be extra training for such people. Obviously if community psychiatric nurses are to take that responsibility, they may well need that training. But how will that be achieved within the provisions of the Bill which state that there will be no further expenditure?
Lord Fraser of Carmyllie: My Lords, in the 10 point plan approach that we have already undertaken I indicated that emphasis has been given to that factor. I hope that I used the present and past tenses. A number of initiatives have been or are already being taken notwithstanding the fact that the Bill has not yet reached the statute book.
The noble Baroness was also concerned that the supervisor should not be a scapegoat for any errors. An important factor is that there is a well-established principle that the delivery of the patient's care plan may be the responsibility of a named individual, but that individual works as part of a team. The individual should know the limits within which the authority is to
In contrast to a number of the observations made about England and Wales, some concern was expressed about existing arrangements in Scotland. I refer to an arrangement of leave of absence from hospital without end. It was believed that we should simply leave that arrangement in place because it was working well. It would be fair to say that, generally speaking, the arrangement has worked well. However, proper concern has been expressed that we should ensure that what is undertaken in relation to the mentally ill should be beyond legal challenge. As I recall, in opening my noble friend indicated that we have been made aware from a decision in the Scottish courts that to allow leave of absence without end is ultimately illogical and threatens to be opened up to legal challenge.
So far as concerns Scotland, we have restricted the provision to 12 months. By the same token, to ensure that we march in step in England the period has been extended from six months to 12 months. That would seem about right so far as we can best judge.
A theme that also ran through the contributionsmy noble friends Lord Mottistone and Lord Haig raised the issuerelated to compulsory medication. It is a matter which raises real issues. Civil liberty arguments have to be addressed. Difficult practical issues on administering compulsory medication in the community to an unco-operative patient have to be addressed. The issue is unlikely to command widespread support in your Lordships' House or in another place, or among professionals. Within Scotland there will be some opportunity for compulsory medication, not in the community but in circumstances where the condition of the individual has so deteriorated that it is considered appropriate to take that individual back to hospital for reassessment. Within the clinical context of the hospital reassessment, such compulsory medication would be permitted. We may return to that matter during later stages of the Bill. But beyond that we do not consider that we can go any further, nor indeed that we should.
The noble Baroness, Lady Robson, raised the issue of the pressure on mental health review tribunals. It is anticipated that there would indeed be additional costs, not only in respect of the tribunals but also in respect of legal aid for those patients, and those extra legal costs would indeed be met.
It has been difficult to attempt to strike a balance. My noble friend Lord Campbell properly emphasised that we have to weigh up the issues regarding human rights and civil liberties of the individual with a mental disorder. At the same time, we cannot lose sight of the rights and liberties of the members of the public to whom we also have a duty. So far as possible, we should seek to keep any danger to the public at large to an absolute minimum. But we wish to maintain the civil liberties of the patients with mental illnesses as best we can. We trust that what we have allowed for in the Bill strikes an appropriate balance. I am grateful to those who have indicated that they believe that we have achieved that balance, although they may have individual points of concern.
We were asked whether we could not simply rely instead on the existing arrangements of guardianship which are to be found on both sides of the Border. As has been rightly pointed out, recently the Law Commission on this side of the Border has reported. We do not consider it appropriate to approach individuals with mental illnesses simply on the basis of guardianship. Guardianship is essentially an arrangement which is oriented towards social care. I believe that these sets of provisions, whether they apply in England, Wales or Scotland, are based separately: they are centred upon the health service; they are rooted in a care programme approach. A separate identifiable, health-led provision is made. I believe that that is the right way to approach the matter. We are not persuaded that simply by adding a power to conveyI believe that it is accepted that it would be necessary in any event if guardianship were relied uponwould be an acceptable way forward.
Beyond the specific contributions made, there was a further and wider debate; namely, whether we should be undertaking a fundamental review of our mental health legislation, applying whichever jurisdiction. I wish to conclude by acknowledging the case for considering whether the Acts still reflect current practice. But there is no clear evidence at present, I believe, to conclude that they fail to meet present day needs or that there is as yet any emerging consensus about how the position might be changed. Our view is that we wish to take stock of the new powers that we propose should be introduced in the Bill before considering any further fundamental changes. However, as has been pointed out more than once, it is recognised that there are, and will continue to be, changes with more and more people appropriately being treated within the community.
If I have failed to answer all the detailed points, I hope that I may be forgiven. This seems to me to be a Bill which is particularly suited to the consideration that your Lordships will undoubtedly give it. There is a great deal of detail to be carefully considered. I have no doubt that we shall be able to do so at later stages.
I was asked whether I was prepared to consider having an additional informal meeting along the lines of that which my noble friend will conduct next week. While I certainly do not rule it out, I suggest that we might take the issue forward at that meeting. If at the end of the meeting there are specific Scottish issues of interest only to Scots, we might consider doing that as a separate exercise.