§ Order for Second Reading read.3.43 pm
§ The Parliamentary Under-Secretary of State for Health (Mr. John Bowis)
I beg to move, That the Bill be now read a Second time.
We have in our keeping the welfare of people who are ill. It is never an easy task, but when the illness is of the mind, it is one of the most difficult areas of policy and practice to get right. Mental illness is often invisible and unpredictable; it can come upon us suddenly, without warning, or steadily over a period of deteriorating months and years. It can usually be managed and can often be cured, but it strikes fear into the hearts of some and many see it as a stigma.
Our aim in the Bill is to improve the care of that small number of severely mentally ill people sometimes characterised by the term "revolving door"—people who need additional supervision of their care if they are to live successfully in community settings. We must keep their needs at the forefront of our minds. Alongside that, we must never forget our obligation to reassure the public as a whole that such supervised care will be effective, because without public confidence and support, mental health policy cannot function in the interests of patients. It is a chicken-and-egg scenario—the egg of mental health policy and the chicken of supportive public opinion.
The Bill is not and must not be seen as an isolated measure, but it is a key component in a coherent and comprehensive strategy by which we seek to address all aspects of the needs of mentally ill people, their families and communities.
§ Mr. Dafydd Wigley (Caernarfon)
The Minister says that the Government's approach is comprehensive. I see nothing in the Bill that addresses the real difficulty that is faced by many people suffering from mental illness in getting adequate services from general practitioners within their communities. Many GPs have not been trained to deal with some of the more complicated aspects of mental illness. How does that aspect fit into the legislation?
§ Mr. Bowis
It fits in very well. The hon. Gentleman is right to raise the matter, not in terms of the wording of the Bill, but in terms of how it will operate. Perhaps we can discuss that in Committee, because we shall want to make sure that the issue that he mentions is included in the guidance that will accompany the Bill when, we hope, it receives the support of Parliament and Royal Assent. We shall ensure that such care is covered.
§ Dame Elaine Kellett-Bowman (Lancaster)
I assure my hon. Friend that GPs in my constituency, which has a long tradition of caring for people in the community and was the first to initiate 24-hour nursing care, are very well trained to look after people who have been discharged from our local hospital.
§ Mr. Bowis
My hon. Friend is right to highlight the good work that is carried out by many general 158 practitioners and community nurses and others, particularly community health nurses, who work with people with mental illness and with the severely mentally ill whom we are debating today. That is not to say that any of us should underestimate the need to improve co-operation among general practitioners and between all the agencies and professionals whom we seek to include in our care programme approach as we look after people in the community.
§ Dr. Norman A. Godman (Greenock and Port Glasgow)
I should like to ask about children. Are the Scottish measures in the Bill compatible with those in the Children (Scotland) Bill? One of the concerns that has been raised with me is that, through this legislation, doctors and social workers would be able to apply to a sheriff to secure control of a child without having to refer to a children's hearing. Is that right? If it is, it would be a disgraceful state of affairs. I see that the Minister is getting advice.
§ Mr. Bowis
I am not getting advice at the moment. I shall return to the matter that the hon. Gentleman raises. It is the sort of issue that we might debate in Committee, and perhaps the hon. Gentleman is volunteering to join in that debate. When one drafts legislation, one takes account of all the needs of other legislation and of other family members. Although on the whole we are debating adults with severe mental illness, children in families may also need our protection. I certainly take the hon. Gentleman's point.
The Bill is a Great Britain measure, which amends both the Mental Health Act 1983 for England and Wales and the Mental Health (Scotland) Act 1984. The most important of its provisions, on which I intend to concentrate in my opening speech, are those to introduce the new power of supervised discharge, which in the Bill is called "after-care under supervision" for England and Wales, and the broadly equivalent "community care orders" for Scotland. The other provisions deal with leave of absence for detained patients and the return of those who are absent without leave.
The words "Patients in the Community" in the Bill's title precisely reflect the way in which the emphasis on the care of mentally ill people has shifted over the past 30 years. There is now a quite different landscape from the one that was characterised so vividly by Enoch Powell in his description of the old, isolated mental hospitals. The change to a service that concentrates on helping people to maintain or resume life in their own homes has, overwhelmingly, been for the better. No one who knows what the old days were like would really want to go back to them. We have promoted the new approach vigorously, both by the increased resources that we have devoted to it and by the initiatives that we have taken to develop it as a policy. In 1979, we were spending on mental illness services provided by hospital, community health and social services some £450 million. In 1992–93, the latest year for which we have full figures, that had risen to £2,350 million, a real terms increase of £1 billion.
Let me make it absolutely clear that the trend to community-based services does not mean that no mentally ill people should ever be in hospital. Many will need access to hospital services, some will need long-term in-patient care and some will need secure care. We need the right balance between hospital and community-based services, and between care and control on the one hand and respect for civil liberties on the other.
159 When my right hon. Friend the Secretary of State for Health, who has probably done more for the interests of people with mental health problems than any of her predecessors—and we should pay tribute to that—announced her review of the present legal powers, she expressed a concern shared by many people that in some respects those elements may have got a bit out of balance, or, to put it another way, that the pendulum may have swung too far in favour of civil liberties and away from care and control.
As a society, we certainly owe a duty to mentally ill people to protect both them and other people from the harm that their illness may cause, and to ensure that each person's quality of life is enhanced by the right balance and blend of asylum and independent living that is appropriate in his or her case. If we are to make a success of care in the community, we must ensure that the community has confidence that the balance and blend are right. That means ensuring that both mentally ill people and other people are properly protected from the risks that they may present.
The tragic cases that have occurred concern us not only because of the failing that they represent in the services for the person who is ill, but because of the damage that they do to public confidence. As a matter of actual fact, the public are not now at greater risk from mentally ill people than they were in the past; indeed, the number of mentally disordered people convicted of homicide under the Homicide Act 1957 has fallen significantly in the past 20 years. Nevertheless, our ability to manage successfully patients who present the greatest potential risk both to themselves and to other people is crucial, both as a test of the effectiveness of the policy and in ensuring that public confidence is maintained.
§ Mr. Archy Kirkwood (Roxburgh and Berwickshire)
I agree with the Minister that no responsible Government can ignore the Silcock and Clunis tragedies; they were indeed tragedies that had to be urgently addressed. However, he is saying that the whole approach to dealing with mental illness has changed, and rightly so, since the introduction of community care. Does he accept, however, that the 1983 and 1984 Acts to which he referred were cast at a time when treatment was undertaken on a wholly different basis? Does he not therefore think that it is right that the Department, as well as dealing with some of the short-term, immediate problems, should be considering in a fundamental manner the way in which we cast the legislative framework within which mental illness is treated?
§ Mr. Bowis
The hon. Gentleman has a point and it has been made to us by many, not least the Mental Health Act Commission. I and my right hon. Friend have thought about that point deeply and we have said clearly—as I told a conference held with the Law Society on the Act—that we have an entirely open mind on the need to review the Act as a whole. I say that genuinely. The time is coming when we shall need to consider the Act to ensure, as the hon. Gentleman rightly says, that the environment and times in which we live, work and help mentally ill people are still as relevant to that legislation, and that that legislation is as relevant to our current practice, as we would like. We shall think hard about when the time is right for a wider review. Meanwhile, it was right that we should come through with our policies and strategy for the 10-point plan and the Bill, and that we should get them bedded in; then we can see how we should progress further.
160 Central to our policy is a clearly defined relationship between the community and hospital services. Under the care programme approach, to which my hon. Friend the Member for Lancaster (Dame E. Kellett-Bowman) referred, and which we started to introduce in 1991 for all patients receiving care from specialist psychiatric services in the community, mental health service providers must co-operate with local social services departments to deliver a package of care to meet the individual needs of severely mentally ill people. Every patient covered by the care programme approach must have a named key worker, and we have given increasing attention to ensuring that services are properly managed and organised and that legal powers are properly understood and applied. However, the cases to which I referred highlighted a need for more effective legal powers in some cases.
Many of the issues were brought to a head by events in the early part of 1993. Even before the subject started to hit the headlines, my right hon. Friend the Secretary of State had made clear her concern about the need for new legal powers. Indeed, by chance an account of her views was published the day before the incident involving the patient in the lions' cage.
My right hon. Friend was not alone in identifying that need. The review of legal powers governing the care of mentally ill people in the community, which she announced in January 1993, took as its starting point the proposals for community supervision orders that had just been published by the Royal College of Psychiatrists, having been developed by a college working party under the distinguished chairmanship of Professor Bluglass.
However, our proposals for supervised discharge involve some significant modifications to the approach that the college proposed. In the first place, supervised discharge gives legal backing to the key features of the care programme approach, including both the power to supervise a patient and the reciprocal obligation on the national health service and local authorities to provide the after-care services that the patient needs.
Secondly, the review team had to consider the impact of the European convention on human rights, and that led it to propose an approach different from that of the college for dealing with the case of a patient who refuses to accept supervision in the community. That also reflected the consideration of the college's proposals by the Select Committee on Health, which concluded thatthe notion at the core of the College's proposals that a patient could consent in advance to compulsory treatment raises so many legal ethical, philosophical and logical complications as to be unworkable".When the college responded to our proposals, it was content to go along with the changes that we had made to its original approach.
The review team's proposals for supervised discharge were published in August 1993 as part of my right hon. Friend's 10-point plan—a plan that I am glad to say has now largely been implemented. Soon after the review report, we published the revised Mental Health Act code of practice, which cleared up a serious misunderstanding that had developed about the criteria for admitting someone to hospital under the Act, and had led some professionals to interpret them too narrowly. Last year, we issued firmer guidance to ensure that patients are discharged from hospital only when it is safe for that to be done, and when proper arrangements have been made for their after-care.
161 We launched a training initiative for key workers, and we shall soon publish the clinical standards advisory group's report on schizophrenia. We also instituted a special study by the mental health task force of problems affecting the services for several mentally ill people in London, with a follow-up report.
In preparation for the Bill, we consulted widely on the proposals, and in the responses that we received, support for the principle of the new power substantially outweighed opposition to it. I am sure that that will be one of the key issues for debate as the Bill goes through the House, but I believe that we have got the balance right.
The Bill benefited greatly from the constructive cross-party scrutiny that it received in another place. We were grateful to the occupants of the Labour and Liberal Front Benches, and to the many noble Lords from all parties and from none who contributed. I am pleased that we could accept the principles of several of the amendments moved by, among others, my noble Friends Lord Mottistone and Lord Campbell of Croy and by Lord Carter, Lord Carmichael, the Earl of Mar and Kellie and Baroness Jay.
Those amendments covered important matters, such as the requirement to consult a patient's nearest relative, the qualifications of the doctor who is to act as the responsible medical officer in the community, and the duty to give written information to a patient about both the effect of after-care under supervision and his appeal rights. I believe that those changes have significantly improved what was already a good Bill, and we are grateful for the help that we received from all sides.
I hope that we can look forward to a similarly constructive scrutiny of the Bill in this House, but I must confess that I am somewhat disappointed by the position that the Labour party appears to intend to adopt. It seems that Labour will not offer the Bill its support. Indeed, it has tabled an amendment that demonstrates its lack of alternative proposals. I notice that Labour has even deleted references to new resources from the original text of its amendment. I would like to take this opportunity to remind Labour Members of the description of the Bill at different stages in the proceedings in another place by their noble Friend Baroness Jay, as both necessary and useful, and of Baroness Farrington, who gave her support to the Bill's principles and the important issues that it seeks to tackle.
If I really wanted to look for support from the Opposition in another place, I would look to the Liberals' noble Friend Earl Russell who, on Third Reading, said:I can recognise a good government Bill when I see it."—[Official Report, House of Lords, 11 May 1995; Vol. 564, c. 195.]We are happy to receive those accolades.
I refer, as my right hon. Friend the Secretary of State did at Health questions, to the missing face in our discussions, Lord David Ennals. I always enjoyed his company and discussing and debating with him. Sometimes we agreed; often we did not. Sometimes he was mischievous; he was always forgivable. We shall miss his robust contributions to this Bill, as we shall to many others.
We have continued to develop our approach in the light of experience and new developments. We have in particular taken very full account of the recommendations 162 of the inquiry into the treatment and care of Christopher Clunis, which was chaired by Miss Jean Ritchie, QC; and of the lessons learned from the Robinson inquiry, chaired by Sir Louis Blom-Cooper, QC.
As a direct response to one of the main recommendations of the Ritchie inquiry, we have prepared a comprehensive inter-agency guide for purchasers concerned with the care of severely mentally ill people and we shall issue that shortly, after wide consultation.
I shall now refer to the main thrust of the Bill, dealing first with the England and Wales provisions. Clause 1 introduces the new power of supervised discharge. Some 20 patients might be eligible for a supervised discharge in the average health district at any one time. The new provisions formalise the supervision in the community of previously detained patients so that they receive after-care in line with the care programme approach. There will be full consultation with all concerned, a written care plan, and a requirement to undertake regular reviews of the patient's needs and the services being provided.
Supervised discharge will be available for patients who are suffering from a mental disorder as described in the 1983 Act and who no longer need to be detained, but who could present a substantial risk of serious harm to themselves or to other people if they did not receive the after-care services they need. The patient's responsible medical officer—the RMO—will make a supervision application to the health authority, supported by recommendations from another doctor and an approved social worker. Before doing so, the RMO must consult the patient and any informal carer, as well as the professional care teams in hospital and the community. Unless the patient objects, the RMO must also consult the patient's nearest relative.
Before accepting the supervision application, the health authority is required to consult the local authority that is jointly responsible for providing after-care services under the existing section 117. When the application is accepted, all those who have been consulted about it must be informed and the patient told in writing of his right of appeal to a mental health review tribunal.
The patient's medical care in the community then becomes the responsibility of a designated community responsible medical officer, who must be approved under section 12 of the 1983 Act as having special experience in the diagnosis or treatment of mental disorder. To supervise the patient's receipt of the after-care services, a supervisor will have been nominated, who is likely to be the patient's key worker under the care programme approach and usually a community mental health nurse.
Clause 1 also defines requirements that the section 117 bodies may impose on the patient: to live at a specified place and to attend specified locations at specified times for medical treatment or rehabilitation services. They may require the supervisor to be given access to the patient where he or she is living. To back up those requirements, the Bill provides a power to convey the patient to a place where he or she is required to live or attend. That is essentially an emergency or fall-back measure for patients temporarily or uncharacteristically unwilling or unable to comply with their care plan requirements.
The power cannot be used to require the patient to accept medication in the community, and compulsory medication is no part of the Bill's provisions. I know that that is something that some, including the British Medical 163 Association, would like, but we are advised that it would risk being in breach of our human rights convention obligations, as well as being opposed by substantial bodies of medical opinion.
§ Mr. Nicholas Brown (Newcastle upon Tyne, East)
One of the principal causes for concern about the Bill is the way in which the power to convey will work in practice and, indeed, what the purpose of that power is. Once the patient—presumably with a degree of reluctance—has been conveyed to the appointed place, could the Minister say what it is intended will happen next?
§ Mr. Bowis
I can make that clear. The purpose is that the patient can continue, with his wholehearted consent, with the care programme. As I said, that power will apply in cases where the patient, temporarily or uncharacteristically, is unwilling or unable to comply. The power to convey is nothing new; it is in the Mental Health Act 1983, as the hon. Gentleman knows. If the patient has been conveyed and is still unwilling to comply with the care plan, it is likely that he is coming to the point at which his case will need to be assessed in terms of whether the care plan is appropriate, whether supervised discharge is appropriate or whether the plan needs to be amended or revised. If it is not working, it may be that the person needs to be considered for return to hospital.
§ Mr. Brown
If the patient's case needed to be reassessed, would not that process happen anyway? Why is the power to convey necessary to act as a trigger? Is not it likely that somebody who has been compulsorily conveyed will not be very willing to take part in whatever is intended at the other end of the journey—[Interruption.]
§ Mr. Bowis
I do not think that the hon. Member for Newcastle upon Tyne, East (Mr. Brown) was asking about absent friends. We are all, not least the hon. Member for Roxburgh and Berwickshire (Mr. Kirkwood), grateful that it—[HON. MEMBERS: "A pacemaker?"]—whatever it is, has been removed.
The question is how we strengthen the supervision of the patient in the community; that is what it is all about. If we strengthen, a little, the arm of the supervisors so that they have the power to convey if a patient is temporarily reluctant, by the time he has reached the destination for treatment, employment, education or whatever, it is likely that he will have recovered his feelings about the programme and will go forward with it. If the power to convey does not work, there is a case for reassessing the patient and the supervised discharge. If it does work, it is an additional strengthening, which is helpful.
§ Mr. Jim Lester (Broxtowe)
I regard the Mental Health Act 1983 as one of the most fundamental pieces of legislation in which I have been involved, and I would not want to see it damaged. I remember that during the discussions on that Act, the principal problem was considered to be with schizophrenics. I understand from what my hon. Friend has said that the power to convey is mid-way between being in the community and having to be sectioned again; it is a halfway house. I have schizophrenic constituents who have decided that they are not mentally ill any more and who, rather than taking the medication, prefer to go to the pub and drink, which makes them more 164 aggressive. The power to convey is a middle way, whereby the care assistant can work with patients to get them back on to medication rather than sectioning them and thus taking them back into full-time care.
§ Mr. Bowis
That is absolutely right and I am grateful to my hon. Friend, with his knowledge of the discussions on the 1983 Act, for the experience that he brings to the subject. I do not know whether he is offering to pursue his interest and to join the discussions on this Bill; we would very much welcome his experience. He is right to say that the power to convey is a halfway measure that will encourage people to stick to the plan to which, after all, they have agreed before coming into the community. We do not want them to have to be taken back. Here we have one step that will encourage people to stick with the plan; we hope that the power will be used rarely.
Health authorities and local authorities are required to keep the after-care services under review and to modify them as necessary. If the patient refuses to accept the services, the next step is that consideration will be given to whether supervision is still appropriate—and, if so, whether the care plan needs to be amended—or whether the patient may need to be readmitted to hospital, using the powers in the 1983 Act.
Initially on discharge, a patient will be subject to supervision for a period of six months, which can be renewed for a further six months and then yearly. Before it is reviewed, there must again be full consultation with the patient and others concerned. The community RMO may end supervised discharge at any time, subject again to consultation. Supervised discharge will provide a legal framework for what should already be widespread good practice and well-co-ordinated services for the most vulnerable mentally disordered patients who have been detained under the 1983 Act.
Clause 2 ends a loophole in the 1983 Act relating to the return to hospital, or guardianship, of detained patients who are absent without leave. Restricted patients who abscond can be returned to hospital at any time, but under section 18(4), as it stands, an unrestricted patient who is not returned within 28 days simply ceases to be liable to be detained—regardless of the state of his or her mental health or the original period of detention.
That is clearly unsatisfactory, so the Bill provides for an unrestricted patient to be returned to hospital or guardianship at any time up to six months from going absent without leave, or within the existing period of detention or guardianship if that is longer. Where a patient is returned after more than 28 days, his or her condition must be reassessed by the RMO. The new limits improve the protection given by the Act to detained patients and the public while taking proper account of patients' civil liberties.
Clause 3 extends from six months to one year in England and Wales the period for which a detained patient may be given leave of absence from hospital. While the patient remains under the care of the hospital team, that time is commonly used as a preliminary period of rehabilitation, to establish whether he is ready to leave hospital care entirely. When we consulted on those proposals in 1993, there was widespread support for extending the leave of absence provision, giving a longer, more meaningful period in which to assess a patient's ability to cope with life in the community before formal discharge.
§ Mr. Ronnie Campbell (Blyth Valley)
What happens if a patient turns up at an accident and emergency department? The Select Committee on the Parliamentary Commissioner for Administration heard recently of a patient being turned away from a department because it could not deal with the case. Are there any policies in place to deal with such patients turning up at A and E departments, because the departments have not got a clue what to do with them?
§ Mr. Campbell
The Minister says "hopefully", but I am looking for something more concrete, so that when such people turn up at A and E departments, they are dealt with properly. The Select Committee heard that, on one occasion, a man was sent home and he hanged himself.
§ Mr. Bowis
I am glad to have the hon. Gentleman's support for the Bill, because such instances are precisely why we need to have closer and tighter supervision of individuals. Supervisors may then keep much closer contact with the individual. Certainly, if word came that somebody had gone to hospital because on a particular day he or she was not feeling well, or whatever, the supervisor would immediately be required to contact the individual. A person may also be on a supervision register—which is a different issue and not to do with the Bill—which would alert people to the need to pay special attention to the patient.
That brings me to the Scottish provisions in the Bill. The Mental Health (Scotland) Act 1984 addresses the care and treatment of people with a mental disorder in Scotland. It is broadly similar to the Mental Health Act 1983 for England and Wales, but there are differences between the two Acts, which influence the way in which the proposals for community care orders in Scotland are framed.
Ministers and officials in Scotland, England and Wales have kept in close contact while developing the respective proposals for the care in the community of people with a mental disorder. However, with regard to extended leave under the 1984 Act, patients who are liable to be detained in hospital in Scotland may be granted leave of absence for a specified period of up to six months and that may be extended for further periods.
There are perceived to be legal problems with a patient who is liable to detention in hospital for treatment also being in the community on very extended leave of absence. A judicial decision raised the possibility of a successful legal challenge to the long-term use of leave of absence. A limit of 12 months for the use of successive periods of leave of absence is therefore also being introduced in clause 5 for Scotland.
§ Dr. Godman
May I point out to the Minister that there is a great deal of concern in Scotland—for it has already been voiced—about the failure of the Bill to define precisely the powers of the sheriff in making orders? Is a sheriff in such a case to be advised by a medical expert, 166 an assessor, or will he or she have to rely on guidelines from the Under-Secretary of State for Scotland, the hon. Member for Edinburgh, West (Lord James Douglas-Hamilton)? One of the serious concerns that some of us have about the Bill is the poorly defined powers of the sheriff.
§ Mr. Bowis
I am sure that the strict issue of how the system will operate vis-à-vis the sheriff will be explored in greater detail in Committee. I intend to refer to the sheriff, the individual and the courts in a moment, so that may cover the points raised by the hon. Member for Greenock and Port Glasgow (Dr. Godman). If not, the Under-Secretary and I will do our best to offer reassurance to those who are concerned about the procedures in sheriff courts.
Community care orders are introduced by clause 4. They will provide for Scotland a safeguard broadly similar to supervised discharge in England and Wales. An application for a community care order may be made for a patient who is liable to be detained in hospital under section 18 of the 1984 Act, or is subject to a hospital order without special restrictions made by a court following his involvement in criminal proceedings. Before an application can be made, the patient must have been liable to be detained in hospital for at least 28 days.
The application process is triggered when the patient's responsible medical officer and another medical practitioner are satisfied that the patient's medical condition justifies a community care order, with a view to ensuring that the patient receives medical treatment and after-care services, for the patient's own health or safety or for the protection of others.
The responsible medical officer may then make an application to the sheriff for a community care order. That is supported by a second medical opinion and a recommendation from a mental health social worker. That mechanism may allay some of the concerns expressed by the hon. Member for Greenock and Port Glasgow. The application to the sheriff reflects the role of the courts in the Scottish mental health system, where it is the sheriff who makes an order for detention in hospital and hears appeals against detention in hospital. The courts do not have that role in England and Wales.
The patient will be consulted before the application is made. He also has a right to be heard and call witnesses when the order is made. The order lasts initially for six months, after which it may be renewed for a further six months, then annually. When the order is first renewed, the patient is accorded a right of appeal to the sheriff. That is comparable to the arrangement for appeal against detention in hospital under the 1984 Act.
The community care order will specify the special medical officer who is to be principally concerned with the patient's medical treatment in the community while the order is in force; and it will specify the after-care officer, who is the social worker responsible for co-ordinating the provision of the patient's after-care services. The conditions of the order will also be specified. They may include a place of residence and a requirement to attend certain places for treatment or training, in common with the English and Welsh system.
The Scottish provisions include a new provision for reassessment in hospital. That will allow a person subject to a community care order to be returned to hospital for a period of up to seven days if his mental state has 167 deteriorated and gives, or is likely to give, grounds for serious concern regarding his health or safety, or the protection of other persons. The reassessment has to be approved by two doctors and the after-care officer must agree to it. Following a period of reassessment, the community care order may be continued or revoked, or an application for the patient's detention- in hospital may be made.
The Mental Welfare Commission for Scotland has a statutory role under the 1984 Act to exercise protective functions in respect of those who may, by reason of their mental disorder, be incapable of protecting their person or their interests. Those duties are specifically extended by the provisions of the Bill. The commission will also have the power to revoke community care orders in appropriate cases. That is entirely consistent with its role in respect of patients detained in hospital subject to guardianship.
There will be no power under community care orders to administer medication in the community without the patient's consent. I make that clear because there appears to have been some misunderstanding about what is being proposed.
Clause 6 is the equivalent for Scotland to clause 3 for England and Wales. It makes equivalent provisions for detained patients or people subject to guardianship in Scotland who abscond, to be taken into custody and returned within their current period of detention or guardianship or within six months, whichever is later.
Clause 7 is a Great Britain clause. It covers the short title, commencement and extent. The commencement date of 1 April 1996 will give sufficient time for regulations to be laid and made and for the necessary guidance to be issued to the NHS and local authorities. That is important because hon. Members have already raised issues today, which we shall have to consider as we issue guidance. We shall consult fully on that guidance before it is issued. The new powers are, of course, a significant addition to the existing arrangements. That guidance has an important part to play in ensuring that those powers are used properly and fairly.
§ Mr. Roger Sims (Chislehurst)
Will that guidance also include advice to clinicians who will be responsible for releasing patients into the community as a result of the Bill's provisions? My hon. Friend has already referred to certain tragic cases, some of which appeared to involve patients with a history of violence, who were, nevertheless, released into the community. Such cases have harmed the concept of care in the community for mental patients. I would be grateful for my hon. Friend's assurance that firm guidance will be given to those who will take such decisions.
§ Mr. Bowis
That is a fair point. As my hon. Friend knows, we have issued new clinical discharge guidance, and that is clearly making people think hard before discharging somebody from the hospital into the community. We must make sure that it is not inappropriate to discharge, and that there is a care team ready and waiting out there to receive each individual. The guidance will be issued after all the consultation, and will go to everyone involved in the planning and implementation of supervised discharge. That applies to people at the discharging end, as well as to those involved in the receipt of patients into community care. We shall make sure that that happens.
§ Mr. Thomas McAvoy (Glasgow, Rutherglen)
I thank the Minister, who has been generous in giving way. I would like to take him back to the situation in Scotland. There is concern at the lack of guidance to sheriffs on how they are to determine the conditions. Bearing in mind the fact that sheriffs in Scotland are not always uniform in how they arrive at their decisions, will there be a system to monitor sheriffs' acceptance of guidance from the relevant professionals in cases?
§ Mr. Bowis
It would be wise for me to distinguish between issuing guidance and seeking to guide the courts. We shall seek to issue guidance, which I hope the courts will find helpful, but it would be wrong—I am sure that the hon. Gentleman is not suggesting this—for us to seek to influence the decisions of the courts or the personal conclusions reached by sheriffs in the Scottish legal system. I shall certainly bear in mind what the hon. Gentleman has said. We shall try to make sure that the guidance for, Scotland is clearly understood by all concerned, including those in the legal profession.
I believe that the Bill provides a coherent, firm, reasonable and compassionate approach to the needs of the most seriously mentally ill people. It strikes a careful balance between taking into account the rights of citizens and the duty we owe to them and the wider public, to protect them from the harm that mental illness can cause. I commend the Bill to the House.
§ Mr. Nicholas Brown (Newcastle upon Tyne, East)
I beg to move, To leave out from "That" to the end of the Question, and to add instead thereof:That this House, acknowledging the widespread public concern about the plight of people with serious mental illness discharged into the community, and noting with concern the growing shortages in the availability of acute psychiatric beds and the considerable strain put on community care services for the mentally ill, declines to give the Mental Health (Patients in the Community) Bill [Lords] a Second Reading because the Bill will inevitably result in a reduction in the funds available for existing mental health services, because the Bill will not improve co-ordination between government departments in administering effective community care strategies or between professionals in devising individual care plans and because, as a consequence, the Bill fails to address the present shortcomings of community-focused care for people with mental illness.Let me say from the outset that there is no division between ourselves and the Government on the two declared issues of principle involved in the matter. We believe that the Government have a duty to make provision for the protection of the public. We believe that it is the duty of the Government to make proper provision for the care and protection of their citizens who are ill, including those who are seriously mentally ill. These are objectives which the Government claim for themselves, as we do.
In introducing the Bill, the Minister set out some of the background, and I too would like to put the Bill in its context. It is a fact that discharged psychiatric patients who represent a threat, either to themselves or to the public, constitute a tiny proportion of all mentally ill people cared for in the community. Sadly, as the Minister said, all the evidence shows that mentally ill people are at greater risk of abuse or harassment from others than they are a danger to the public.
A number of high-profile cases have inspired the legislation that is before us today—the stabbing and killing of Jonathan Zito by Christopher Clunis in 1992, 169 the murder of occupational therapist Georgina Robinson and the injuries received by Ben Silcock after he climbed into the lions' enclosure at London zoo. Those are three examples of community care going terribly wrong, and that is the issue which—in my view—the House should be addressing today.
It is, of course, important not to let those terrible incidents go by without attempting to draw conclusions about how they might have been averted. It is equally important to retain a sense of just how atypical those cases are. It is the view of the parliamentary Labour party—in this we are at one with the Government—that we should move from institution-based care for the mentally ill to care in the community. We acknowledge the problems that have arisen as a result of that policy, but we advocate efforts to solve those problems and to move forward rather than retreat or return to the old-fashioned way of containing the mentally ill in large, anonymous and undignified asylums.
In enabling Parliament to consider important issues such as how best to protect the public and how best to care for the mentally ill, we are assisted by a number of very thorough and well-informed inquiries into the individual incidents that have occurred as well as into more general issues. The various reports about the recent tragedies have served two important functions: they have identified failings in the community care system, and they have made comprehensive recommendations to address those failings.
The very valuable and thorough "Report of the Inquiry into the Care and Treatment of Christopher Clunis"—which no less a person than the Secretary of State for Health described as "essential reading"—offers some guidance. The report does not pin responsibility for the incident on any one individual involved in the care of Christopher Clunis, but indicates a range of problems besetting the community care system. The authors do not argue that the Christopher Clunis case was an exception. They say:we are very concerned that these failures may well be reproduced all over the country, in particular in poor inner cities".The report contained a range of criticisms. Most importantly, it criticised poor liaison between different agencies, the failure of the responsible authorities to act upon warning signals, and the failure to provide social workers to assess new referrals and provide supervision.
The report made special mention of the lack of psychiatric beds in London. The number of psychiatric beds in the capital has halved in the past decade. London also has fewer medium-secure unit places per head of population than most other regions, even though there is a disproportionate number of mentally ill people living particularly in the inner-city areas of the capital. The report also mentions the shortage of suitable accommodation providing a supportive environment to enable patients to readjust to life in the community and avoid admission to hospital.
The Clunis report does not stand in isolation. The Health Select Committee, in its report "Better off in the community? The care of people who are seriously mentally ill", which was published in March 1994, concluded thatlevels of performance nationwide are highly uneven".170 It repeated many of the concerns that were raised by the inquiry into the Clunis case. "The Falling Shadow", the report on the killing of Georgina Robinson, which was published in January this year, pointed to a number of mistakes made by staff at the Edith Morgan centre in Torbay. The authors went on to argue thatmuch of the maladministration and malpractice derived from a fundamentally flawed statutory framework".It went on to propose, as does the Labour party, a thorough revision of the Mental Health Act 1983 and the consequent legislation for Scotland. The authors are not alone in calling for a new Act. The chairman of the Law Commission recently described the law in that area asnow out of date and full of gaps".We contend that this Bill does not fill those gaps adequately. The Matthew Trust report entitled "Victims of Care", which was issued in February 1995, had much of value to say to the House. It is a powerful report which tells a selection of very moving personal stories of mentally ill people who sought financial help from the trust having been turned away by all other agencies and charities. The report concludes:the sweeping changes in the management of care appears to be putting vulnerable people even more at risk".The House should concern itself with that issue.
Today we have to decide whether the Bill tackles those significant problems. The purpose of our amendment is to say that it does not. The reports to which I referred—there are several others—provide an accurate critique of the condition of community care for mentally ill people. They point to many problems and a range of solutions. Each report, as one would expect, offers a slightly different perspective, but it is perfectly possible to notice where the common ground lies. It does not lie in the Bill before us. It is the duty of the House to establish whether the Bill adequately tackles those widely accepted shortcomings of community care for mentally ill people.
In summary, the shortcomings are as follows. There is a lack of co-ordination between the different departments and agencies responsible for providing community care services. The Bill will not improve that. There is poor recording of incidents that might serve as a predictor of future dangerous behaviour. The report into the Clunis case says:Despite the fact that an accurate history is widely recognised to be invaluable in assessing a patient's dangerousness, we found time and again either violent incidents were minimised or omitted from records, or referred to in the most general of terms in discharge summaries.The report had a fair amount to say about the role of the police in those matters as well as the role of other health care professionals.
Behavioural patterns are probably the best predictor of future behaviour that it is possible to obtain. Therefore, one would have supposed that the Minister might have made some mention of it in his speech and that the Bill might make some special mention of it; neither is the case.
However, the Minister did refer to resources as an issue. The allocation of resources at the moment fails to take into account need, and results in often desperate shortages in deprived inner-city districts. The Audit Commission report, headed, "Finding a Place", demonstrates that need can vary from district to district by as much as four or five times.
171 As a proportion of total expenditure in the national health service, spending on mental health services has decreased in the past three years from 12.3 per cent. in 1988–89 to 10.8 per cent. in 1993–84—I have the answer given by the Secretary of State to a parliamentary question as recently as 9 June 1995. That is despite repeated assurances from Ministers that mental health services are a priority.
A study of all 18 districts in north London found acute psychiatric bed occupancy rates increasing from 94 per cent. in 1990 to 101 per cent. in 1993, with some units running to an occupancy rate of more than 120 per cent. The Royal College of Psychiatrists believes that an 85 per cent. occupancy rate is optimal.
§ Mr. David Nicholson (Taunton)
Of course there will be interest and concern, as the Bill proceeds through the House, in the resource arguments; I do not deny that for a moment. I was interested in the percentages that the hon. Gentleman gave a moment ago. That may be an example of an occasion when statistics mislead, because between 1988–89 and 1993–94 there was a massive expansion of resources in the national health service as a whole, and therefore the percentages that the hon. Gentleman gave mislead. Probably the absolute amounts of money going to mental health increased substantially between those years
§ Mr. Brown
It is a broader argument and is of course one of the issues that are very much in contention between the parties. However, extra resources that have gone to the national health service from the mid-1980s to the present day have been sucked into a spiralling bureaucracy and into the installation of the internal market rather than being spent on patient care. I do not want to broaden the argument; I would prefer to focus on the Bill but, if the Minister wishes to broaden it out, I am happy to allow him.
§ Mr. Bowis
The Minister never broadens anything if he can help it, but he is certainly interested in getting at the facts. The hon. Gentleman referred to a parliamentary question. If he had read that carefully, he would have read the caveats that those figures were not comparable for those years. I gave the actual figure, and I gave it in both ways. First, when we came into office, £450 million was being spent on mental health services—social services and health together—and that has now increased to £2,350 million. Secondly, I gave him the real terms increase, which was £1 billion. That is significant extra money going into the national health service and mental health care.
§ Mr. Brown
I am just quoting the Minister's parliamentary answer back at him. I am not responsible for answering the question; all I did was ask it. The Minister says that there is a caveat relating to the capital programme. Still, the way the Government choose to compel the NHS to deal with these matters in internal budgets means a reduction in both percentage and real terms. If provision is adequate, perhaps the Minister will tell the House why the Secretary of State has to go and discuss these matters with the Government's senior Law Officers, and why people are trying to drag her before the courts to get these issues resolved. That does not sound to me like adequate provision—but perhaps the hon. Gentleman would like to defend the Secretary of State.
§ Mr. Bowis
I would certainly wish to defend the Secretary of State—and the facts. The facts are that the beds 172 to which the hon. Gentleman refers—medium-secure beds—were perceived as being needed by the Glancy committee in 1974, but when we came to office in 1979 not a single such bed had been provided. By the end of next year there will be about 1,200 such beds. That is a sign that the Government provide medium-secure beds when they are needed, to meet the needs of the courts, the prisons and the secure health services. The hon. Gentleman might pay tribute to that fact and ask why, in his period of government, nothing happened for five years.
§ Mr. Brown
My period of government has yet to come. I am looking forward to it, as are many in my party. If the polling evidence is to be believed, the British public are looking forward to it too.
The Minister tells us his view of the laws of supply and demand in the provision of psychiatric beds. The courts seem to be taking a different view. Perhaps the Minister is right and the rest of the world is wrong, but I doubt it. In any case, I wish to move on.
Another criticism that has been made and which we wish to make again today concerns the failure of the Mental Health Act 1983 to provide an adequate legal framework for today's community-focused mental health strategies. That view is not unique to the parliamentary Labour party. In a memorandum to the Secretary of State, her own Mental Health Act Commission accurately described the problem thus:The incremental distancing of mental health services from those which pertained in the 1970s, and for which Parliament was appropriately legislating in the early 1980s, is such as to call for legislation, to match the substantially changed environment of mental health services, in the facilities for care and treatment, psychiatric practices and public expectation of the services for the mentally disordered.The Bill addresses none of those central problems. Consequently, we believe that it represents a missed opportunity to deal with a number of clearly identified problems.
Professor Chris Thompson, registrar of the Royal College of Psychiatrists—the organisation that originally proposed the new community supervision order—wrote, referring to supervised discharge, which is the key component of this Bill:To many psychiatrists and others it is the worst of both worlds. The mentally ill will be subject to the power of 'arrest' to no apparent purpose. Psychiatrists remain deeply sceptical and believe that the Bill will not provide the extra public safety which the Government is hoping for.The supervised discharge idea to which Professor Thompson refers has been condemned by a range of groups representing the mentally ill, groups representing mental health professionals and carers, and civil liberties organisations too. If the Bill gets a Second Reading, we shall want to explore these matters in Committee—but clearly, the civil liberties issues must be treated seriously.
There are those, including MIND, who argue that the Bill contravenes the European convention on human rights, in particular the right to liberty, the right to respect for private life, and the right to exercise these rights free from discrimination on grounds of race, gender, sexual orientation, class or any other status. The key area of concern is the power to take and convey. The necessity of a power to convey a person under supervision to a place of treatment, training, education or residence specified under the terms of the supervision order is highly questionable. I do not understand how such a 173 power, which may be exercised by anyone nominated by the patient's supervisor, is appropriate for a co-operative and humane approach to community care. If the power is exercised against a patient's will, it is highly unlikely to encourage that patient's compliance with his or her treatment plan.
There is also a danger that the coercive elements of the new arrangements will compromise the important relationship of trust which ideally should exist between patients and carers. Parliament should not legislate to compromise that relationship.
The Minister has not yet explained to my satisfaction why the power to convey is necessary. In particular, he has not explained what it will achieve. It will certainly undermine the relationship between the carer and the patient.
A possible alternative might have been to look again at the use of guardianship for which the Mental Health Act already provides. It seems anomalous to have a new power of supervised discharge when such provision is already in place. It is at least worth the House exploring—perhaps in Committee if the Bill is read a Second time—whether greater use of guardianship would facilitate increased effective community care for the serious mentally ill and make supervised discharge unnecessary, particularly if attention were paid to patterns of behaviour.
I accept that guardianship affects a relatively small number of people. Only 326 people were placed under guardianship orders in 1993–94, but its use is increasing and the use of guardianship procedures rather than the rather coercive supervised discharge procedures might better make the Government's case.
§ Mr. Bowis
I shall return to guardianship a little later, if I succeed in catching your eye again, Mr. Deputy Speaker. If the hon. Gentleman believes that the power to convey is a danger to civil liberties in respect of supervised discharge, why did Labour Front-Bench spokesmen suggest that it was missing from the guardianship procedures and advocate the power to convey for guardianship?
§ Mr. Brown
The Minister seems to have misunderstood my point. The power forcibly to convey is clearly a coercive power. The Minister was unable to explain what would happen at the end of the conveyance to a patient who had been aggravated by the use of a coercive measure. If the Minister could tell the House that when a patient had been conveyed, a particular outcome was necessary for the protection of the public or the well-being of the patient, he would be able to make a case, but the power exists in isolation, as if it were left over from an earlier examination of these matters, but without fitting into any overall scheme. The power exists to be used or not, but for no particular purpose.
The Minister has not explained to my satisfaction why forcible conveying will somehow help a patient's treatment or mental well-being. It seems to me that the opposite is likely to be the case.
The workability of supervised discharge has been widely questioned. It appears to be a proposal left over from the earlier consideration of options. The new provisions sit uneasily with the present joint health and social services arrangements for providing after-care 174 services under the care programme. The Bill effectively superimposes health authority-led powers on present procedures without, for example, allowing social services to refuse a supervision arrangement if services are not available or appropriate.
There is no role in the procedures before the House today for the Mental Health Act Commission, which could monitor patients under supervision orders. Everyone who has commented on the issue says that monitoring is of enormous importance. The commission is a special health authority with a statutory remit to monitor the care of patients detained in hospital under the Mental Health Act. It has requested its scope to be widened to include supervised discharge and guardianship. MIND and the Royal College of Psychiatrists support that request. As both organisations express the same point of view, it is incumbent on the House at least to take notice of it. It was part of the inquiry into the Clunis case.
The Minister gracefully acknowledged the unmet resource implications, although I may have misunderstood him. Most parts of the country would need substantial increases in services to meet the requirements of the Bill. Although the Bill is accompanied by a money resolution, it covers only the costs of the appeals process in England and Wales, but not in Scotland. The new money is provided to pay for professional advisers and lawyers, not for the direct care of the mentally ill.
The supervision orders may be made only in cases where the patient, being subject to after-care under supervision, is likely to receive the after-care services to be provided. If the after-care services are simply not in place—that will be the case in many inner-city areas—presumably it will not be possible for the patient to be discharged under a supervision order. If that will not be possible, perhaps when the Minister replies to the debate he will tell us what alternative procedure will be followed.
My final point concerns ethnic discrimination. There are some who believe that supervised discharge will be applied disproportionately to ethnic minorities. The evidence is that black people are more likely to be diagnosed as mentally ill and compulsorily detained under the Mental Health Act and less likely to receive adequate care after being discharged. All that combines to give the impression that the more coercive powers in the Bill will operate in a discriminatory way. I am certain that that is not the intention of the Minister or the Government, but it might happen and the House should not allow it.
Having outlined my objections to how the Bill will work in practice, I repeat that there is no issue of principle between the Government and the Opposition. We believe that Parliament has a duty to make provision for the protection of the public and to care for those citizens who are ill, including those who are seriously mentally ill. How we achieve those objectives is under discussion tonight. Our amendment and a more thorough-going review of the 1983 Act offer a better way, so I urge the House to support the amendment and decline to give the Bill a Second Reading.
§ Mr. Michael Spicer (Worcestershire, South)
I shall be brief. This is a good Bill, but if, as a result of the Chairman of the Committee of Selection hearing that I 175 said that, I find myself on the Standing Committee, I am sure that I shall be able to find masses of objections to it and speak for hours on end.
Quite properly, the Bill has been set in its historical context. I do not think that there will be much controversy about its history or the fact that the closure of the big asylums was intrinsically good. When I first entered Parliament 21 years ago, I had two big asylums in my constituency. Although I battled to save the, at that time, famous rehabilitation hospital, St. Wulstan's, for various reasons on which I shall touch, it was right to close such institutions in order to prevent people from becoming so institutionalised that they were lost to and forgotten by the community.
The issue arose, and still arises, as to exactly what should replace such institutions. Part of the controversy was the medical issue. The psychiatric profession's expertise is still underdeveloped, in both diagnostic and treatment terms. The hon. Member for Roxburgh and Berwickshire (Mr. Kirkwood), and I think the hon. Member for Newcastle upon Tyne, East (Mr. Brown), seemed to ask for some grand systematic solution which did not involve options and different institutional and legal approaches—or the least flexibility there—but that seems to discount the fact that there is much uncertainty in, above all, the medical profession about the way forward.
When I first joined the debate 20 years ago, the buzz phrase was "comparable facilities". The case for not shutting St. Wulstan's for 10 years was based on the fact that there were not considered to be comparable facilities. That concept seems to have been a little forgotten recently, but it deserves a place in the argument. As has been said, there is a clear role for some institutional treatment within the health service. To provide that in a modern, decentralised and humane way should clearly be an objective of any Government.
That concept needs to be revitalised from time to time. It has now been largely replaced by the concept of care in the community. My constituency was one of the first experimental areas for care in the community, so I have watched it develop over many years. Clearly, it is intrinsically a good thing that the mentally ill should be returned to a normal way of life, linked, if possible, to their relations and families.
However, care in the community has two implications. One, which is at the centre of the Labour party's concerns, and perhaps those of the Liberal Democrats, is back-up resources. I do not understand the phrase in the Labour party's amendment, which says:the Bill will inevitably result in a reduction in the funds available for existing mental health services".The opposite seems to be the case. Not only have resources for mental health risen by 40 per cent., or £1 billion, in real terms but, if there is any inevitability, because care in the community is inevitably more expensive, there must be more, not fewer, resources.
§ Mr. Nicholas Brown
The Bill is accompanied by a money resolution which provides new resources for the appeals process, but not for the actual provisions of the Bill. The Government intend that the new duties that the Bill requires will be paid for from existing resources. Therefore, resources will be moved from the treatment of people with other mental illnesses in order to carry out 176 the Bill's purposes. That is what we are referring to in our amendment, which I hope the hon. Gentleman will support.
§ Mr. Spicer
I certainly do not support the amendment. Because the Bill is largely related to the concept of care in the community, there will, if anything—if one is to use words such as "inevitable"—be an increase in funds.
The issue is how the money will be spent. I do not agree with MIND's campaign on the Bill, but I support MIND in its succouring role. That is not only cost-effective—if one wants to use such a term—but an extremely good way of involving the community in regular care.
I have been president of my local branch of MIND, and I am particularly impressed with the regularity and consistency, day after day and week after week, with which people concerned with MIND provide assistance in the community. The Government devote large sums of money to the cause, and my only appeal to them is not always to think in terms of great official slices of money, and not to forget organisations such as MIND, which, certainly in my area, is beginning to lose out. It is taking on more and more responsibilities, but is losing the necessary funding. I am talking not about total extra funds, but about the Government perhaps being more involved in earmarking some of the funds they provide for such quasi-voluntary organisations which are so directly related to the community.
The second implication of the policy of moving mental health care out into the community is undoubtedly the issue of supervision which is covered by the Bill. The Labour party seems to be concentrating its criticism of the Bill on the power to convey. The power to convey exists; the question is how it is to be applied.
I am sure that hon. Members from both sides of the House have come across examples of people who are schizophrenic and potentially dangerous who move in and out of the penal system. The central issue, which the Opposition seem to be missing, is that the Bill seeks to make the health system work better, rather than, as happens at the moment, patients moving in and out of the penal system.
A person may be arrested for some offence, put into the penal system, found to be inappropriate for it and returned to the medical system, which cannot cope in a regular and controlled way. Such a person comes out without proper supervision and ends up back, a few days or weeks later, in the penal system. That is what goes on on the ground. In the penal system, to which there is often no alternative, from the point of view of such people the power to convey often exists in a frightening way.
I promised that I would not speak at length. but the central issue seems to be that people who are a danger to themselves and other people, who, because they are schizophrenic, because they are capable of being cured, because they are thought to be cured at any one moment, and because of the problems of diagnostics within the medical system, are in and out of institutions where there is, rightly, a constant attempt to return them to the outside world, but where they may prove to be a danger. Currently, such people may go back into prison or perhaps the prison hospital, which in turn cannot cope, so they are sent back out again.
177 In the interests of the community and the patients, this is an excellent Bill. That the medical system should have a greater power of supervision, control and monitoring of patients is well overdue. The Bill will be good for the patient and for the community.
§ Mr. Kevin Hughes (Doncaster, North)
I give a qualified welcome to the Government's decision to take some action over the increasing crisis of confidence in mental health services. We know that public confidence has been shaken by the number of tragedies and deaths, including one in Doncaster, which resulted in the tragic killing of a 12-year-old girl, Emma Brodie. I am sure that the Minister is well aware of that case, so I shall not go into the details now.
My concern with the Bill is that the Government are reacting to the crisis of public confidence in mental health services rather than to the crisis in those services. It seems to me that the Bill fails to address many of the fundamental problems in mental health care. Much of what is proposed already exists, for example, in guardianship. The only thing that is truly new is the power to take and convey to places of treatment people with mental illness.
The switch from hospital-based care to community-based care has replaced one set of problems with another, and now we are faced with a shortage of psychiatric beds for those who really need them. People can be pushed out of hospital because of pressure on those beds, before adequate services and support in the community are available. That seems to be the key issue.
Patients' health will suffer. They will become revolving-door patients, making no long-term progress in the community. We must recognise that patients will need access to an income, suitable housing and activities to suit their needs if there is to be a sustained improvement in their mental health. Without those, they cannot seriously be expected to prosper in the community.
The Bill does not try to improve the health of the patient. Rather, it is a reaction to the failure of current services and treatments. The power to take and to convey is a reaction to a deterioration in the health of the patient. It is a reaction to the failure of community services. It is for that reason that we need to ensure better organisation and resourcing of those community services.
The Royal College of Psychiatrists has pointed to the danger of the Government skewing resources and paying attention to one group of patients at the expense of the less severely mentally ill. It said that, in most parts of the country, there would need to be a substantial increase in services provided if the after-care provisions of the Bill are to be met.
The Government's claim that the Bill is essentially resource-neutral is difficult to sustain. The claim ignores the problem of staff training and appropriate work loads for community psychiatric nurses, whom both the Royal College of Nursing and the Royal College of Psychiatrists identified.
If the Government are serious about tackling these problems, they should consider reviewing the Mental Health Act 1983 as a starting point. The Act should be revised to help it to address the community emphasis that is now placed on care and treatment following the 178 introduction of community care. Instead, the Government have brought before the House a measure that could undermine the professional relationships between carers and patients, and which fails to address the real problem in mental health care: service provision and resources.
I hope that the Government will think hard about more long-term solutions, particularly when the Bill is in Standing Committee, and act to secure service improvements that will benefit those with mental health problems and the public at large. The issue is too important to be left to the quick fix that we all too often see from the Government.
§ 5.3 pm
§ Mr. David Atkinson (Bournemouth, East)
I believe that mental illness represents one of the greatest challenges facing our health and social services today. I fear that it will become even more so in future, as a result of the accelerating pace of change in our daily lives and, increasingly, the breakdown in traditional family life, with more people becoming patients in need of help and treatment than ever before.
I echo the tribute that my hon. Friend the Under-Secretary paid just now to my right hon. Friend the Secretary of State, for having done more for the mentally ill in this country in the past five years than has been done in the previous 50—or, indeed, 500—years. I believe that that will be acknowledged by all those involved in mental health today.
The Bill that my hon. Friend the Under-Secretary is introducing tonight was announced before—although it had anticipated—the outcome of the Ritchie inquiry. That it is necessary has been demonstrated far too often in recent years by highly publicised homicides and violent incidents, for which severely mentally ill people, such as Christopher Clunis, were responsible. Many of those homicides and incidents were committed by those being cared for in the community, having recently been discharged. As the Ritchie inquiry found, such care can be patchy, neglectful and inappropriate. The Government must address, and they are addressing, that situation today.
I welcome the new power of supervised discharge that my hon. Friend is proposing today, as it represents that element of my right hon. Friend's 10-point plan for developing successful and safe community care which requires legislation. I do so also on behalf of the National Schizophrenia Fellowship, as one of its two honorary parliamentary consultants, with the hon. Member for Birmingham, Selly Oak (Dr. Jones). It provides such excellent help and support for sufferers and their families, and for carers, to whom I pay tribute—as, I am sure, does the whole House. The fellowship will wish to thank my hon. Friend for being so helpful after we met him last December in ensuring that Forresters, its respite hotel in Hylton near Southampton, which was threatened with closure because of lack of funding, will remain open.
Before I express my two reservations about the Bill, I shall make a general comment about the background and experience against which it has been prepared. As my hon. Friend reminded us this afternoon, the community care approach aims to eliminate for all time the old remote and inhumane asylums. It was encouraging to see that the 1993 survey of attitudes towards the mentally ill supported that view by some 77 per cent.
179 There are today a growing number of fine examples of hostels and residential homes for those with mental health problems, and they often represent the first and only haven for the discharged. One such hostel is Charles house, in my constituency, which was opened some three years ago by Esther Rantzen for the Bournemouth National Schizophrenia Fellowship, in a joint venture with Dorset social services, Dorset Healthcare NHS trust and the Western Challenge housing association. The family atmosphere that its dedicated staff provide, with the support of a very caring GP, Dr. Chris Williams, in which all the residents are encouraged to participate, represents a happy contrast to their experience in hospital, where there appeared to be no time to listen to their needs and problems, and where medication was the means to keep them quiet.
Charles house is proof that community care can and does work for the mentally ill. Only the establishment of a comprehensive network of such long-stay, short and medium-stay hostels, sheltered homes or homes based in each district throughout the country for the mentally ill to be treated and cared for, ideally close to friends and family, will ensure the success of the care approach, provided that such care is backed up by an adequate number of hospital beds.
Although I am aware that my right hon. Friend the Secretary of State will approve hospital closures only when she is assured that adequate community care is already in place, what continues to concern me, and also the fellowship, is the apparent lack of co-ordination and monitoring of the discharges from hospital beds to care beds.
According to the House of Commons Library research paper on the Bill, between 1981 and 1991 the number of beds for mentally ill people in English hospitals fell from 85,000 to 50,000. In the same period, the number of day hospital places increased from 15,300 to 22,500. How can we be sure, however, that the balance of the 27,800 discharged patients are being properly accommodated in non-hospital, residential beds in the community? How can we be sure that they will not fall—or have not already fallen—through the net of care, although it is the statutory responsibility of the health and social services departments to provide for them?
That brings me to the principal concern of the National Schizophrenia Fellowship in regard to the Bill. I attempted to reflect that concern in early-day motion 1214, which was signed by many hon. Members on both sides of the House. The fellowship fears that, because the Bill provides for no new funds apart from those for an increased number of mental health review tribunals, it will not succeed in its purpose, but will divert existing resources to the supervision of "revolving-door" patients at the expense of others who are just as severely ill or who are voluntary patients.
My hon. Friend the Minister will probably say that what is proposed is merely a statutory extension of what should be existing best practice—for example, the existing guardianship arrangements, which are little used—and that his Department is issuing guidelines and advice on what good practice should be.
The fellowship points out, however, that the legislation requires involvement with no fewer than eight different professionals and non-professionals at six-monthly intervals as after-care under supervision continues—not to mention any extra consideration if changes are proposed, 180 or discussions with housing agencies, day centres and the like. All that will require more staff time, which must be properly resourced.
Moreover, although the Bill provides for the cost of the additional number of tribunals, it does not appear to provide for the cost of the additional time required for psychiatrists and social workers to prepare reports for the additional tribunal hearings. The Ritchie report recommended new funding for specialist psychiatric teams to supervise discharged patients needing intensive after-care.
Without such extra resources, the Bill will undoubtedly result in a reduction in staff time and other resources for patients who are not subject to after-care under supervision, but who are still severely ill. That is bound to make those patients a risk to others—as well as to themselves, through self-neglect or attempted suicide—and will only add to the number of those needing care under supervision. In other words, without extra resources, the Bill could prove counter-productive and self-defeating, rather than fulfilling its intention of making the community safe for patients and making patients safe in the community.
I have a second reservation, which has already been voiced by a number of speakers. I believe that the Bill is no substitute for a fundamental review of the 1983 Act. I was a member of the Standing Committee that scrutinised that legislation; it was one of those rare Bills that are subjected to the Special Standing Committee procedure, which allowed us to invite representations and to question experts. In my view, the eventual Bill was all the better for that, and I am sorry that most legislation is not subject to the same process: I think that, if it were, it would be better legislation.
The 1983 Bill was enacted at a time when patients were treated in long-stay residential settings, and is no longer relevant to today's approach to care. We cannot ignore the case of Stephen Laudat, who stabbed a man to death having previously refused to take his medication, and had declined psychiatric follow-up treatment; nor can we ignore the Blom-Cooper inquiry into the case of Andrew Robinson, which called for powers to allow compulsory treatment for patients who decide not to comply with their recommended care programme.
I hope that, when the Minister winds up the debate, although he has already told us that he has an open mind about a review of the 1983 Act, he will tell us whether he accepts the recommendation of the British Medical Association that appropriate safeguards should be in place, and that compulsory treatment should he imposed only when patients pose a serious danger to themselves and others. I hope that he will give some thought to what the safeguards should be.
§ Mr. Archy Kirkwood (Roxburgh and Berwickshire)
I remind the House and the hon. Member for Bournemouth, East (Mr. Atkinson) that it is a mistake to make too powerful and perceptive a speech in the hearing of a member of the Committee of Selection. As the hon. Member for Worcestershire, South (Mr. Spicer)—who also made an interesting speech—was not present to hear the argument of the hon. Member for Bournemouth, East and the answer to his question about resources, I propose to ensure that both of them are selected to be members of 181 the Standing Committee. Indeed, I might appoint myself to the Committee so that I can watch the fun as the argument between them develops. I shall include the Minister as well, just so that he does not feel left out.
Like the Minister, I hope that the Bill can be discussed on a non-party political basis, as it was in the House of Lords. I do not think it necessary to be politically partisan. I was encouraged by the sensible and rational speech that we heard from the official Opposition spokesman—
§ Mr. Kirkwood
No, it is not surprising, but I have heard one or two Opposition Front-Bench speeches in my time.
I am sure that the Bill, and the work of the Standing Committee, will be the better for that non-partisan approach, although I feel that it should really have gone straight into a Special Standing Committee. I endorse what the hon. Member for Bournemouth, East said about the Special Standing Committee procedure that was used in the case of what became the 1983 Act. I do not know why the Government have set their face against that procedure; perhaps the House of Lords was considered a substitute for a Special Standing Committee, but I do not think that it was. Legislation such as this would be much better framed if we had direct access to the views of the National Schizophrenia Fellowship and other pressure groups, although some views have been expressed adequately to hon. Members in writing.
I pay tribute to the work that the hon. Member for Bournemouth, East has done for many years. Schizophrenia is a terrible illness. We have all read case histories that tell of the destruction of families who have tried to deal with the condition. I accept that it is difficult for the Government to respond, and I therefore think it important for us to do what we can on a cross-party basis to get the legislation right.
On a slightly carping note, I want to raise a procedural matter. As a Scots Member and, in a previous incarnation, a humble provincial solicitor—none of the big silk hankie brigade for me—I feel that we must rid ourselves of a certain habit. I address my complaint to the Under-Secretary of State for Scotland—the hon. Member for Edinburgh, West (Lord James Douglas-Hamilton)who is seated diligently in his place. We must stop mixing Scottish and English legislation: it is fiendishly difficult for practitioners who are trying to disentangle Acts of Parliament to find Scottish legislation in unified United Kingdom Bills, because the legal systems are so different. The powers of the sheriff and the rules of guardianship are substantially different.
I understand that there are problems with finding enough compos mentis Scottish Tory Back Benchers for Standing Committees. The Under-Secretary of State for Scotland disagrees, but I know that there are difficulties. When the Government decided to move on this matter, they should have introduced two separate pieces of legislation. I hope that the Bill will be the first step towards a proper review in the new atmosphere of the whole framework of legislation in this field. I say that in passing because the point was made adequately earlier in the debate and I tried to make it in an intervention. The Minister said that he has an open mind. Ministers always 182 have open minds. I am grateful for small mercies and take that response at face value because I know that he is genuinely concerned. I hope that his open mind will focus on getting the legislative time that he needs for the fundamental review for which the whole House appreciates the need.
These are difficult matters. Clunis and Silcock and the other events that have been mentioned, all of which were individual tragedies, give a heightened, almost hysterical, background against which we have to try to deal with this intractable problem. By far the biggest problem concerns mentally ill patients who damage themselves, commit suicide or leave themselves in terrible positions which destroy their families. When contemplating legislation, we must put in the balance not just the cases that get the headlines; we must also address the desperately distressing cases of neglect and worse among the mentally ill.
Resources are an important part of the argument. If there were adequate facilities for after-care, housing, employment, training and recreation, the problem would not be nearly as bad, particularly in inner cities. I do not have any special expertise in that respect because mine is a rural constituency, but the problem is bad enough there. I know that my colleagues, who know about these things and have studied them in more detail than I have been able to do, are concerned about the lack of facilities in areas such as central London. That must be dealt with.
Some of the representations that all hon. Members have had from the British Medical Association, the Association of County Councils and some other bodies such as the National Association for Mental Health and the Scottish Association for Mental Health cannot but cause concern about alleged omissions and anomalies and the Government's lack of a proper and systematic approach to this problem. When the Bill is in Committee, we will have to address some of those problems as best we can.
I think that the Scottish Affairs Select Committee's report is due almost any day now. It is currently preparing a report on the problems associated with the closure of psychiatric institutions in Scotland. I hope that the report will not be ignored by the Standing Committee and that any conclusions reached by that important Select Committee will inform the work of the Standing Committee, certainly in relation to the Scottish sections of the Bill. I would not like to think that it was too late to weigh the Select Committee's conclusions in the balance of arguments in the Standing Committee.
More than anything else, resources must be taken into account. I hope that the Committee will have an opportunity for sensible discussions about that. There is obviously a good deal of difference between the Government and the Opposition parties about the increase in resources that has occurred, how the money has been spent and whether it has been put to proper use. It would be in the public interest for the Committee to try to get to the bottom of the statistics and to establish how they work out in practice.
If I heard him correctly, the Minister estimated that there are about 20 cases to which supervision orders might apply in each health authority area. That figure is new to me. I found it difficult to discover how many people the Bill would affect. I assume that the figure relates to England and Wales. It is very small. Is it a firm figure? I 183 know that there is uncertainty about statistics and I shall happily give way to the Minister if he would like to clarify the matter.
The figure that I gave was the estimate of an average for each district health authority. A figure of about 3,000 nationally has often been quoted and when that is divided by the number of health authorities the result is about 20. The figure would obviously depend on each health authority, the practice of individual clinicians, decisions by psychiatrists and facilities that are already in the community. My figures are no firmer than that, but I thought that they were helpful in terms of the scale of the operation.
§ Mr. Kirkwood
I appreciate that helpful intervention. If the Minister had not made the position clear, I could have set off in a spurious direction. The figure could mask substantial discrepancies between inner-city areas and other parts of the country, but I am grateful to the Minister for his clarification.
The Committee will also have to look at co-ordination. I am not convinced that the Bill does anything like enough to get appropriate co-ordination between the various agencies. I am on the parliamentary panel of the Royal College of Nursing and try to work with it, obviously on an honorary basis. It is worried about the extra resources that might be needed to get properly trained mental health nurses, give them further training and deal with the increased work load if the Bill reaches the statute book.
There are a number of detailed questions I should like to ask, but it would not serve the purpose of the House to go through them at length. I am still a bit sceptical and have not yet formulated a final view, but as the Committee's deliberations proceed I shall be interested to see whether a purely legal approach of this kind is the right way forward. Some people say that such an approach is not right and that we should go for a better resourced, administrative solution. The Committee may want to turn to that. There is a real worry that the new supervised discharge system that we are considering will not sit all that comfortably with community care—certainly not in Scotland. The term "community care order" is a misnomer and the Committee should spend some time considering whether it is the right name. Community care orders are driven by psychiatrists; care in the community should be driven by social workers. There could be a great deal of confusion if we do not get these matters right at the beginning.
I think that it was the hon. Member for Greenock and Port Glasgow (Dr. Godman) who asked about the powers that are to be made available to sheriffs. There is real concern north of the border that the powers given to sheriffs are indeterminate and too vague. I am still unclear about the extent to which the Bill will affect children and young people. I do not think that it can north of the border because they will be subject to the panel procedure, although it will affect young people in England and Wales, but I am not sure about that.
Does the Bill apply to people with learning difficulties? Questions such as that cause me concern but they may be clear to the Minister. There is enough confusion in people's minds for it to be important to use the Committee to clarify some of these matters. The Minister was kind enough to refer to my noble Friend the fifth Earl Russell who is no less a person than the author of a book entitled 184 "The Crises in Parliaments, English History from 1509 to 1660". I am unlikely, therefore, to controvert anything that my noble Friend says.
This is a good Bill, but it is not perfect. I am persuaded by the argument in the reasoned amendment but, if we support it, it will not be because we are totally and implacably opposed to the principle of the Bill, as the hon. Member for Newcastle upon Tyne, East (Mr. Brown) said, but because we think that much work will have to be done in Standing Committee to get the Bill right before it goes on to the statute book.
§ Mr. David Nicholson (Taunton)
I welcome the Bill for what it contains and points to, but in particular I welcome the opportunity that it gives us—here I echo the thoughts of the hon. Member for Roxburgh and Berwickshire (Mr. Kirkwood)—to reconsider, analyse, discuss and debate the care in the community system as it affects people with severe mental difficulty. Naturally, I regret that the Opposition have moved an amendment and will be dividing on Second Reading, but I welcome much of the speech by the hon. Member for Newcastle upon Tyne, East (Mr. Brown), as I welcome that of the hon. Member for Roxburgh and Berwickshire, who spoke for the Liberal party.
I was especially glad that the hon. Gentleman echoed a point that the National Schizophrenia Fellowship has made: although the few cases where severe mentally ill people, often suffering from schizophrenia, have attacked and occasionally killed members of the public—which have been accompanied by sensational publicity—may have triggered the legislation and concern, alas, less attention has been paid to the mortality rate of people with schizophrenia, which is estimated at twice that of the general population, mainly because of suicide. Through our families, friends and constituencies, we probably all know individuals whose lives, even in recent years, have had a tragic end in those circumstances.
In addition to the direct interest of families and neighbours of people who suffer in that particular way, there is a much wider interest in us getting the system right. Even now I hear, in letters or in conversation—although I am glad to say that it is less frequently stated—"This is all a disaster and completely wrong. Wouldn't it be better to have these people incarcerated in those Victorian buildings out in the countryside?" That attitude is wrong, but Parliament and all the people involved in operating the care in the community system must constantly work to assure the general population that the new system, which is very recent—it came into practice only two or three years ago—is the right way to deal with these matters and does provide proper protection for the safety and amenity of the general population, as well as being in the best interests of patients.
My interest in this subject has increased from, I must confess, near zero when I was first elected, largely through discussions with interested constituents, whether they be doctors, nurses, practitioners, the families of patients, or the small group that the National Schizophrenia Fellowship has established in my constituency and, I hope, in many other constituencies. Regular meetings are held with practitioners, families of sufferers or sufferers themselves. I have been grateful to have been invited to some of those discussions to talk in 185 a calm and measured way about the concerns that those people have. I have been grateful for the insights that that has given me.
If we intend to use—and I think that we will—the Standing Committee to probe and to explore this matter, of course we will depend on those outside organisations to help us with briefing and raising questions. My hon. Friend the Member for Bournemouth, East (Mr. Atkinson) may recall that we were reminded of that some weeks ago. Parliament, especially when it considers a Bill in detail, cannot operate in an ivory tower, separate from what happens outside. We are anxious, through certain other matters that are being considered by people in high office, properly to regulate the way in which outside interests—they may be economic and commercial, but often they may be caring institutions and organisations—influence and inform our procedures here and to make progress in that respect.
I have been personally involved in some cases in my constituency. In one case, I took part in having someone, alas, sectioned. In others, I have tried to ensure that schizophrenia sufferers were properly looked after when their families were convinced that they were not taking their proper medicine. Like the hon. Member for Blyth Valley (Mr. Campbell), I am a member of the Select Committee on the Parliamentary Commissioner for Administration—the parliamentary ombudsman—who also acts as the health service commissioner. The Select Committee has had cases before it—I mentioned one in a debate on the parliamentary ombudsman just before Christmas—where it has been shown that the system has not worked. It is vital that we take what measures we can to minimise those occasions where this cumbersome system has not worked, involving practitioners from various specialties.
I am interested in the passage in the Opposition's amendment about Government Departments coordinating. Of course it is vital that Government Departments, local authorities and, if necessary, the police and various other bodies should properly co-ordinate. When something goes wrong, it is vital that individuals in a community get together to put it right as quickly as possible. I hope that, as the Bill proceeds, we will consider how that works.
My wife is president of Taunton Mencap; that is a slightly related matter. I am glad that the Prime Minister's wife and the Prime Minister himself take a great interest in that charity. I am particularly pleased to say that both my hon. Friends the Under-Secretary of State for Health and the Under-Secretary of State for Scotland, who will be responsible for the Scottish aspects of the Bill, are excellent Ministers. I knew them both long before they entered the House—indeed, I have known them for more than 30 years, so I could not believe that this matter would be in better hands.
§ Mr. Menzies Campbell (Fife, North-East)
Do not say that, they will put it in their election address.
§ Mr. Nicholson
I do not know what election address the hon. and learned Member for Fife, North-East (Mr. Campbell) is talking about.
Before I discuss some of the concerns that have been raised, I shall refer to some of the successes that the local services, including the Avalon, Somerset national health 186 service trust, have had. This might be nearer to the election address to which the hon. and learned Gentleman referred. It is well known and, I think, my hon. Friend the Minister will recognise that Somerset was one of the relatively few regions where co-ordination and co-operation between the health authority and county council social services were of such excellence that Somerset was ready to go ahead with care in the community at the earlier date envisaged by the Government. After care in the community was finally set up, it progressed extremely well in Somerset. I salute all the people who have been responsible for that in the local community.
I shall give the House some figures to show how progress has been made in past 10 years. In 1985, the number of Somerset hospital beds for mental health was 746 in six locations and the number of day places was 97 in four locations. Ten years later, the figures had changed to 382 beds in 21 locations and 413 day places in 21 locations, with community mental health teams working with social services, primary health care teams and the voluntary and private sectors to ensure that people had a range of options for dealing with their mental health problems, bringing them into the community, which is the purpose of the exercise. In the past year, occupancy levels for hospital beds averaged 81 per cent., ensuring that it was always possible to find a bed in Somerset if one was needed. One may not have been available at the nearest unit, but a bed has always been available.
Another important factor that reflects the massive changes that have taken place is the closure of large Victorian institutions. Tone Vale, in the middle of my constituency, closed in March, and a housing estate and other facilities will be developed on the site. I have visited the new units at Rydon house and Pyrland house for mental health patients and other people needing care, and I was most impressed by the work that went on there.
Over the past three years the proportion of staff employed in direct patient care has increased by 3 per cent. as a consequence of the changes in service delivery—mainly because of a reduction in estate staff and others needed to maintain large obsolete buildings, and an increase in nursing and medical staff. However, I am told that there is still a problem with the number of consultant psychiatrists and junior medical staff available to cover a community-based service.
Although the closure of large hospitals has reduced the number of beds, the value of the estate employed in the care of mentally ill people has increased considerably. In 1993 that estate was valued at £14.8 million; in March 1995 it was valued at £28 million. The buildings are now purpose-designed, with low maintenance costs, and are liked and valued by users of the service. That shows the practical way in which changes have taken place in Somerset.
My hon. Friend the Member for Bournemouth, East referred to some of the concerns raised by the National Schizophrenia Fellowship, and I simply echo some of those. A small minority of people, perhaps about 3,000 of them, are never offered appropriate care or reject it. That can happen because the services do not exist, or are not co-ordinated, or because they concentrate on those who are easier to work with. But it can also happen because the patient is suspicious of everyone, has lost all motivation and stays in bed all the time, or dislikes the services offered or those offering them—those are 187 common features of schizophrenia. Or the patient may be too ill or too disorganised to keep appointments or to take prescribed medication. The NSF says that that is the group of patients whom the Bill aims to help.
The NSF also says, and my hon. Friend the Member for Bournemouth, East reiterated, that the Bill requires involvement with no fewer than eight professionals and non-professionals at six-monthly intervals—more often if some change is proposed—through requirements either to give information or to consult patients. Staff time costs money, so there will be costs there.
Indeed, I have just received a letter from the director of social services for Somerset county council saying that revenue support grant needs to be increased to allow for the growing pressures and for capping to be relaxed. We debated capping last week, and Somerset's experience is somewhat happier than that of some other counties. Nevertheless, the director says that capping needs to be eased in line with the new demands, because for more and more people the promise of community care will not be satisfied unless that happens.
Finally, I shall develop the argument about resources in a wider sense. I heard the Minister say that, as a Minister, he did not want to widen the issues, but when we talk about care in the community wider issues inevitably crop up.
§ Mr. Deputy Speaker (Mr. Michael Morris)
Order. I do not wish to anticipate what the hon. Gentleman intends to say, but I hope that we shall not hear about revenue support grant, capping, area cost adjustment or any of those aspects.
§ Mr. Nicholson
I am happy to say, Mr. Deputy Speaker, that I have finished talking about those matters.
I hope that the Minister will continue his work on the resource aspects that arise when elderly people need geriatric care in private nursing homes. That is a big issue facing us now, and although the causes are not the same, the problems that those people have are not very different from the problems of the people with whom the Bill attempts to deal.
Secondly, referring also to people with mental difficulties, I wish to raise the problem of the people whom we see on the streets of our large cities, especially London, begging and sleeping rough. Many initiatives have been taken by the various Departments responsible for helping them. I know that they are generally described as "the homeless", but we all know that homelessness is not their main problem. Some suffer from drug abuse, alcohol abuse or other forms of abuse.
I recall what was said about the state of mental health services in London and the south-east. Many of those people have mental difficulties, and I should like to impress on the Minister the need for all responsible Departments to co-ordinate action effectively so that those people, whom we now see every day and every night, are dealt with and helped. A sight that is becoming offensive to many of us could then be removed.
With those provisos, I welcome the Bill.
§ Dr. Jeremy Bray (Motherwell, South)
Undoubtedly new legislation is needed, but this is not the Bill with which many Opposition Members would have chosen to start. However, it could be substantially improved in 188 Committee, and I hope that when we reach that stage the Minister will be as open minded as his colleagues were in the House of Lords.
The Bill is not about improving the delivery of community care services for the great majority of mental health service users. As at present drafted it is essentially about the control and containment of the severely mentally ill. I do not underestimate the importance of that need, and I attach particular importance to what was said by the hon. Members for Taunton (Mr. Nicholson) and for Bournemouth, East (Mr. Atkinson) when they paid tribute to the role of the National Schizophrenia Fellowship, many of whose members strongly support the Bill and say that it is much needed.
The Bill is about the control and containment of a small proportion of the mentally ill who have been "sectioned"—that is, detained under sections 3 or 17 of the Mental Health Act 1983 or the equivalent provisions for Scotland. The Government introduced it in response to some distressing incidents of violence. However, as several hon. Members have said, the number of people injured or killed by the mentally ill is tiny compared with the number of deaths caused, say, by road accidents, or even by drunken drivers alone. The person most likely to be injured—sadly, all too often fatally—is the mentally ill person himself.
The best that can be said of the Bill is that it could be significantly and usefully amended to stimulate the development of services appropriate to the needs both of those who have been formally detained and of others.
The representations that have been submitted to the all-party mental health group, of which I am proud to be chairman, all emphasise the importance of involving the users of mental health services in their care plans. There is little of that in the Bill as originally drafted, although, as the Minister said, amendments made in the House of Lords have improved the emphasis on informing patients and, if they consent, their closest relative—and, to a more limited extent, their informal carers, to whom in practice so much of their care devolves.
However, much more could be done to amend the Bill so that users could be more fully involved in their care plan programme. The benefits are genuine. Obviously, a user's consent makes the life of the mental health worker or social worker easier. But in a more profound way, involving the user in his or her care plan improves the effectiveness and appropriateness of treatment. It can build a therapeutic relationship and gives the user more control and a better incentive to recover.
Involvement is a key concept in a number of recent reports, including Department of Health reports such as "Advocacy—a code of practice", "Black mental health dialogue—a dialogue for change", and especially "Guidelines for a local charter for users of mental health services", which was produced by the mental health task force user group of the national health service executive.
The Mental Health Acts of 1983 and 1984 placed on Ministers a duty to draw up, after consultation, a code -of practice for mental health workers; to lay it before Parliament and to update it regularly. In England, the code of practice has been recently updated; the Scottish code, first published in 1989, still awaits its first revision. Both codes will need to be revised in the light of the Bill. I hope that the Minister, in replying to the debate, will be 189 able to tell the House that consultations will start soon and will involve user groups, as well as those who deliver the service.
There is a point that is not dealt with in the Bill and I hope that the Minister will carefully consider it. In parallel with the code of practice, there should be a new duty laid on Ministers in Scotland and in England and Wales to provide a charter for mental health users. When I say "a duty on Ministers to provide a charter", I am well aware that the guidelines are for a local charter for users of mental health services.
It is interesting that in the model charter that is provided, only two lines make provision for local input—the names of people to whom resource can be had. There are, nevertheless, local factors which, if they could be taken into account effectively in so many different situations, would clearly be helpful.
In the report, a user commented:Much work is needed on general care of the patient. Even basic care like bath, shampoo, shave, dental care, clean clothing is being neglected.I doubt whether that is the case in Taunton, but certainly it is in Brixton.
Another user commented:Black patients, and other patients from minority groups, feel isolated with their illness, doubly, because their opinions and cultural needs are overlooked. For example, native food and drinks are not seen as important. Roots food, tonic remedies, herbal treatment and therapeutic massage are sources of alternative care that must be considered.The perpetual cry from every user organisation that is ever consulted is echoed by this comment:Emergency care is needed out of hours to talk and defuse situations, not just medication. It is wrong that the police should be involved".If there were a duty on Ministers to provide a charter for mental health users, it would be perfectly possible to provide for local additions to it dealing with the sort of problems that I have outlined and being specific about the channels of access to those resources.
An enlightened code of practice would, of course, interact with the charter and could help to change the climate of mental care and—I hope that this is still regarded as important—safeguard the civil rights of the mentally ill.
The Bill should require that each time a patient is informed of a supervision order or of changes to a supervision order, he should be given a copy of the charter and have its provisions explained orally. Likewise, the patient's closest relative and his or her informal carer should be fully informed. Those are the people who are crucial to the patient's well-being and their involvement is vital.
Some would query whether the persons sectioned are the right client group to involve in a charter for mental health users. I would argue that it is necessary to start with them. Patients who have been sectioned are not necessarily the most violent or severely or chronically ill, or even the most disturbed. They are simply those seen by doctors or social workers as liable to endanger others or themselves.
In its operation, sectioning is a rather arbitrary act. Some people have been sectioned for one brief, traumatic breakdown and live the rest of their lives without any sign 190 of mental instability. Some may be sectioned during one episode of illness and not the next. For others, the illness is a long-term problem with, perhaps, repeated admissions to hospital. They may sometimes be sectioned and sometimes not. The consultant's attitude, rather than the severity of the illness, may be the determining factor.
It is right to involve the users precisely because they are the people who in hospital are deprived of their liberty and to whom the Bill relates. They, above all, merit the sort of respect, involvement and empowerment that the charter for mental health users offers.
Users, above all, need appropriate treatment. The Bill says a good deal about appropriate things but little about appropriate treatment. The charter is not an easy option and it would be a way of giving practical effect to appropriateness of treatment which, at present, is not covered in the system.
In giving people rights, we also place on them responsibilities. The task of keeping well is very difficult for many people whose lives are shot through with mental illness. It is a serious matter. I hope that the Mental Health (Patients in the Community) Bill can be so amended as to help formerly detained patients to keep well and maintain their dignity and self-respect.
§ Mr. John Marshall (Hendon, South)
I apologise to the House for not being able to attend the beginning of the debate. Some hon. Members may know that the Prime Minister was addressing a meeting of the Conservative Friends of Israel. As an officer of the CFI, I thought it only right and proper to be there.
I should like to declare an interest. I am a member of the advisory council of JAMI, the Jewish Association for the Mentally Ill. The advice comes from it to me, rather than from me to it. I pay tribute to the work that that wonderful charity does and emphasise the difficulty that it faces, from time to time, because some local authorities take advantage of its services but refuse to pay anything in the way of a contribution towards the cost of providing those services.
Like my hon. Friends the Members for Bournemouth, East (Mr. Atkinson) and for Taunton (Mr. Nicholson), I should like to pay tribute to the work of the National Schizophrenia Fellowship. It was one of the first groups that I saw after I was elected in 1987. The stories that I was told by individual parents underlined the difficulties that were being created by the care in the community policy.
I went up to one member and asked, "What is your problem? Who is affected? Is it your daughter or your son?" She said that her daughter was schizophrenic. I asked where she was and she told me that her daughter was sleeping somewhere on a park bench in London and that she did not know where she was. That was typical of the problems that I heard about. It was not a unique situation.
One of the tragedies of mental health in London is that many of those who sleep rough in London are people who were sent out of mental hospitals to be treated in the community. They have ended up with a quality of life that is substantially poorer than that which they once enjoyed. There was another case I saw that evening of a lady who was concerned about the treatment that her son was 191 receiving from psychiatrists. Unfortunately, despite many letters, the psychiatrist did not listen and, last year, the boy committed suicide.
One of the problems, and one with which the Bill seeks to deal, is that many of those who are released into the community refuse to co-operate with the treatment that is suggested for them. Their medication is unpleasant and it is very difficult to tell patients that they are sufficiently well to go into the community but sufficiently ill to need to carry on with their treatment. All too often, the result is that they say, "Yes, we are well enough to go into the community, therefore we are well enough not to have this rather unpleasant treatment." The result of that is that they become violent, lose their friends and end up in a different form of institutional care. It is quite wrong that people should be released into the community from an institution that is caring for them and then end up in prison as a result of committing some crime.
The Bill is obviously going to help deal with that through the concept of supervised discharge. However, I believe that that must be viewed as part of a package because for too long, the mentally ill have been the Cinderella of the health service.
In all these great issues, the pendulum swings too far one way and then too far the other way. In the 1940s and 1950s, it was far too easy to have someone admitted to a mental hospital. The Victorian asylums were too large and too impersonal, but unfortunately society, in a crisis of conscience, went from one extreme to the other. In the revulsion against our history in this matter, we have gone on to make different mistakes. The fact that too many people were admitted to mental hospitals led to a failure to recognise that many who would be released into the community might be better off in an asylum which, traditionally, is a place of care and rest. The fact that the Victorian institutions were too large and too impersonal led to a failure to recognise that smaller hospitals might be necessary.
In 1961, Enoch Powell decided to close all the large mental institutions by 2000. There is no doubt that the Treasury was seduced by the capital receipts that it anticipated and that it believed that care in the community might become a cheap option. The Treasury did not realise, however, that care in the community, if it is to be done properly, is more expensive than hospitalisation because it requires a lot of investment in training and people. Care in the community is labour intensive and cash intensive; that was not recognised by the Treasury or by others in the beginning.
Whatever the situation may be in sunny Taunton, there is no doubt that in London and the south-east, we suffer from a lack of beds for the mentally ill. All the evidence is that there is an inadequate number of beds for the mentally ill in London and the south-east. It is also the case that in London and the south-east, we do not have sufficient psychiatric nurses to deal with the number of schizophrenics we have. A third of those needing psychiatric services in London are homeless. That underlines the problems, which the Department and my hon. Friend the Minister recognise.
Those who say that the supervised discharge offends against individual civil liberties do not hit the right point. First, it is a paradox to say to someone, "You are sufficiently ill to need treatment, but you are sufficiently sane to recognise the fact that you need treatment and to 192 say that you will undergo that treatment." A small number of people do not recognise that fact and then cause problems for themselves and for others.
Secondly, many of the relatives of those who will be affected by the Bill are praying for it to become law because of the traumas that they suffer when they see their sons and daughters not responding to treatment, when they know that their children are sleeping rough in London and not having the treatment that they need. I suggest that anyone who talks about civil liberties should talk to the relatives of those who will benefit from the Bill; they will get a very rough answer. The relatives worry the whole time whether their sons or daughters will commit suicide, they worry about whether they will become violent towards an innocent individual and they worry about their quality of life. For some who are released into the community, the quality of life is little more than a scandal.
The other civil liberty to be considered is the civil liberty of an innocent individual who may be harmed if we do not have the power of supervised discharge. There is no doubt that a number of murders have taken place—a relatively small number perhaps, but one unnecessary murder is the denial of someone's civil liberties and there is no greater liberty than the freedom to live. We are dealing, however, not only with the civil liberties of those who are killed by people who are not taking treatment.
Let us face the fact that there are many schizophrenics who have been released into the community and who then commit suicide. The official figures show that there were 266 suicides in three years, but that severely understates the number. There is a reluctance on the part of coroners to say that someone took his own life because some people have a religious revulsion at the thought of suicide. Sometimes there may be insurance policies which will not be honoured in the case of suicide and it is not unknown for the coroner to take that fact into account.
There are many people whose civil liberties will be affected if we do not pass the Bill; we must bear that in mind. I very much hope that the Bill will pass speedily through its Committee stage. The hon. Member for Roxburgh and Berwickshire (Mr. Kirkwood), who is a member of the Committee of Selection, is present this evening. I volunteer to be a member of the Standing Committee; we have had three volunteers already this evening, which means that we may have a relatively short Committee stage. I hope so because the Bill is important and will benefit part of our society which has been neglected for too long.
§ 6.5 pm
§ Ms Ann Coffey (Stockport)
The Bill provides for the after-care supervision of patients who have been subject to treatment or hospital orders. As some of my hon. Friends have already pointed out, there are concerns about how the after-care supervision will be implemented and by whom, and there are issues about the role of the supervisor that will be considered carefully in Committee.
The supervision orders will apply to a minority of patients whose illness is chronic—patients whose behaviour may place them at risk or may place other people at risk. It is right and proper that we should be concerned about those patients. The intention seems to be twofold. First, it is to secure for a patient after-care services, which will be provided under section 117 of the 193 Mental Health Act 1983. Secondly, supervisors will have to ensure that patients attend for treatment, occupational therapy, education, training or whatever—a wider policing role.
As the Bill explains, there should be no additional cost for health authorities and local authorities. However, after-care services self-evidently require resourcing, so it is hardly surprising that the Bill is viewed as legislation that emphasises the social policing role of social workers and health workers. They are the people at whom the finger can be pointed when something goes wrong, enabling the Minister to wash his hands of any responsibility to provide resources for them to do their jobs. As the Minister is aware, even social policemen need resourcing.
Before the Minister asks where the resources will come from, I point out that when the trusts were set up in Stockport, the taxpayer had to pay for a £1 million increase in the salary bill. If I am asked where extra resources for mental health care should come from, I can say that they could easily come from the administrative costs resulting from setting up the trusts. One million pounds would have gone a long way towards helping mentally ill people in Stockport; unfortunately, they did not get that money.
Mental health is the Cinderella of the health service for a number of reasons. There is, unfortunately, a great deal of fear among some of the population who regard all mentally ill people as exceedingly dangerous. That is far from the truth. Many mentally ill people face sad and painful lives with great courage—more courage than the rest of us may have. Mental illness can also he a source of shame and embarrassment for those who suffer from it because their difficulty in coping may be seen as a mark of failure.
I do not know the exact figures, but I know that a high proportion of the population will suffer an acute period of depression or a disabling anxiety episode in their lives. Most will recover hut, sadly, some will not. Stress at work and at home, when communities have become less supportive, has increased the likelihood of breakdown in the general population. For some, schizophrenia and recurring psychoses are totally disabling. The high proportion of such people among the homeless is a sign of their ultimate fate and shows what community care has brought for them.
There is not a magic division between mental health and mental illness. Death, redundancy, mental breakdown and other crises can bring even the strongest of us to the brink of disintegration. Perhaps the fact that vast investment has gone into bringing about technological changes, while we are unable still to heal a traumatised child or return to health a schizophrenic person reflects our priorities as a society. In the absence of such help, it is crucial that resources are available in the community and hospitals to offer care and support for those who may never get better and also for those who, with help, can overcome their difficulties.
Resources such as day provision, acute beds, long-term beds, community nurses, social workers, funding for self-help and support groups, carers and supported employment are all necessary for an infrastructure of community care. In reality, that infrastructure is not there. Since the closure of long-stay hospitals and the transfer 194 of beds to local district hospitals, often hospitals cannot fulfil conflicting needs for beds. Over the past five years, there has been a 30 per cent. increase in the number of patients admitted to hospital under the Mental Health Act 1983. Unfortunately, the shortage of resources means that beds have not been available for voluntary patients or hard-pressed relatives who require respite care.
Indeed, I recently had to take up an issue concerning that very problem on behalf of one of my constituents. My constituent was informed by the hospital that as 42 per cent. of the beds at that time were occupied by people under compulsory admission, there was not—unfortunately—a bed for someone who was exhausted by having to cope with a husband who had a long-term mental illness.
Against that background, my concern is that, with no new resources being made available for wider community care, staff time will be taken up with implementing supervision orders. That will mean fewer community nurses available to support people such as my constituents. Without such valuable help, more families will be stressed, there will be further diminution of community care and it will be more likely that the health of people will deteriorate to the point at which they will have to be admitted to hospital. If services were available earlier, some of that illness could be prevented.
Where are the after-care resources to come from? We are talking about suitable housing, because we cannot just dump somebody in the community. Often much work has to be done with neighbours, who are sometimes very hostile to mentally ill patients. All that requires staff time. Day centres require money, but it is very important for patients to be able to attend them to talk, receive support and get help. Community nurses are invaluable—we need more of them. Where are they? Support for employment is also vital.
All those provisions are necessary in identifying and providing after-care services for patients on supervision orders. After all, good-quality after-care services are those that the patient needs, and they cannot be provided by trying to fit the patient into the available after-care services. Such a mismatch leads to coercion in the supervision order, when patients know that they are going somewhere that is not able to meet their needs, while being told that there is not an alternative.
If resources are to be pooled to meet supervision orders—no new resources are being made available by the Government—what will happen to the other mentally ill people who need help? It is all very well talking about targeting resources—if they can be prioritised—but mental illness covers two groups of patients with different needs. People with long-term psychiatric problems will need on-going help, but the illnesses of patients with acute problems can be prevented from getting worse, with help when they need it. Both those groups need prioritising. I am concerned about the latter group, because those people will not receive the necessary services, which will inevitably lead to the development of longer-term illnesses.
The Minister is right to be concerned with those who trouble society—we are all concerned about that—but he should also be concerned with those members of our society who are troubled. He should seek ways in which to help and support them. He should take this opportunity to tackle the problems of mental illness on behalf of all those who suffer from it. At the end of the day, it is they who bear the burden.
§ Mr. Mark Wolfson (Sevenoaks)
I shall not need to detain the House for very long because a number of points that I would have covered in more detail have been most adequately and effectively dealt with by my hon. Friend the Member for Hendon, South (Mr. Marshall), whose speech was a model contribution towards the sensible passage of the Bill. He was speaking from obvious experience of the families of severely mentally ill people, and the Bill specifically addresses the concerns of such families and patients.
I have always taken the view that the decision to close rapidly all the large mental hospitals was in some ways wrong. We should have moved rather more slowly. Although I accept that at the end of the day care in the community is more beneficial than those old asylums, nevertheless such institutions provided a level of care for very sick people which was of real value to them. We all carry a heavy responsibility for cases where the quality of people's lives has worsened.
I appeal to my right hon. and hon. Friends to move with extreme care in future closures and to ensure that the facts live up to their commitments; that they will not implement such closures until adequate care is available in the community. There is nothing in itself wrong with residential care and we should not forget that. Often it is right for people who are severely ill.
I cannot support the Bill, let alone vote for it tonight, without signalling the fact that I find the wording in the Bill on financial effects unrealistic. It says:The Bill should give rise to no additional costs for Health Authorities (in England and Wales), Health Boards (in Scotland) or local authorities. The new provisions … provide a legislative framework for existing good practice.In the purest terms, that may be right, but we should talk about reality and practicalities. If more social workers and all other agencies involved are doing a better job under the supervision orders, their time will be used for such work and, as other hon. Members have said, there will be less time to deal with less severely ill people. Therefore, I argue that the Bill will require more resources.
All too often we in the House pass legislation, often with support—in principle—from all parties, yet we do not accept that additional resources will be needed as a result. I put my flag up on that issue now. I am absolutely certain that additional resources will be necessary. The work requires additional case conferences. Others have mentioned the involvement of up to eight different agencies and their staff when the orders are put in place. Giving support to the mentally ill in the community is a cumbersome process. I am not denigrating the process, but it is very time consuming. The problem has been that so many of the individuals who may require such assistance have dropped out of the net, and picking them up again, let alone giving them continuing treatment, will be very time consuming. Let there be no mistake—I emphasise the point to my right hon. and hon. Friends in the Department of Health—mental health service staff, whether they are employed by local authorities or by the NHS, are severely overstretched already.
So much progress has been made in looking after people better that those engaged in that work are now suffering a great deal of stress. I am not being soft about that, nor am I suggesting that management methods cannot be improved to achieve better productivity from 196 those who care for the mentally ill. It would be unrealistic, however, to believe that such care will not involve additional time, and therefore additional resources.
I support the Bill because it is absolutely essential that we establish a legislative framework to deal with those who are discharged, but who are still severely ill. As has already been said, those people often come out into the community and are pleased to be in a freer, more comfortable and pleasant environment. They often do not, however, take the very medication that has enabled them to be discharged in the first place. It is essential for them to take that medication. Without the proposed legislative framework to ensure that, I cannot see how those people will continue to improve, let alone make progress in the community or not put themselves and others at risk. On that basis, the Bill is long overdue.
Mr. John 'Gunnell (Morley and Leeds, South)
I have listened to the entire debate, so I intend to underline briefly certain points that have been raised. The unanimity that has marked hon. Members' contributions is perhaps not surprising, because I assume that those present are interested in mental health services and the particular problems posed by the Bill. I have identified three particular weaknesses in the Bill and it is interesting to note that two of them have already been the subject of much comment.
I do not think that the closure of the large mental health institutions caused the difficulties that the Bill is designed to address. As the hon. Members for Hendon, South (Mr. Marshall) and for Bournemouth, East (Mr. Atkinson) said, those difficulties have arisen because of the loss of 35,000 acute psychiatric beds between 1981 and 1991. Without that loss, a certain number of people living in the community now would still be receiving hospital care from time to time, if not long term. Unfortunately, such care is no longer available to them.
The Bill's efforts to overcome the difficulties of care provision prompt me to raise three points. First, there is some confusion between the role of a health authority and that of social services departments. The health authority is clearly the lead authority, which nominates the responsible medical officer and supervisor. No doubt the health authority will take overall responsibility for taking and conveying patients who are subject to supervised discharge. No doubt health authorities will turn to the police to get that job done on many occasions, but according to the Bill, they are the lead authority. Social services take the lead, however, in providing community services and community care. Perhaps social services should also take the lead after the responsible medical officer has done his work. A greater input from social services is warranted rather than simply one social worker's approval of a supervised discharge. Baroness Jay suggested in the other place that the guardianship principles in the Mental Health Act 1983 could have served the Government's purpose instead of the Bill. She suggested that the guardianship powers envisaged in the 1983 Act could be beefed up to accommodate difficult cases, but that the original role of the guardian would be better suited to the needs of the mentally ill generally. I urge the Government to consider revising the 1983 Act to bring it up to date in line with current practice and available facilities.
197 If social services are not at least an equal party to the health authority when considering an application for a supervised discharge, their professional partnership, which is vital to making a success of care in the community, will be downplayed. There should be a partnership and liaison not just between health authorities and social services, but between voluntary agencies. Some of those organisations have already expressed their concerns to us about the Bill. Housing authorities should also be party to that partnership, which should be as extensive as possible. As my hon. Friend the Member for Motherwell, South (Dr. Bray) said, it should embrace carers and those who use the services.
We must develop such partnerships and liaison rather than simply rely on the strong-arm-of-the-law approach, which seems to be explicit in the Bill, given the role of the police in taking and conveying those who are described as mentally disordered patients to a place of residence or training. I have no doubt that the public safety aspect is important and must be taken into account, but we proceed best through partnership. Certain powers must be invested in that partnership, but I am not convinced that the power to take and convey should be one of them.
Secondly, people are confused about the scope of the take-and-convey power. I know that in the Bill it applies to those under supervised discharge, but that is not clearly understood by those in the community. The Government estimate that around 3,000 people may be affected by the Bill, because should they not take their medication, they might be a danger particularly to themselves, but also, on occasion, to others. Far more than those 3,000 people were discharged from institutions ages ago. There is no likelihood of them being affected by the Bill, but many believe that they are under threat from what they judge to be a power of arrest. Were it applied loosely, that power would be draconian. No explanation has to be offered when someone is taken and conveyed, provided that the appropriate care workers have agreed to that.
The meaning of the term "mentally disordered", to whom the procedure will apply, is not clear to those in the outside world. It may be clear when seen in the context of the Bill, but more effort must be made to explain it, because some of my constituents are worried by the Bill for no reason. Their fear may be explained by the fact that many former mental health patients have been scarred by their earlier experiences. Some were kept for years in institutions that were unable to offer them any help. That happened either because of errors in their diagnosis or, in the not too distant past, because they had been sent to such institutions as inappropriate punishment for alleged offences. We have all heard of women who were put in institutional care when they became pregnant out of wedlock. I know of one constituent who spent 25 years in institutional care because he stole a bottle of milk. It is not surprising that people with such experience, who are now settled in the outside world, living unobtrusively, still feel under some kind of threat and in a sense discriminated against. They are worried that the Bill might apply to them and that the police might come to take and convey them without being told on whose authority that decision has been taken. Their anxiety is due to the experiences that they have suffered.
198 We have to make it crystal clear to whom the Bill might apply. The Minister will be aware that we are not happy about its phraseology, nor about the manner in which he will seek to implement the take-and-convey procedures. I believe that the extent to which those procedures might apply must be clarified.
Thirdly, nearly all hon. Members have said that it is unrealistic and impractical to offer no financial resources for the Bill's implementation. The Bill's necessary measures should not be implemented at the expense of the overall standard of general mental health services.
The Select Committee on Health studied mental health provision and envisaged an expanded service. It wanted more resources to be devoted to it. Even more significantly, the Department of Health's own review team—whose report back in August 1993 led to the Secretary of State's points on mental health—made it clear that extra financial provision was necessary for this measure to work. In these cash-straitened times, it is impractical to expect health authorities or social services departments to find those extra resources.
The original Mental Health Act saw itself as an expression of the commitment to supporting the role of the community, rather than institutions, in the care of the mentally ill. Without resources, the new Bill's intentions to ensure that that is not at the expense of the safety of the public will be just that—good intentions. Unless people with mental illnesses are dealt with by adequately resourced support services in an atmosphere of understanding, the Bill's objectives will not be realised.
Nobody denies that the public must be protected from potentially violent patients in the community. But denying those patients the means to reintegrate themselves into the community by depriving the responsible agencies of additional cash is what makes the Bill more about control than about care in the community.
§ Mr. David Hinchliffe (Wakefield)
We have heard a range of concerns expressed in the debate, both about the current state of community care—especially for those facing mental illness—and about the implications of some of the measures proposed in the Bill. I reiterate the comments of my hon. Friend the Member for Newcastle upon Tyne, East (Mr. Brown) that the Opposition recognise the extent of public concern about the difficulties which have arisen in a number of instances with tragic consequences, where vulnerable mentally ill patients have slipped through the net of care services.
I am conscious that some of the cases which have occurred away from London have not been reported, and I am aware of the case to which my hon. Friend the Member for Doncaster, North (Mr. Hughes) referred, of a tragedy affecting a child. Other cases have occurred elsewhere in the country.
While we share the Government's desire to move towards care in the community provision for vast numbers of people who would previously have been incarcerated in mental hospitals, we have serious worries that the policy of bringing about a rapid rundown of large, long-stay psychiatric hospitals has not been accompanied by a similar commitment to proper development provision within the community. It is that one-sided community care policy that is at the heart of the problems that the Government seek to address with the Bill.
199 While we will use the opportunities provided by the measure to offer constructive proposals to safeguard the public and the patients, our central concern is to press the Government to take seriously the fact that community care is about rather more than just closing mental hospitals.
A number of hon. Members present for today's debate were also present for the debate on mental illness initiated by the hon. Member for Hendon, South (Mr. Marshall) on 10 May. They will recall that I posed two key questions to the Government that day of direct relevance to the measure that we are considering this evening. First, I asked what happened to the patients concerned when 70,000 psychiatric beds were removed in the 10 years up to 1992–93. Secondly, I asked what happened to the public resources released by that huge closure programme.
The record shows that the Minister answered neither question when he wound up, because the Government have admitted on several occasions in answer to myself and to other hon. Members that they simply do not know the answers. There is no year-by-year breakdown of how many patients have been discharged to independent or semi-independent accommodation or to hostel provision, or how many have been discharged to attend day centres, day care or other forms of community provision. There is no record of what subsequently happened to them on their discharge or as they moved on from care provision within the community.
As we are charged as Members of Parliament with safeguarding public resources, we must be concerned at the fact that we have lost not only the patients but apparently billions of pounds of funding which was previously tied up in the resourcing of hospital care. The Government cannot tell us where that money has gone, but it is obvious from the problems to which the Bill is a response that it has not been diverted into the programme of re-provision within the community that is obviously required to ensure that the rundown of hospital care means improving the quality of patients' lives.
Our central concerns in relation to the measure relate to the two new orders at the heart of the Bill—the supervised discharge order and the community care order in Scotland. They are the culmination of a lengthy period of debate on whether a change in the law was needed to ensure that patients within the community could be required to follow a particular care plan. The initial proposals some years ago for compulsory treatment orders have reappeared in a range of forms, with the Government finally opting for supervised discharge orders and their Scottish equivalent.
It is surprising—given the length of time that this debate has been under way—that the Bill's central proposals have so little support from the individual organisations that will have the task of applying the legislation in practice. Virtually all those directly concerned have been vociferous in their criticisms, especially of the new powers introduced by clauses 1 and 4. The Community Psychiatric Nurses Association, the British Association of Social Workers, the Royal College of Nursing and the Royal College of Psychiatrists have all expressed reservations, as has the Law Society.
My background before entering Parliament in 1987 was as a social worker, and a number of colleagues here today—including my hon. Friends the Members for Dulwich (Ms Jowell) and for Stockport (Ms Coffey) —have similar backgrounds. I approach my evaluation of the measure with a particular eye on its application in practice. From that perspective, I—like others—am at a 200 loss to understand the need for the introduction of a completely new order when the existing power of guardianship offers an almost identical provision.
During my time in local authority social work, I worked for many years as an authorised mental welfare officer. I looked to guardianship to offer the safeguards necessary when, in a few situations, it was felt that some statutory supervision was required. That power was used sparingly, but my experience was that it was used in a positive way to enhance the opportunities available in the community to a small number of patients who would otherwise have spent lengthy periods in hospital under section. Guardianship facilitated community care, while offering protection to the patient and to the public.
My hon. Friend the Member for Doncaster, North said that the supervised discharge orders and the similar Scottish provision duplicate the existing guardianship powers in a way that will inevitably cause confusion among those who have to differentiate between the two. The main difference that has been proposed is a new power to take and convey the patients to a place where they are required to live or to attend. That power has been mentioned by a number of hon. Members, and has been the subject of particular criticism as a provision that could totally undermine the consensual relationship upon which the most successful after-care supervision is based.
It is important to underline the fact that one cannot care for people in a community environment without some consent and trust between the person being supervised and the supervisor. Those involved are concerned about how the measure will operate when it is implemented, as they recognise that that element will cause difficulties between the person supervising the patient and the person being supervised. I hope that the Government will listen to that. It is not a partisan political point, but a point of practicality that has been raised with us—and with Conservative Members—by the organisations and individuals concerned.
The provision to take and convey could have been understood if the Government had taken the step of also including compulsory treatment within the new order, although I emphasise that I am not suggesting that that should have been done. But as it stands, a patient taken or conveyed under the order would be within his or her rights to refuse subsequent medical treatment. It will be necessary to make an application under a separate section of the Mental Health Act to enforce such treatment. As one writer with a legal background has put it, the community psychiatric nurse would have the power to take a horse to water, but not to make him drink.
The hon. Member for Worcestershire, South (Mr. Spicer) —who was critical of the provision—failed to grasp the key issue in this measure which is causing great concern to a number of organisations and individuals. If a patient no longer complies with a care plan, the only additional provision is the obligation on the care team to inform an approved social worker, who may consider applying for compulsory admission to hospital. But nearest relatives can do that already under existing law. Unlike guardianship, the new powers would be in the hands of health authorities in a move away from the lead agency status on community care which the Government introduced in the National Health Service and Community Care Act 1990.
201 As well as the confusion with guardianship that I have mentioned, the shift from local authorities will raise more questions about who is responsible at a local level. The organisational responsibility question is another area that causes us extreme concern. We need to know exactly who is doing what. The clear similarity with the guardianship provisions organised by local authorities will cause immense confusion among practitioners at a local level.
While I understand that the measure is intended to formalise the care programme approach in some respects, that could have been achieved with fairly minor amendments to existing guardianship powers, with health authorities given similar status in law to local authorities. Amending guardianship would have been more in line with the wider policy moves in the direction of care in the community, because it would have enabled the development of a non-hospital route to formalised supervision in a way that the Bill does not allow.
It is not helpful to convey the clear message—as the Bill Does—that the legal enforcement of key elements of the care plan within the community depends upon discharge from in-patient hospital care. While I appreciate that the prime motivation for the measure has been severe problems concerning patients who have left hospital, it is important to recognise within the context of current policy that care does not necessarily have to begin with an experience of hospital in-patient treatment. The hon. Member for Roxburgh and Berwickshire (Mr. Kirkwood) touched on that point.
The fact that the proposals seem to be at odds with wider policy developments to some extent underlines the Mental Health Act Commission's argument that existing legislation, which was based substantially on policies that were in place in the 1950s—the 1983 Act was based primarily on the framework of the Mental Health Act 1959—has been largely overtaken by radical moves in the direction of community care. It is pretty obvious that those who are charged with the task of overseeing the legislation believe strongly that simply tampering with elements of existing mental health law will not succeed in making current legislation relevant to current circumstances.
The need for a new mental health Act, which offers a framework reflecting current policy, will clearly not go away. I was pleased to hear the Minister concede that his mind was not closed to a much wider review of the legislation. Clearly, the legislation is grossly outdated. The Mental Health Act Commission has stated that there is a need for new legislation that reflects contemporary policies in contemporary times, and I hope that the Government will take that call seriously.
The prime reason for introducing the Mental Health (Patients in the Community) Bill is, as the Government said, public protection. As my hon. Friend the Member for Newcastle upon Tyne, East made clear at the outset, the Labour party is as concerned as the Government to ensure that the public and the patients themselves should not be put at risk by inadequate care policies. As our amendment shows, we take a wider view of the causes of the problem and of the solutions.
202 Public protection must be a key objective, but as the Mental Health Foundation inquiry put it last year:If everyone with a severe mental illness had appropriate services, sensitively provided and adequately funded, there would be much less concern about this issue".Such services and provisions do exist in some areas, but, as the Audit Commission and the Health Select Committee have pointed out, they vary markedly in their quality and availability.
There are good examples of patients being offered long-term supported accommodation. There are some excellent models of asylum within the community, with safe houses and other forms of sanctuary along the lines that my hon. Friend the Member for Motherwell, South (Dr. Bray) mentioned.
There are excellent mental health resource centres in some areas, with round-the-clock crisis services and outreach provision. But in other areas, such key elements of community care provision are either minimal or non-existent.'They have not been developed alongside the hospital closure programme, and that fact must be addressed. We must recognise also that access to acute hospital-based services offers an important back-up to care in the community, but it is clearly grossly inadequate in some parts of Britain. A number of Conservative Members made that point today.
Those factors have an important bearing on the reasons for the mental health Bill, but the Bill itself will clearly do nothing to ensure that adequate services are available to patients who are subject to the new order. The Department of Health review team said that the use of the new power implied a reciprocal obligation on statutory services to provide the support that patients need, but the Government tell us that it is a nil-cost measure. Without the necessary back-up support and services, any formalised supervision—whether under discharge orders or guardianship—will mean very little.
That point is central to our amendment, which reflects the very serious concerns about the Bill expressed by a range of organisations. There is a clear need to ensure that patients and the public are protected. However, we believe that the Government were very badly advised in bringing forward a measure that has not been thought out properly. For that and for the other reasons that I have outlined tonight, I urge hon. Members to support the amendment.
§ Mr. Bowis
With permission, Madam Deputy Speaker, I shall respond to some of the points that have been raised by hon. Members on both sides of the House.
I think that there has been something of a competition—which is unusual in this place—to catch the eye of the hon. Member for Roxburgh and Berwickshire (Mr. Kirkwood), who has identified himself as the guardian of the Select Committee on Selection. Conservative Members have appealed to him to look after their interests as the legislation moves towards the Committee stage, and there have been similar hints from Labour Members as well. I hope that we have established in the hon. Gentleman's mind that there is a lot of interest in the measure.
And a lot of talent. Despite some of the comments made during the debate, hon. Members have 203 expressed broad agreement that we should look carefully at the measure, and that we must protect those people in the community who have severe mental illnesses, while also protecting their families, their carers and members of the general public.
Madam Deputy Speaker, you have graciously allowed the debate to range quite widely today. Perhaps that is inevitable, when one examines the background to the measure. It is interesting to see how the pieces of the jigsaw to which I referred in my opening speech will come together. I make it absolutely clear that the measures in the Bill are not an end in themselves. They will operate with all the other pieces of the strategy to secure the safety and well-being of severely mentally ill people and of the wider community.
I do not promise to cope with every point raised in the short time available to me, but I have no doubt that some of them will be raised again during the Committee stage. The hon. Member for Greenock and Port Glasgow (Dr. Godman)—who explained that he had to leave the Chamber—inquired about the Bill's compatibility with the Children (Scotland) Bill. I am assured that the measures are compatible with both the existing and the proposed legislation. Children under 16 may, in very rare circumstances, be detained in hospital under the Mental Health (Scotland) Act 1984, and that is why we have made community care orders available for such patients.
The hon. Member for Doncaster, North (Mr. Hughes) referred to a tragedy of which I am aware, and emphasised the need to improve the system. He gave a qualified welcome to the Bill, and said that it does not address all of the problems. That is a perfectly fair comment: the Bill does not seek to achieve everything. It is a narrow, measured Bill and only one part of the Government's strategy.
The hon. Gentleman is quite right to refer to the need for better community services. The Government preach that constantly to health and social services and to community health services, and we have made the money available to ensure that there can be improvements. However, we must ensure that those resources are targeted, and are used wisely.
My hon. Friend the Member for Bournemouth, East (Mr. Atkinson)—I hope that I have the geography right in this case—rightly paid tribute to the National Schizophrenia Fellowship. Tributes have been paid on both sides of the Chamber to the NSF and other voluntary organisations such as MIND and the Jewish Association for the mentally ill. I join in those tributes.
My hon. Friend the Member for Bournemouth, East rightly paid special tribute—as others have—to carers. We have done much to support carers in the House in recent months, and nowhere is that more important than where carers of people with severe mental illness are concerned. They have a tremendous burden to carry for people in their families whom they love, and we should do what we can to support them. The best way to support those carers is to ensure that they have the assurance that the services are there—the range of services, encompassing provision of beds and community services. I believe that those carers would welcome the measure.
The number of beds was mentioned several times. I can best respond to that by drawing attention to the survey of English mental hospitals published in March 1993, which showed that the number of places for people with mental illness had been steady, at about 80,000. The difference 204 is in the new range of provision that exists. That is not to suggest for a moment that I do not accept some of the arguments about beds, but the number of places has been fairly steady in recent years.
There is talk about new funding, and that was reflected in several speeches from both sides of the House about the resources needed to make the Bill work effectively. The specific figures on the face of the Bill refer to the tribunals and those specific additional costs.
We must regard the reference to resources and the references to the cost of the Bill in the context of the greatly increasing resources that have been made available for mental health provision—for the national health service and social services—in recent years. I have no doubt that those resources will continue to increase, because mental health is a priority in the NHS and in social services. The more we are able to make progress—as we will—with our inter-agency purchasing guide and to encourage joint commissioning and so on, the more resources will be made available for those measures, but they will be made available for the whole of provision for mental health.
In connection with the Bill, we have spoken about the numbers of people that we are dealing with. They are quite small numbers in any one district. Nevertheless, although it is unquantifiable, one needs to take account of the cost to the community and to the health and social services if that type of measure is not implemented. There are enormous costs in trying to locate and look after people who have not been adequately supervised, so the Bill could, in some ways, be a cost-saving measure. Certainly it will make for a more efficient service.
Compulsory medication was mentioned. Our line, as I said earlier, is that, where medication has to be compulsory, that should be decided in the setting of a clinical decision by psychiatrists in a hospital, not out in the community, but I know the opinions about that.
The hon. Member for Roxburgh and Berwickshire mentioned titles, and no doubt he will return to that in Committee. I do not believe that the title "community care order" is misleading to professionals. Perhaps I have a greater faith in their ability to understand guidance and titles than he has, but I am sure that we can consider that in Committee.
The hon. Member for Roxburgh and Berwickshire referred to the Scottish Select Committee. That has been considering the closure of psychiatric hospitals in Scotland, and when that report is published, it will be useful background to some of our discussions. However, as I said, we have an overall policy of ensuring that beds are provided. I shall return later to the argument of my hon. Friend the Member for Sevenoaks (Mr. Wolfson) about the range that we need, and I absolutely agree with what has been said.
The hon. Member for Roxburgh and Berwickshire spoke about the pressures on community psychiatric nurses. I understand the anxieties, but we need to get close to CPNs to talk them through the role because, as I said, we would regard them as being the supervisors and carrying out that role, just as we regard them on the whole as doing the key worker role under the care programme approach. The new role only formalises in law what they would have done under the old, and reflects the well-established principle that a patient's care plan should be the responsibility of a named person.
205 CPNs will work as a team, with joint responsibilities for decision making. Numerically, that should not make a great difference to their case load. However, those are fair arguments to make.
My hon. Friend the Member for Taunton (Mr. Nicholson) rightly referred to the fact that suicide is the great threat to the people we are discussing, and one of our targets is to reduce the number of suicides. It is one of our "The Health of the Nation" strategies. The Somerset progress is encouraging. My hon. Friend rightly referred to the way in which Somerset got ahead of the game in care in the community.
My hon. Friend the Member for Taunton also mentioned homelessness. That is outside the scope of the Bill, but I would draw his attention to two things. One is the homeless mentally ill initiative, which has been remarkably successful in the streets of London. Various hon. Members mentioned central London and its needs. That initiative has helped to take people out of the boxes and blankets and into hostels and long-term accommodation. I believe that it can build on that.
Yesterday—it seems a long time ago now—I took part in the third of the seminars that we have been holding jointly with the Department of the Environment, considering the way in which housing can play its part in community care as a whole, and especially the care of those with mental health problems. Much joint work is going on between Departments and between agencies.
The hon. Member for Stockport (Ms Coffey) mentioned the number of CPNs, which is important. They have quadrupled in our time, but we shall obviously need to continue planning the manpower and womanpower needed in that regard.
I pay tribute to the work of the hon. Member for Motherwell, South (Dr. Bray) as chairman of the all-party group, which has got off the ground again and has been very helpful to us. He emphasised the need to involve users, and I wholly agree with that. The Bill does that, and we shall ensure that they are consulted on any revision of the codes of practice that follows from the Bill.
Some of the most valuable times that I have spent have been with conferences of users and purchasers, at which they come together to consider local needs. Users are involved in the care programme approach to planning. We can build on that. Everyone seems to want a charter nowadays, and that is a tribute to the initiatives of my right hon. Friend the Prime Minister. Charters are obviously regarded as guarantees of good—quality service—guarantees of people being involved in planning the services they need—and we shall certainly consider those in mental health. I believe that much of what the hon. Member for Motherwell, South said will be covered in guidance.
My hon. Friend the Member for Hendon, South (Mr. Marshall) made what has already been described as an excellent speech, supporting the Bill. He also mentioned some of the issues, not least concerning London. As he will know, the mental health task force has carried out its survey of London and followed it up. I believe that progress is already visible on that, but we need to do much more work, and work much harder, on London's problems to begin to solve them for the longer term. My hon. Friend is also right to mention families and their civil liberties, which we should remember.
206 I said that I would return to my hon. Friend the Member for Sevenoaks on hospital closures. I understand his argument. We have said clearly that we are not closing hospitals until and unless we are sure that the services are there in the community. However, I go much further. I say that we need to ensure that there are hospital places for different categories of need for people with mental illness. That goes for medium-term needs, with hospital hostel-type concepts, it goes for secure accommodation, for acute beds, for 24-hour crisis beds, for long-term beds and for asylum. We need all that. We need the package of beds, just as we want the package in the community.
I know that I have not mentioned one or two hon. Members. I wanted briefly to mention the hon. Members who spoke from the Opposition Front Bench, to thank them for their broad support, if I may call it that, even if they will divide the House on their amendment.
The Opposition acknowledged that we are trying to fill a gap that needed filling and which has been identified, as both Opposition Front Benchers said, by reports and inquiries. We have discussed the medium-secure beds, and their provision. We have talked about resources, too. I did not hear much from the Labour party as to what additional resources it will pledge over and above what we have provided. We have come to accept that; the Opposition talk about the general need for more resources but do not give any specific pledges. I am therefore not surprised that they changed the terms of their amendment tonight.
Several hon. Members raised the issue of guardianship. I remind them that we want to encourage guardianship. It is not used a great deal; when it is, it is generally used for people with social functioning problems. We believe that it should be a medically led regime. Baroness Jay sought to promote guardianship by adding to it the power to convey. We do not think that is the way forward; we think that this Bill is.
We shall also examine the role of the Mental Health Act Commission when reviewing the Bill generally.
Black mental health is an issue that I take very seriously. I appreciate the way in which the hon. Member for Newcastle upon Tyne, East (Mr. Brown) raised it. The first initiative that I took as a Minister was to launch an inquiry into the reasons for the apparent variations in treatment and diagnosis and in the type of accommodation for black mentally ill people. We are going to look carefully and objectively—without too much emotion—at this subject, without ducking any of the questions. I shall go on doing that, but it is separate from this Bill, and I hope that it will not be seen as a threat to these people.
The Bill seeks to protect some very vulnerable people, whose illness can cause harm to themselves or others. Tragedies are rare, but that is no reason not to try to avoid them by strengthening supervision. We must reassure the public and the families who have people with severe mental illnesses living among them. I have listened carefully to everything said this evening. I shall listen again in Committee.
Everything that I have heard confirms what I said earlier: that this Bill is but one measure in the overall strategy, together with the CPA, registers, key workers, discharge procedures and a range of bed and community services. The resources are important; their effective use even more so. Resources have risen and will no doubt go on doing so.
207 Everyone has mentioned the revision of the Mental Health Act, but nobody has really told me what they want changing in it. In due course, we shall certainly look at the Act; in the meantime, a lot of people need not changes in the law, but a tightening of performance. The few who do need a change in the law are those whom we have dealt with in this Bill.
I hope that the House will reject the amendment, and give the Bill a Second Reading.
Question put, That the amendment be made:—
§ The House divided: Ayes 224, Noes 236.210
|Division No. 167]||[7.02 pm|
|Adams, Mrs Irene||Dewar, Donald|
|Ainger, Nick||Dixon, Don|
|Ainsworth, Robert (Cov'try NE)||Donohoe, Brian H|
|Allen, Graham||Dowd, Jim|
|Anderson, Donald (Swansea E)||Dunwoody, Mrs Gwyneth|
|Armstrong, Hilary||Eagle, Ms Angela|
|Ashdown, Rt Hon Paddy||Eastham, Ken|
|Austin-Walker, John||Etherington, Bill|
|Banks, Tony (Newham NW)||Evans, John (St Helens N)|
|Barnes, Harry||Fatchett, Derek|
|Bayley, Hugh||Faulds, Andrew|
|Beckett, Rt Hon Margaret||Field, Frank (Birkenhead)|
|Beith, Rt Hon A J||Flynn, Paul|
|Benn, Rt Hon Tony||Forsythe, Clifford (S Antrim)|
|Bennett, Andrew F||Foster, Rt Hon Derek|
|Benton, Joe||Foster, Don (Bath)|
|Betts, Clive||Foulkes, George|
|Blair, Rt Hon Tony||Fyfe, Maria|
|Blunkett, David||Galbraith, Sam|
|Boateng, Paul||Galloway, George|
|Bradley, Keith||Gapes, Mike|
|Bray, Dr Jeremy||George, Bruce|
|Brown, Gordon (Dunfermline E)||Gerrard, Neil|
|Brown, N (N'c'tle upon Tyne E)||Godman, Dr Norman A|
|Bruce, Malcolm (Gordon)||Godsiff, Roger|
|Burden, Richard||Golding, Mrs Llin|
|Byers, Stephen||Gordon, Mildred|
|Caborn, Richard||Graham, Thomas|
|Callaghan, Jim||Grant, Bernie (Tottenham)|
|Campbell, Mrs Anne (C'bridge)||Griffiths, Nigel (Edinburgh S)|
|Campbell, Menzies (Fife NE)||Griffiths, Win (Bridgend)|
|Campbell, Ronnie (Blyth V)||Grocott, Bruce|
|Campbell-Savours, D N||Gunnell, John|
|Canavan, Dennis||Hall, Mike|
|Carlile, Alexander (Montgomery)||Hanson, David|
|Chidgey, David||Harvey, Nick|
|Chisholm, Malcolm||Heppell, John|
|Clapham, Michael||Hill, Keith (Streatham)|
|Clark, Dr David (South Shields)||Hinchliffe, David|
|Clarke, Tom (Monklands W)||Hoey, Kate|
|Clelland, David||Hogg, Norman (Cumbemauld)|
|Clwyd, Mrs Ann||Home Robertson, John|
|Coffey, Ann||Hood, Jimmy|
|Connarty, Michael||Hoon, Geoffrey|
|Cook, Frank (Stockton N)||Hoyle, Doug|
|Cook, Robin (Livingston)||Hughes, Kevin (Doncaster N)|
|Corbett, Robin||Hughes, Robert (Aberdeen N)|
|Corbyn, Jeremy||Hughes, Roy (Newport E)|
|Corston, Jean||Hutton, John|
|Cunliffe, Lawrence||Illsley, Eric|
|Cunningham, Jim (Covy SE)||Ingram, Adam|
|Cunningham, Rt Hon Dr John||Jackson, Glenda (H'stead)|
|Cunningham, Roseanna||Jamieson, David|
|Dafis, Cynog||Jones, Barry (Alyn and D'side)|
|Davidson, Ian||Jones, Jon Owen (Cardiff C)|
|Davies, Bryan (Oldham C'tral)||Jones, Lynne (B'ham S O)|
|Davies, Ron (Caerphilly)||Jones, Nigel (Cheltenham)|
|Denham, John||Jowell, Tessa|
|Keen, Alan||Pope, Greg|
|Kennedy, Charles (Ross,C&S)||Powell, Ray (Ogmore)|
|Kennedy, Jane (Lpool Brdgn)||Prentice, Bridget (Lew'm E)|
|Khabra, Piara S||Prentice, Gordon (Pendle)|
|Kilfoyle, Peter||Primarolo, Dawn|
|Kirkwood, Archy||Purchase, Ken|
|Lestor, Joan (Eccles)||Quin, Ms Joyce|
|Lewis, Terry||Radice, Giles|
|Liddell, Mrs Helen||Raynsford, Nick|
|Livingstone, Ken||Reid, Dr John|
|Lloyd, Tony (Stretford)||Rendel, David|
|Llwyd, Elfyn||Robertson, George (Hamilton)|
|Loyden, Eddie||Robinson, Geoffrey (Co'try NW)|
|Lynne, Ms Liz||Roche, Mrs Barbara|
|McAllion, John||Rooker, Jeff|
|McAvoy, Thomas||Rooney, Terry|
|McCartney, Ian||Ross, Ernie (Dundee W)|
|Macdonald, Calum||Ross, William (E Londonderry)|
|McFall, John||Simpson, Alan|
|McKelvey, William||Skinner, Dennis|
|Mackinlay, Andrew||Smith, Chris (Isl'ton S & Fsbury)|
|McLeish, Henry||Smith, LJew (Blaenau Gwent)|
|Maclennan, Robert||Smyth, The Reverend Martin|
|McNamara, Kevin||Soley, Clive|
|McWilliam, John||Spearing, Nigel|
|Madden, Max||Spellar, John|
|Maddock, Diana||Squire, Rachel (Dunfermline W)|
|Mahon, Alice||Steinberg, Gerry|
|Marek, DrJohn||Stevenson, George|
|Marshall, David (Shettleston)||Stott, Roger|
|Martlew, Eric||Strang, Dr. Gavin|
|Maxton, John||Sutcliffe, Gerry|
|Meale, Alan||Taylor, Mrs Ann (Dewsbury)|
|Michael, Alun||Taylor, Matthew (Truro)|
|Michie, Bill (Sheffield Heeley)||Timms, Stephen|
|Michie, Mrs Ray (Argyll & Bute)||Tipping, Paddy|
|Milburn, Alan||Touhig, Don|
|Miller, Andrew||Trimble, David|
|Molyneaux, Rt Hon James||Tyler, Paul|
|Morgan, Rhodri||Vaz, Keith|
|Morley, Elliot||Walley, Joan|
|Morris, Estelle (B'ham Yardley)||Wareing, Robert N|
|Mowlam, Marjorie||Watson, Mike|
|Mudie, George||Welsh, Andrew|
|Mullin, Chris||Wicks, Malcolm|
|Murphy, Paul||Wilson, Brian|
|Oakes, Rt Hon Gordon||Winnick, David|
|O'Brien, Mike (N W'kshire)||Wise, Audrey|
|O'Brien, William (Normanton)||Worthington, Tony|
|O'Hara, Edward||Wright Dr Tony|
|Olner, Bill||Young, David (Bolton SE)|
|Orme, Rt Hon Stanley|
|Parry, Robert||Tellers for the Ayes:|
|Pickthall, Colin||Mr. Eric Clarke and|
|Pike, Peter L||Mr. Dennis Turner.|
|Alison, Rt Hon Michael (Selby)||Bottomley, Peter (Eltham)|
|Amess, David||Bowden, Sir Andrew|
|Arbuthnot, James||Bowis, John|
|Arnold, Jacques (Gravesham)||Brandreth, Gyles|
|Ashby, David||Brazier, Julian|
|Atkins, Rt Hon Robert||Bright, Sir Graham|
|Atkinson, Peter (Hexham)||Brooke, Rt Hon Peter|
|Baker, Rt Hon Kenneth (Mole V)||Brown, M (Brigg & Cl'thorpes)|
|Baker, Nicholas (North Dorset)||Bruce, Ian (Dorset)|
|Banks, Matthew (Southport)||Burns, Simon|
|Banks, Robert (Harrogate)||Burt, Alistair|
|Bates, Michael||Butcher, John|
|Batiste, Spencer||Butler, Peter|
|Beresford, Sir Paul||Carrington, Matthew|
|Biffen, Rt Hon John||Carttiss, Michael|
|Body, Sir Richard||Channon, Rt Hon Paul|
|Bonsor, Sir Nicholas||Clappison, James|
|Booth, Hartley||Clarke, Rt Hon Kenneth (Ru'clif)|
|Boswell, Tim||Clifton-Brown, Geoffrey|
|Coe, Sebastian||Johnson Smith, Sir Geoffrey|
|Colvin, Michael||Jones, Gwilym (Cardiff N)|
|Congdon, David||Jones, Robert B (W Hertfdshr)|
|Conway, Derek||Kellett-Bowman, Dame Elaine|
|Coombs, Anthony (Wyre For'st)||King, Rt Hon Tom|
|Coombs, Simon (Swindon)||Kirkhope, Timothy|
|Cope, Rt Hon Sir John||Knapman, Roger|
|Cormack, Sir Patrick||Knight, Mrs Angela (Erewash)|
|Couchman, James||Knight, Greg (Derby N)|
|Cran, James||Knight, Dame Jill (Bir'm E'st'n)|
|Davies, Quentin (Stamford)||Kynoch, George (Kincardine)|
|Davis, David (Boothferry)||Lait, Mrs Jacqui|
|Day, Stephen||Lang, Rt Hon Ian|
|Deva, Nirj Joseph||Lawrence, Sir Ivan|
|Devlin, Tim||Legg, Barry|
|Dicks, Terry||Leigh, Edward|
|Douglas-Hamilton, Lord James||Lennox-Boyd, Sir Mark|
|Dover, Den||Lester, Jim (Broxtowe)|
|Duncan, Alan||Lidington, David|
|Duncan-Smith, Iain||Lightbown, David|
|Dunn, Bob||Lloyd, Rt Hon Sir Peter (Fareham)|
|Dykes, Hugh||Luff, Peter|
|Eggar, Rt Hon Tim||MacKay, Andrew|
|Elletson, Harold||Maclean, Rt Hon David|
|Emery, Rt Hon Sir Peter||McLoughlin, Patrick|
|Evans, David (Welwyn Hatfield)||Madel, Sir David|
|Evans, Jonathan (Brecon)||Maitland, Lady Olga|
|Evans, Nigel (Ribble Valley)||Malone, Gerald|
|Evans, Roger (Monmouth)||Mans, Keith|
|Evennett, David||Marlow, Tony|
|Faber, David||Marshall, John (Hendon S)|
|Fabricant, Michael||Marshall, Sir Michael (Arundel)|
|Field, Barry (Isle of Wight)||Martin, David (Portsmouth S)|
|Fishburn, Dudley||Mates, Michael|
|Forman, Nigel||Merchant, Piers|
|Forsyth, Rt Hon Michael (Stirling)||Mills, Iain|
|Fox, Dr Liam (Woodspring)||Mitchell, Andrew (Gedling)|
|Fox, Sir Marcus (Shipley)||Moate, Sir Roger|
|Freeman, Rt Hon Roger||Monro, Sir Hector|
|Fry, Sir Peter||Montgomery, Sir Fergus|
|Gale, Roger||Needham, Rt Hon Richard|
|Gallie, Phil||Nelson, Anthony|
|Gardiner, Sir George||Neubert, Sir Michael|
|Garel-Jones, Rt Hon Tristan||Newton, Rt Hon Tony|
|Gill, Christopher||Nicholls, Patrick|
|Gillan, Cheryl||Nicholson, David (Taunton)|
|Goodlad, Rt Hon Alastair||Nicholson, Emma (Devon West)|
|Goodson-Wickes, Dr Charles||Onslow, Rt Hon Sir Cranley|
|Gorman, Mrs Teresa||Oppenheim, Phillip|
|Gorst, Sir John||Ottaway, Richard|
|Greenway, Harry (Ealing N)||Page, Richard|
|Greenway, John (Ryedale)||Pawsey, James|
|Griffiths, Peter (Portsmouth, N)||Peacock, Mrs Elizabeth|
|Hague, William||Pickles, Eric|
|Hamilton, Rt Hon Sir Archibald||Porter, Barry (Wirral S)|
|Hampson, Dr Keith||Porter, David (Waveney)|
|Hannam, Sir John||Powell, William (Corby)|
|Hargreaves, Andrew||Redwood, Rt Hon John|
|Harris, David||Renton, Rt Hon Tim|
|Haselhurst, Sir Alan||Richards, Rod|
|Hawkins, Nick||Riddick, Graham|
|Hawksley, Warren||Robathan, Andrew|
|Hayes, Jerry||Roberts, Rt Hon Sir Wyn|
|Heald, Oliver||Robertson, Raymond (Ab'd'n S)|
|Heathcoat-Amory, David||Robinson, Mark (Somerton)|
|Hendry, Charles||Roe, Mrs Marion (Broxbourne)|
|Hicks, Robert||Rowe, Andrew (Mid Kent)|
|Higgins, Rt Hon Sir Terence||Ryder, Rt Hon Richard|
|Horam, John||Sackville, Tom|
|Hughes, Robert G (Harrow W)||Scott, Rt Hon Sir Nicholas|
|Hunt, Rt Hon David (Wirral W)||Shaw, David (Dover)|
|Hunter, Andrew||Shaw, Sir Giles (Pudsey)|
|Jack, Michael||Shepherd, Colin (Hereford)|
|Jackson, Robert (Wantage)||Shersby, Sir Michael|
|Jenkin, Bernard||Sims, Roger|
|Jessel, Toby||Smith, Tim (Beaconsfield)|
|Spencer, Sir Derek||Twinn, Dr Ian|
|Spicer, Michael (S Worcs)||Viggers, Peter|
|Spink, Dr Robert||Walden, George|
|Spring, Richard||Walker, Bill (N Tayside)|
|Stanley, Rt Hon Sir John||Waller, Gary|
|Steen, Anthony||Ward, John|
|Stephen, Michael||Wardle, Charles (Bexhill)|
|Stem, Michael||Waterson, Nigel|
|Stewart, Allan||Wells, Bowen|
|Streeter, Gary||Wheeler, Rt Hon Sir John|
|Sweeney, Walter||Whittingdale, John|
|Sykes, John||Widdecombe, Ann|
|Taylor, Ian (Esher)||Wiggin, Sir Jerry|
|Taylor, John M (Solihull)||Wilkinson, John|
|Taylor, Sir Teddy (Southend, E)||Wilshire, David|
|Temple-Morris, Peter||Winterton, Mrs Ann (Congleton)|
|Thomason, Roy||Winterton, Nicholas (Macc'f'ld)|
|Thompson, Sir Donald (C'er V)||Wolfson, Mark|
|Thompson, Patrick (Norwich N)||Wood, Timothy|
|Thomton, Sir Malcolm||Yeo, Tim|
|Thumham, Peter||Young, Rt Hon Sir George|
|Townsend, Cyril D (Bexl'yh'th)|
|Tredinnick, David||Tellers for the Noes:|
|Trend, Michael||Mr. Sydney Chapman and|
|Trotter, Neville||Mr. David Willetts.|
§ Question accordingly negatived.
Main Question put forthwith, pursuant to Standing Order No. 60 (Amendment on Second or Third Reading), and agreed to.
Bill read a Second time, and committed to a Standing Committee, pursuant to Standing Order No. 61 (Committal of Bills).
§ Mr. George Robertson (Hamilton)
On a point of order, Madam Deputy Speaker. Given the developments in regard to Brent Spar since Prime Minister's Question Time, when the Prime Minister made an explicit statement on the matter, and given the change of mind by Shell in the interim, have you been given notice that a Minister will make a fresh statement to the House this evening'? As the issue is of crucial importance and there has been a major change of policy by the Government and Shell since Prime Minister's Question Time, will you ensure that the House is briefed before anybody else?
§ Madam Deputy Speaker (Dame Janet Fookes)
The answer to the first question is that I have received no such notification. The other matters are really the responsibility of the Government and I cannot ensure anything from the Chair, but I am sure that those points will have been noted by those on the Treasury Bench.
§ Mr. Matthew Taylor (Truro)
Further to that point of order, Madam Deputy Speaker. Today's events are not only a triumph for the environment movement and the general public, but a total humiliation for the Prime Minister. Although it may appear that matters are resolved, Government policy apparently has not changed. They have made no statement and, potentially, another 50 installations could be buried under the North sea. Surely the Government must explain to the House whether Government policy has changed or whether the decision was taken by Shell.
§ Mr. Calum Macdonald (Western Isles)
Further to that point of order, Madam Deputy Speaker. As the Prime Minister repeatedly affirmed the Government's policy to dump at sea, would it not be appropriate for him to come to the House to explain the latest developments and 211 apologise to those hon. Members he disparaged during Prime Minister's Question Time who tried to put forward just this policy?
§ Mr. Patrick McLoughlin (West Derbyshire)
Further to that point of order, Madam Deputy Speaker. Surely that is absolute nonsense. There is no Government responsibility whatsoever. The company made a commercial decision which was for that company to make, and the Prime Minister has no responsibility whatever in the matter.
§ Mr. Alex Salmond (Banff and Buchan)
Further to that point of order, Madam Deputy Speaker. As you are well aware, there is direct Government responsibility. Yesterday, the Prime Minister himself described the proposal for onshore decommissioning as "incredible". As the Prime Minister put his personal authority behind that policy yesterday and today, is not he the appropriate Minister to make a statement to the House? Usually, when the Prime Minister backs people to the hilt, they end up sinking. In this case they have ended up not sinking. Are we not due an explanation?
§ Madam Deputy Speaker
Order. I must make it clear to the House, as the representative of the Chair, that these matters do not lie within my control.
§ Dr. Godman
No. I wish to make a point concerning the announcement of the change in direction. As the hon. Member who first demanded in the House that the installation be brought ashore, may I point out by way of 212 clarification that the Government have every responsibility for such decisions under part I of the Petroleum Act 1987? The Government allowed Shell to go ahead with its plans until they lost their collective nerve.
§ Madam Deputy Speaker
Order. We must beware of this turning into a mini-debate. The point of order for the Chair is clear. I can only draw the matter to the attention of the members of the Treasury Bench. Apart from that, it is not my responsibility.
§ Mr. Dennis Skinner (Bolsover)
Further to that point of order, Madam Deputy Speaker. Since the points of order began, two Scottish Office Ministers have appeared on the Treasury Bench. Would it be appropriate for one of those to come to the Dispatch Box to make a statement, and would you agree to that, or would it be better if the President of the Board of Trade came to the House to make such a statement, because it is he who now acts on behalf of the Prime Minister to mop everything up?
§ Madam Deputy Speaker
Those are all very interesting suggestions, but they are not matters for me. We must move on to the next business.