§ 7.39 p.m.
§ The Earl of Longford rose to call attention to the treatment of mental offenders and ex-offenders; and to move for Papers.
§ The noble Earl said: My Lords, I am told by those who have listened to the previous debate that it was a debate of much distinction, but I believe that the quality of our debate will be at least as high find, in my supposition, still higher.
§ I am very grateful to all noble Lords, and in particular to the noble Baroness and to the noble Baroness the Minister, for lingering so long. I shall just mention the noble Baroness, Lady Farrington, because I am sure that she will make a contribution filled with great wisdom. I shall not go over all her qualifications but as a feminist I venture to think that the quality of the speeches made by the female Members of the House is, on average, of an even higher quality than the others; but I may be mistaken about that. I am sure that my noble friend will add to that glory and to ours.
§ This is a very complicated subject and I shall not speak in a partisan or dogmatic way. The Minister who is to reply is particularly well qualified, as we all know, to cope with these immensely difficult problems but I am sure she will agree with me on the complications. It is impossible to simplify matters.
§ A little while ago I was talking to a young man aged 28 who, when he was 16, was diagnosed to be a paranoid schizophrenic. He has been in minor trouble of various sorts ever since. It is no good pretending that any government, however wise or full of munificence or money, would be able to cope with his problems at all easily. And so it goes on.
§ I first became interested in these problems in the late 1930s when I became a prison visitor at Oxford. One of the people who I was trying to help then was a young arsonist. Sometimes he was sent to prison and sometimes he was sent to Littlemore, a mental asylum. It was not possible to decide which he needed. There are a great many people about whom it is not possible to say whether they should be punished in prison or treated as a patient in hospital.
§ Last week I was sitting in court when a man was being charged with kidnapping and holding a librarian for 14 hours. He has been convicted since and I do not know how he will be dealt with. I have known him for a good many years. He is man of humourous charm. He has written a book which I hope will be published. But he is subject to fits of rages and he is immensely strong, which makes him somewhat fearsome. I visited him in prison and he is obviously greeted with awe by the prison officers. In the room next to the one where I was sitting with him, there were five prison officers. They thought it needed five men to cope with this Samson. Who is to say how he should be dealt with? I do not know what his sentence will be but I mention him merely to illustrate how difficult are these problems.901
§ Another man that I am visiting in prison I have know for many years. He has been a patient in mental hospitals for short times. He is a very intelligent man. He has been in mental hospitals and prison quite often. He is now in his late forties. When he appeared in a television programme not long ago he was the star really and compared well with the other members of a panel of experts. On this occasion when he was arrested on a charge of stealing many thousands of pounds from the DSS, he took an overdose. Before he was due to appear in court, he took another overdose. Now he is in the psychiatric ward of a general hospital.
§ It is no good trying to find a label for these people. We are dealing with very difficult human cases. Those people need, if not a great deal of hard thinking, an extra dose of human sympathy if we can conjure it up.
§ Where do we look for solutions? There are a number of voluntary bodies which are doing splendid work in this field. One thinks straight away of the Mental Health Foundation which has recently published a remarkable report on mental offenders. One thinks of the Mental After Care Association, the National Schizophrenia Fellowship, the Effra Trust and one thinks in particular of the Matthew Trust with which I have been associated for many years.
§ I have one question to ask in relation to the Matthew Trust. I have given the Minister notice of this question. The Matthew Trust is a kind of home of last resort for some of the most difficult people and it does not receive a grant from the Government, although other excellent bodies do. I understand that is because it gives assistance to individual people. The Minister has had time to look at this matter and I wonder whether she is ready to say anything about why the Government refuse to give help to the Matthew Trust. That is one particular case.
§ Speaking generally about those bodies, one is bound to ask what it all amounts to. I am sure that noble Lords will deploy their wisdom on the subject in the course of the debate. But in general terms—and I have been in touch with those and other organisations—the answer is twofold: more resources and more co-ordination are needed.
§ It is easy to ask for more resources but in this field there is an urgent need for more resources. I am sure that other noble Lords will labour that issue. I hope that the Minister will be able to tell us how she sees the future, even if she cannot announce this evening that more resources are available. We are told that we are now coming out of the recession and that the country is doing extraordinarily well. In that case, how does the Minister see the extra resources, which surely now are becoming available, being deployed?
§ Everybody agrees on the need for more co-ordination. I give one old example, although it has not been mentioned here. Many years ago I tried to help Ian Brady who had been convicted of the terrible Moors murders. He was treated as a prisoner and was in prison for a number of years. Ronnie Kray and Peter Sutcliffe, called "the Ripper" have eventually been transferred from prison to special hospitals. Likewise, very soon after the Moors murders case, the Home Office agreed, 902 after taking psychiatric advice, that Ian Brady should be transferred to a special hospital. That was agreed by the Home Office at the highest level, but was refused by the Minister for Health; presumably on the advice of Broadmoor. That is an example of where there is a total difference of opinion between the Home Office and the Ministry of Health about a particular man. That happens all the time.
§ I have given notice to the Minister that I should be raising the matter of co-ordination. She has not had very much time but she has had time to think about it. I strongly urge the Minister to consider the proposal which all the voluntary bodies seem to favour—that there should be some kind of Cabinet Committee to co-ordinate the work of the departments. That involves the Home Office and the Department of Health in the first place but other aspects such as education and housing are also involved. That is the first proposal which I put before the Minister. A Cabinet committee sounds innocuous enough but it would certainly give a great deal of encouragement to the voluntary bodies.
§ How do I point the way forward? In the book Prisoner or Patient which I published two years ago, and which the Minister was kind enough to praise in this House, I concluded with half a dozen proposals. I refer to those proposals now, not necessarily in the same terms but in the same general sense.
§ To start with, nothing will dissuade me from saying— and my noble friend Lord Ennals will be able to speak with much more authority on this and other matters— that the Prison Medical Service should be included in the National Health Service. I say that because a number of people in prison are suffering from psychiatric problems. Some of them, if you like, ought to be in hospital; but even that would not cover the whole field. Many of those people just have psychiatric problems. Indeed, it has been said that one-third of them have such problems. I do not know the correct figure. That is the first thing that I would ask for, although somehow I do not expect the Minister to concede that tonight. Nevertheless, I felt that I should put it on the record.
§ There is then the question of how to ensure that people who ought to be in hospital are actually in hospital and not left in prison. I have two general ideas in mind in that respect. First, one wants to make sure that in the courts, for example, psychiatrists are much more readily available and, that, in general, the machinery for assessment is improved. The Minister can hardly say that it is perfect at present. If that were so, how was it that the three gentlemen to whom I referred—namely, Mr. Brady, Mr. Sutcliffe and Ronnie Kray—were in prison for several years before being sent to special hospitals? No one can say that they were not mental cases until they had been in prison for a time. If you like, they were just diagnosed incorrectly in the beginning. How does one arrange such things? Well, the Minister has all the facilities at her disposal. How does she suggest the system could be improved?
§ I return to the case that I mentioned earlier of Ian Brady not being transferred soon after imprisonment. How does one deal with that situation? It seems to me that we should give the courts power to ensure that, in some cases, they and the Home Secretary can make sure 903 that such transfers are made. However, in that case, the request was simply resisted by the Ministry of Health. When I talk of co-ordination, I do realise that the Minister who is to respond to the debate tonight is a Minister in the Department of Health. So, although we are talking generally about health matters, much of the time we are actually talking about Home Office responsibilities. That is where co-ordination ought to come into the matter.
§ I turn now to a most difficult subject. Indeed, I gladly wait to hear what the Minister has to say without trying to lay down the law. Two years ago, I suggested that the special hospitals should be broken up and much smaller units established. Well, something of that kind seems to have been suggested by that highly expert committee under that remarkable man who is an expert—if there is such a person in the field—Dr. Reed. He would like to break them up. However, I also know someone else to whom I listen with much deference and who does not agree with the Reed report. I refer to Peter Thompson, who was himself a patient in Broadmoor many years ago. He went into Broadmoor with nothing and started the Matthew Trust, which has been a great success over the years. Recently he was received with acclamation when he visited Broadmoor and actually preached a sermon. I have been with him to Broadmoor and have seen the respect with which he is treated.
§ From a purely practical and economic point of view, I believe that the Minister might find it easier if the Government were trying to secure degrees of security within the hospitals and setting up separate units on the same spot. That might be more economical. On the other hand, Dr. Reed and those who think like him—a very expert body —want to try to spread those places around so that they are nearer the homes of the patients. It is a very difficult question and I hope that the Minister will be able to give us some idea of her thinking tonight.
§ One would hope that the original target laid down years ago of 2,000 places in regional secure units will be achieved. I hope that that is part of the Government's target. I should like to know what is the Government's target for such units and how soon it will be achieved.
§ I turn finally to the question of community care, which I must leave to other speakers. It is a colossal subject. In my book I described it as a farce, and I do not run away from that wording now. Community care is a very ambiguous phrase. It could mean simply moving people out of hospitals and hoping that the community or the local authority will look after them. It could mean almost anything. However, until now it has certainly not meant much as regards the case of mentally disordered offenders.
§ During the proceedings on the Criminal Justice Bill I moved an amendment, that I subsequently withdrew, which would have placed a statutory responsibility on the Government to try to help all those people who come out of prison. I should certainly say the same about special hospitals. However, I shall listen with deference to other opinions as to how community care could be expanded, remembering always that it does mean an increase in resources. I believe that we can at least ask the Minister to say, as time goes on, in what direction she hopes to see such resources applied.904
The subject of mental offenders is, to say the least, not very popular. Indeed, they are not a popular community. Their lot is a poignant one and always will be. There is not much public sympathy for such people. So far as concerns prisoners and sick people, I remember the words in the Gospel:
I was sick and ye visited me:
I was in prison, and ye came unto me …
Inasmuch as ye have done it unto one of
the least of these my brethren,
ye have done it unto me".
§ That was a reference to sick people and prisoners. Well, mental offenders seem now to suffer from the pains and penalties of both. I urge the public, through this House, to give much more attention to these people in the future. I have no qualifications for speaking on such matters. I am only sorry that the right reverend Prelate is not present this evening to help us on the matter. I have a lurking suspicion that, if Jesus Christ were to return today, he would make a beeline for mental offenders. I beg to move for Papers.
§ 7.57 p.m.
§ Lord Addington
My Lords, I thank the noble Earl for drawing our attention to such an important matter. It is rather a pity that we are discussing it as the last item before Prorogation at the end of a very long parliamentary Session. When dealing with the mentally ill, it is worthwhile, first and foremost, remembering that such people are ill. They require treatment of some description and help from the medical profession. That is what makes the problem so difficult. It is not a permanent set of conditions; it may well change.
Moreover, we are not talking about one group of people; we are talking about a vast number of types of problem and the usual eternal degree of severity. We must try to discuss a system which will help such people in the various stages of the problem. I refer to those who have problems before they go into prison and those who acquire them while they are serving prison sentences. There are also those who suffer from mental after shocks as a result of being in the prison system.
There is another factor we should all bear in mind. The vast majority of people with mental health problems may disturb other people, but they are only a risk and a threat to themselves, not to other people. They may well be in prison for a variety of, say, annoyance offences. However, it is worth remembering that something like one-third of the people who commit suicide in our prisons—an appallingly high figure—have a history of mental health problems. Moreover, if I remember correctly, something like 21 per cent. of those who commit suicide in prison actually had mental health problems when they committed the initial offence.
We are talking about people who ultimately threaten and damage themselves. Such people are suffering from an illness which needs treatment. Perhaps I may use figures provided by NACRO and taken from the Gunn report produced for the Home Office in 1991. A sample was carried out of 1,365 prisoners serving long term sentences, that is, of over six months. The conclusion reached was that 40 per cent. had a disorder of some description. One arrives therefore at a figure of over 905 9,000 members of the then prison population who had mental problems. The document also established that 3 per cent. of the prisoners should not be in prison at all but should be in hospital to enable them to receive the appropriate level of help and assistance. That amounted to over 1,000 people who were in the prison system when they should be in hospital. We must try to establish some means of preventing these people ending up in custodial institutions because it is not helping them; and if it is not helping them it will not prevent their re-offending. Effectively we are creating a turnover of members of the prison population because we are not addressing their needs.
The prison service cannot address such needs. A prison is not a hospital; it is a system designed to detain people for a length of time and to restrict their liberty. Prison officers may, and often do, skilfully practise first aid on those with mental problems in that they administer drugs and make sure that prisoners do not damage themselves. However, prison officers are not doctors or trained nurses and in the vast majority of cases one cannot expect them to fulfil that role. It would be unfair to expect them to undertake such a job as, if they did, the prisoners concerned would end up by disrupting the prison.
The most effective way forward is undoubtedly some form of screening before sentencing for those prisoners who appear to have mental problems. This can be done, and has been done successfully, in the magistrates' courts at Peterborough, Clerkenwell, Bow Street, Marlborough Street, Horseferry Road and other London magistrates' courts. Two days a week psychiatrists are present to carry out assessments before someone is sentenced. As the psychiatrists attend regularly, people are not kept waiting before they are sentenced. The most up-to-date figures I have received date from 1992. According to the figures people were being assessed in under a week as opposed to over a month. Another result has been the awarding of appropriate sentences; for example, cautions or suspended sentences with conditions attached whereby the person concerned had to receive a certain level of care or had to take certain medication. Such sentences attempt to deal with the underlying problem and do not merely put prisoners into an already overburdened prison system.
As the noble Earl, Lord Longford, rather damningly said, community care has a long way to go in this area. Many people may be socially inadequate and may not wish to be assisted within their own community as they cannot appreciate the fact that someone is trying to help them or cannot organise themselves to enable help to be given to them. We require more staff to tackle this problem and possibly more secure housing units or at least sheltered housing units to make care in the community more of a reality. My expertise is not sufficient to enable me to speak for longer and I believe 906 that the noble Baroness, Lady Farrington, knows far more about the subject. I shall not delay her maiden speech.
§ 8.3 p.m.
§ Baroness Farrington of Ribbleton
My Lords, may I say first of all how grateful I am to my noble friend Lord Longford for providing the opportunity for me to address your Lordships on this extremely important topic. He has a long and distinguished record in caring for the interests of prisoners; I would say a record which is recognised well beyond the confines of this Chamber.
I start from the position that in a truly civilised society prisoners' needs are treated humanely within a requirement for punishment for crimes committed and rehabilitation prior to release. Mentally disordered prisoners need suitable provision either in hospital or a secure unit and ex-offenders may need care in the community. Indeed, such provision is needed from the time when someone is arrested on suspicion that he has committed an offence.
On a personal note, I have been a member of Lancashire County Council since 1977. During that time I have served in the past as a member of the police committee and as a Lancashire Police Authority lay visitor. In that capacity I have always taken the view that we must listen and respond when police officers express the need for appropriate provision for people whom they detain when police station cells are clearly inappropriate. This experience, if I may say so, has also highlighted the need for more facilities to help people overcome drug and alcohol dependency problems.
Furthermore, my experience since 1981 as a member of the Council of Europe Standing Conference of Local and Regional Authorities is relevant. During that time many warnings were given by colleagues from other countries, especially speakers from the United States of America. They warned that greater demands would be placed on law enforcement agencies due to the spread of drug dependency and abuse. In my capacity as a county councillor, especially chairing the education committee from 1981 to 1991, it has always been my view—and it has become increasingly clear—that such warnings were accurate.
I refer to the Department of Health local authority social services letter, Guidance on the Discharge of Mentally Disordered People and their Continuing Care in the Community, and in particular to paragraph 41 regarding mentally disordered offenders. I would remind your Lordships that it refers to the requirement for National Health Service authorities to work with local authority personal social services and criminal justice agencies to develop strategic and purchasing plans. These are to be based on the Reed review of services 907 referred to by my noble friend, which was produced jointly by the Department of Health and the Home Office. These services must include,An effective range of non-secure and secure services—including those for patients with special or differing needs such as people with learning disabilities or psychopathic disorder, ethnic minorities young people and women—Arrangements for multi-agency assessment and, as necessary, diversion of offenders from the criminal justice system—Meeting the mental health care needs of transferred or discharged prisoners—The placement within six months of special hospital patients who no longer require high security".The ideals lying behind care in the community are unexceptionable; indeed they have all-party support. It cannot be right for anyone whether, for example, they are frail, elderly, have learning difficulties or are recovering from or suffering from mental illness to be institutionalised unnecessarily. Many ex-offenders could stay in their own homes if their needs could be met in the community, although for some people their needs will always have to be met in specialist residential accommodation.
The problem facing local authorities in fulfilling their obligations is the high level of need and expectation arising from present policies for care in the community. If the idea behind care in the community was simply to save money by closing large, long-stay institutions, it was never a starter. My noble friend has, however, identified ex-offenders whose needs may be met in the community. It is quite clear that in the current year many local authorities are unable to meet the level of demand for care in the community. In passing, I would note that many county councils face a particularly acute problem due to the way funds are allocated.
As your Lordships are aware, national decisions are difficult, with competing priorities. The problem of meeting care in the community needs becomes even more difficult when it is a question of individual cases at local level. For example, often elderly people are cared for by elderly husbands, wives or even children who themselves are over retirement age. The families of those with learning difficulties need day care and respite care. The families of mentally ill people, sometimes children coping with mentally ill single parents, need support. All these are important and heart-rending cases. Nevertheless, within those competing demands the needs of mentally disordered prisoners and ex-offenders also need to be met, and met urgently.
I should like to pay tribute to the dedication and skill of professional staff, including those who have worked or continue to work in long-stay institutions. Such expertise must now be used increasingly within the community as well as within needed hospitals and secure units.
My noble friend Lord Longford has made a compelling case, citing individual examples. The House will be aware from what I have said that that is linked with the problem of care of the mentally ill generally. Prisoners and ex-offenders are a particular example of that general problem.
908 I have tried this evening to present my views based on my own experience on how we may improve the quality of life—if I may use that expression—of those: who, through no fault of their own, are among the most disadvantaged in society. I am privileged to have the opportunity to do so. I hope that my noble friend's Motion will encourage further debate on these matters. I am sure that your Lordships will understand that on a future occasion I may be more controversial in the points that I make on care in the community.
§ 8.11 p.m.
§ Lord Ennals
My Lords, it has several times been my privilege to welcome a maiden speaker. However, no doubt by accident, I have never had the pleasure of welcoming a maiden speaker from my own party. I do so today with great joy and satisfaction because of the enormous breadth of experience which my noble friend Lady Farrington brings to this House. I believe that we are inadequately provided with people with local authority experience. In my noble friend's outstanding maiden speech we could see the value of having with us a chairman of the Association of County Councils, a Labour Member of Lancashire County Council since 1977, the chair of the Education and Training Committee of the Regions, and member of the Council of Europe Congress of Local and Regional Authorities, and so on. She brings a welcome experience. That was apparent in her speech, and I know that it will be apparent in other speeches which she makes during her stay in this House, which I hope will be very long, and which I hope will be contentious until such time as she finds herself, with me, sitting on the other side of the House.
I also want to say some very friendly words to my noble friend Lord Longford. I call him my friend in a sense of deep personal admiration. My noble friend is one of those people for whom I would do anything he asked, if I could. He is a most persuasive man. On the subject of the debate tonight, there is no one who has been more persistent, more loyal, more constant and more caring, because of his own personal experience. He is not one to make speeches and stop at that. He is a man who knows people and visits them in prisons and hospitals, and wherever they may be. He is an example to this House. Therefore, it is an honour for me to take part in a debate in which he is involved.
We are dealing with a very difficult subject. The term "mentally disordered offender" is used to describe a broad group of people within the health and social services and the criminal justice agencies. It includes people with mental health problems who have come to the attention of the courts or forensic services. Mental disorder is defined in the Mental Health Act 1983 as:mental illness, arrested or incomplete development of mind, psychopathic disorder and any other disorder or disability of mind".It also includes people who have committed drug offences. It covers a wide variety of our society, almost all of whom deserve and need our sympathy and understanding.
909 As your Lordships know, there is a high level of suicide among such people. That level seems to be growing, although the Minister may say that it is merely that the publicity concerning such cases is growing.
The Mental Health Act 1983 contains provisions whereby a person can be detained against his or her will. I sat on the Standing Committee which dealt with that Bill. I believe that there is an obligation under certain circumstances to detain against their will people who cannot know what is best for them.
One of the forms of mental disorder is psychopathic disorder. This is defined as:a persistent disorder or disability of mind (whether or not including significant impairment of intelligence) which results in abnormally aggressive or seriously irresponsible conduct on the part of the person concerned.The government policy applies in the community and in prison. Once someone with a mental disorder is in prison it is all the more important that that person is transferred to NHS facilities given the inadequacy of health care in the prison service. My noble friend Lord Longford referred to that issue, which we have touched on many times. It is important that medical services within prisons should be brought within the confines of the National Health Service. I am sure that that would improve the quality of treatment within the prison service.
As your Lordships will know, I have the honour to be President of MIND. My noble friend Lord Longford referred to the many voluntary organisations which are closely involved in this field, not only in policy formation but also in helping people up and down the country, in their 230 local associations.
MIND's concern is that the law, and appropriate provision of services, are inadequate to the task, with the result that people with mental disorders remain in prison.
Research commissioned by the Home Office on the remand population and the sentenced population within prisons established that, for example, 37 per cent. of men serving a prison sentence of six months or longer suffered identifiable mental health problems. For women, the figure was 56 per cent., which is very high.
There are many examples of inadequate treatment facilities, and sometimes an inadequate approach. A recent MIND publication on physical treatments states:Where distress is seen as mental illness, drugs or ECT are likely to be prescribed. Yet the social roots of distress, the impact of poverty on mental health, the far-reaching effects of childhood trauma, particularly sexual abuse, are known. The majority of people who hear voices can identify a traumatic or emotional event when the voices started. Life stresses can provoke, prolong or worsen mental distress. Major frustrations of mental health service users are the services' failure to address the hidden roots of distress, and to meet the pressing needs for income, satisfying work and someone to talk to".Under Section 4 of the Criminal Justice Act 1991, where a defendant is found guilty and the court believes the defendant is suffering from a mental disorder, a psychiatric report must be obtained. The court can request information. If the regional health authority does 910 not have a bed available, it is empowered to purchase facilities elsewhere. If it says that it has no funds to do that, the court cannot require funds to be made available.
The issue was raised at the Central Criminal Court (the Old Bailey) on 27th October this year, when a defendant named Hart was convicted and the court felt that a hospital order was the appropriate disposal. No bed was forthcoming and the judge stated that Virginia Bottomley, the Secretary of State for Health, would be brought before the court to explain why that was the case. We do not have Virginia Bottomley present, but we have the Minister. I do not suppose that she will make a statement on that case. I invite her to do so in case she can be persuaded. That is an immediate example of a real shortage of facilities.
Recent reports by the Royal College of Psychiatrists, the Audit Commission, the Mental Health Task Force and the Mental Health Foundation have all stated that there is a lack of appropriate resources for the care and treatment of people with mental illness—that covers those who are mentally disordered—and that there is inadequate provision in the community of services such as appropriate housing. That means that in-patient facilities contain patients who could leave hospital but do not have suitable accommodation and services in the community. That is grossly wasteful in time, money and human lives. As a result, in London some wards have an occupancy rate of up to 130 per cent. Some people will become involved with the police and the courts and possibly will be remanded to prison because of the lack of adequate services in the community. Regional secure unit facilities are overcrowded with patients who have been transferred from prison and with those who could be discharged into the community. Special hospitals are unable to transfer many patients to less secure facilities because of the blockage of regional secure unit beds in this way. Therefore we are faced with a problem.
I give one further example. I read a report in September of excruciating delays in Crown Court hearings which are jeopardising a pioneer project aimed at keeping mentally ill offenders out of prison. The Bentham Unit, funded by the Department of Health and North West Thames Regional Health Authority, is based at Ealing Hospital, West London, in a locked ward on the St. Bernard's wing, a former Victorian mental asylum that I know well. Set up in February, it aims to relocate suicidal or mentally ill prisoners into hospital for more appropriate care. After the initial assessment, the unit expects to refer them to longer stay facilities within a month. However, beds are being blocked by patients forced to stay on the ward for up to six months waiting to come to court. Kevin Murray, consultant forensic psychiatrist, stated:It puts a major strain on our unit. People remain in a state of anxiety until their court cases are finalised, and the possibility of doing therapeutic work with them is compromised".It is not enough to understand the problems. The last speech—it was a brilliant maiden speech—indicated how well the noble Baroness, Lady Farrington, understands the situation. There must be more resources. The absence of more resources is expensive. It is 911 expensive to keep people in hospital when they should not be in hospital. Example after example demonstrates where money is wasted because it is not properly used.
I again thank my noble friend Lord Longford. I look forward with great interest to what the Minister says.
§ 8.26 p.m.
§ Lord Rea
My Lords, it was a pleasure to listen to my noble friend opening this short debate, carrying forward what is a truly personal crusade on behalf of those who, rightly or wrongly, have fallen foul of the law. His views remind me of Samuel Butler's Erewhon in which criminals are regarded as sick and in need of help. However, I do not suggest that he believes in the other half of the Erewhon code which regards ill people as criminals!
I, too, congratulate my noble friend Lady Farrington on her elegantly presented and cogent maiden speech. It has not taken her long, non-controversially, to break her duck. But I am delighted that she will be playing an active part in our proceedings, duly hitting controversial fours and sixes around the House.
As I knew at only rather short notice that I would speak tonight, I have to apologise to my noble friend for the fact that I have not had a chance to read his book Prisoner or Patient. It probably says everything that I shall say and answers the questions that I shall ask. The noble Earl and others drew attention to the report by the Mental Health Foundation describing the 12 regional conferences on mental offenders, promoting care and justice. It is an impressive document and gives the consensus views of thousands of professionals throughout the country concerned with mentally disordered offenders who met at those conferences. The only disappointment for me as a doctor with an interest in epidemiology—that is, the study of the health of communities—is that the report leaves us not much wiser with regard to the actual size of the problem. However, the noble Lord, Lord Addington, and my noble friend Lord Ennals have given some figures indicating what an enormous proportion of our prison population is comprised of people who have mental health problems.
Many offenders sent to prison or community service are in fact mentally ill or handicapped or have a personality disturbance—that is the modern word for a psychopath; one has a personality disturbance. An article in the British Medical Journal about three weeks ago entitled Who's Psychopathic Now? indicated how difficult it is to define that group of people. However, it is also clear from the report that many involved in the whole criminal justice system are not well informed as to how to identify, handle or refer mentally disordered offenders.
It is sad to read that the conferences did not always attract enough defence solicitors, senior social service managers or senior police officers. What a shame it is— and I regret the fact—that no noble and learned Lords are taking part in the debate tonight because they could have thrown some useful professional light on the problem, which is very much a socio-medico-legal one. As other speakers have said, the subject requires the co-operation of the caring professions, the legal 912 profession, local government and central government. I agree that solicitors, social service managers and senior police officers are busy people. However, they hold key positions and are in a position to influence those under their direction. It would have been useful for them to have been at those conferences. That fact illustrates that there is no doubt that this client group—the mentally disordered offender—is several pegs down the priority list for many decision makers.
In that group I do not necessarily include the Home Office or the Department of Health, which I know are concerned about the problem. But are training packs and circulars, however good, the answer? My noble friend quoted one publication which has recently been produced. I believe that two more are planned. Perhaps I may repeat what every speaker, without exception, has so far said and which comes out over and over again in the report. It is that the real need is to strengthen community care for the mentally ill and handicapped as a whole.
Most mentally disordered offenders are not dangerous. They can and should be contained in the community. The report says:The consensus is that services for mentally disordered offenders should be part of mainstream mental health services and seen in the context of contemporary community care policies. However, community services for the mentally ill are the least developed of all services and continuous effort at both professional and political levels is needed to improve them".As the noble Baroness knows, community care is not a cheap option. Again, nearly every speaker has mentioned that. However, the noble Baroness also knows and believes, as I do, that it is the best way to care for most mentally ill people, other than perhaps the most acutely disturbed, for whom there will always be a need for hospitals and secure units. Although there are now excellent examples of community care around the country, there are too many cases where the reverse is true. As my noble friend Lord Ennals said, if suitable, well-staffed community care placements had been available in the Hart case, Judge Laughlen would not have had—theoretically—to threaten the Secretary of State for Health with a subpoena to be brought before the court to explain why no suitable hospital place was available.
My noble friend quoted the recommendations and the statement of the problem which MIND—of which he is president—put forward, so I shall not repeat them. The Mental Health Foundation report usefully points to a range of steps which would help the care of that group of unfortunate people.
However, behind all that looms the question of lack of resources. Forty-one per cent. of participants in the series of conferences—all professional, experienced workers in the field—felt that their own organisation was inadequately resourced. Only 6 per cent. said that they were satisfied with their resourcing. Until that problem is addressed, we shall be left with the present worrying situation in which expensive prison places are occupied inappropriately. Mentally sick people, some of whom are potential offenders and some of whom are 913 past offenders, are left inadequately cared for or supervised in the community. That is dangerous for them and for you and me.
§ 8.32 p.m.
§ The Parliamentary Under-Secretary of State, Department of Health (Baroness Cumberlege)
My Lords, I am grateful to the noble Earl, Lord Longford, for initiating this debate and for his customary courtesy in giving me advance notice of his questions. His extensive knowledge and continuing interest in offenders and ex-offenders is well-known, respected, admired and it has been paid tribute to tonight. Mentally disordered offenders are not a group who inspire great public affection. Working with them is hard and often unrewarding. But, through his writings and work with individuals and organisations, the noble Earl has done much to ensure that their special needs are not forgotten, especially by those who have a responsibility in both health and social services.
On behalf of these Benches, I should also like to extend a very warm welcome to the noble Baroness, Lady Farrington of Ribbleton, and congratulate her too on a remarkable maiden speech. I know that she had and indeed still has a distinguished career in local government. I share a little of her background but I have to say that I never reached the dizzy heights of chairing the Association of County Councils. I very much look forward to other contributions that she will make in your Lordships' House, which we know will be well researched and based on experience.
As the noble Lord, Lord Addington, reminded us, the needs of mentally disordered people who come into contact with the criminal justice system are complex. They often require intervention over a period of months or even years and almost always involve contact with several different agencies. The task of planning and providing services includes the probation and social services and housing departments as well as the NHS and informal carers. But, as the noble Earl, Lord Longford, reminded us, voluntary bodies also play an important part—both locally and nationally.
An important principle underlying government policy and reiterated in the report of the joint Home Office and Department of Health review—the Reed review— showed that mentally disordered people should receive the care and treatment they need from the health and social services rather than through the criminal justice system. Care should be provided under conditions of security commensurate with, but not exceeding what is justified by the degree of danger they present to themselves or to others. That policy can be traced back at least to Victorian times, but in the wake of the Reed review we honestly believe that we have made greater strides in the past two or three years than ever before.
Many of the review's recommendations relate to good practice and must be led by the people who work with offenders on a daily basis. I have been encouraged by the many changes which have taken place, often in very difficult circumstances.
914 I certainly do not accept the suggestion of the noble Earl, Lord Longford, that community care for mentally ill people is a farce. But I do agree with the noble Baroness, Lady Farrington, and the noble Lord, Lord Ennals, that the vast majority of people with a mental illness can live and indeed are living successfully in the community without posing any threat to themselves or others. Perhaps I may assure her and the noble Lord, Lord Rea, that the objective of community care is not to save money but to offer more appropriate and acceptable care. Research shows that overall costs are broadly comparable between a service based on a large hospital institution and a more local service.
Research evidence, both here and abroad, strongly supports the conclusion that mentally ill people, including chronic and severely ill patients, can be successfully treated in the community so long as hospital services are available when needed. The policy has the support of the vast majority of professionals and, according to a recent government survey, is supported by three out of four people in the general population. Recent reports by the health Select Committee, the Mental Health Foundation, the Audit Commission and the Royal College of Psychiatrists have all endorsed the principle of community care for mentally ill people. I share some of the views expressed by the noble Lord, Lord Rea, that until now mentally disordered offenders have not been seen as a high priority. But that is changing. This year we have specifically made it a first order priority for health authorities to assess their needs and to commission the range of services necessary to meet those needs. This means that the NHS must work with other agencies to develop supported housing and community services as well as specialist hospital care. In a number of areas, health commissioners have established formal links with criminal justice agencies and social services to develop joint plans.
Effective co-operation between agencies is one of the keys to success. I agree with the noble Earl on that. I think it is the key to success for community care generally, but more especially for this particular group of people. Probably the single most important criticism in the report of the inquiry into the care and treatment of Christopher Clunis was that the various agencies did not act in a co-ordinated way. Mr. Clunis was not denied services—indeed, he received hundreds of hours of professional interventions. But again and again he was allowed to slip through the net. If we are to avoid future tragedies of this kind, agencies and those who work in them need to be clear about each other's roles and responsibilities.
To help to ensure that, we have prepared a guide to arrangements for inter-agency working. The guide was issued for consultation last month. It is designed to provide a point of reference and it gives examples of good practice for people who work across agency boundaries. I understand that my right honourable friend the Home Secretary intends to issue similar guidance to those working in the criminal justice system.
Over the past four years we have provided pump-priming funds for 96 multi-agency schemes. A number of them involve housing associations and 915 voluntary agencies, which often play a vital role in maintaining mentally disordered people in the community.
In August last year, my right honourable friend the Secretary of State for Health announced a 10-point plan. This plan incorporates our hope to introduce a power of supervised discharge as an amendment to the Mental Health Act as soon as there is space in the legislative programme. The new power would apply to a small number of the most vulnerable people, typically those whose symptoms are well controlled by medication but who have a history of relapse after discharge from hospital. In proposing this we are very aware that legal powers can never be a substitute for properly planned and delivered services. Use of the power would need to be matched by a commitment to provide the services identified in the individual care plan.
Priority mental health registers, or supervision registers, were introduced in April this year to include patients who are judged to be potentially at significant risk of seriously harming themselves or others. The registers will provide a point of reference for relevant and authorised health and social services staff, will make clear whether individuals are at risk, and will help plan the facilities and resources needed by this group of patients. The new registers will complement existing systems for supervision of restricted patients who are conditionally discharged from detention under the Mental Health Act.
Guidance on the discharge of mentally ill people and their continuing care in the community was issued in May. The guidance is based on application of the care programme approach and puts special emphasis on the importance of risk assessment before patients are discharged. The guidance was highlighted effectively this evening by the noble Baroness.
It is very important that those working in the community with mentally disordered offenders have the knowledge and skills to respond appropriately to their needs. Last year we funded the National Association for the Care and Resettlement of Offenders (NACRO) to develop a training pack for social services staff. Copies have been provided for all social service and probation departments and chief officers of police in England. A series of six seminars have been held to promote its use. The department is funding further work to develop forensic social work training this year.
A number of recent reports—from the Mental Health Foundation, the Mental Health Task Force in London, the Royal College of Psychiatrists and the Audit Commission—have drawn attention to the current pressure on NHS mental health services. I am afraid that some of them have failed to give proper credit to positive achievements.
The noble Earl, Lord Longford, and the noble Lords, Lord Ennals and Lord Rea, were concerned about resources for mental health services. A total of £1.8 billion is spent each year within the NHS. Gross expenditure on local authority social services for mentally ill people increased by 171 per cent. in real terms between 1978 and 1991 to £179 million.
916 We have also set aside £45 million to support the development of medium secure psychiatric facilities in the NHS. This will increase the number of beds available from 600 in 1991 to over 1,150 by 1996— going a long way towards meeting the needs for medium secure places identified in the assessment exercise undertaken by regions last year. The important thing is that health authorities have clear strategies to meet their population's assessed needs for all types of secure places, and this is what we are requiring them to do.
The noble Baroness, Lady Farrington of Ribbleton, also cited the need for sufficient professional expertise. We agree with her. In the past four years we have increased the number of forensic psychiatric posts in England from 50 to 82 for consultants, and from 11 to 29 for senior registrars. For this year alone, 22 additional senior forensic registrar posts have been agreed. This adds up to a substantial programme of initiatives to improve services for mentally ill people in general and mentally disordered offenders in particular. We have also been playing our part to ensure that mentally disordered people who have found their way into the criminal justice system get the treatment and care they need.
The noble Earl, Lord Longford, and the noble Lord, Lord Addington, highlighted the value of having psychiatric assessments available in the courts. We agree with them very strongly, and it is a growing area of provision. Eighteen months ago I was able to tell your Lordships that 40 court-based assessment schemes were in place. The number has now increased to over 100. I am sure that the noble Earl and the noble Lord, Lord Ennals, will also be pleased to learn that the number of prisoners transferred to the NHS for treatment under the Mental Health Act has increased from 325 in 1990 to over 750 last year.
Like noble Lords, we are concerned that prisoners who have some degree of mental disorder but who do not require transfer under the Mental Health Act should receive high quality care in prison. The health care directorate is working closely with the NHS to develop the services they provide and to ensure that the health and social care needs of prisoners are assessed and met on discharge.
We welcome the fact that the health service is responding so well to the needs of prisoners but also recognise that, as a result, there are additional pressures on staff and resources. As I said, we are responding through the expansion of medium secure services. But meeting the needs of mentally disordered offenders remains among the most challenging tasks faced by health and social services. I take this opportunity of acknowledging the hard work and commitment of the people who work in those services.
The noble Earl and the noble Lord, Lord Ennals, raised the question of greater power for the courts to enforce hospital orders. The Mental Health Act allows such an order to be made only if arrangements have been made for the patient's admission to hospital; in other words, the hospital must be prepared to take the patient. Strictly, this does not apply when the Home Secretary directs the transfer of a prisoner to hospital although in practice it is unheard of for this to be done 917 without the hospital's co-operation. However, the court also has the power under Section 39 of the Act to require a report from the regional health authority on the availability of hospital places, which can be quite an effective sanction. On the whole we think this is a fair balance and are not persuaded that hospitals need to be placed under greater constraint, especially considering the increase I have just mentioned in the number of prisoners transferred to hospital.
The noble Lord, Lord Ennals, referred to a particular recent case. Perhaps I should explain that the problem was not that a bed was not available but that the judge did not accept the doctor's advice that hospital was not necessary. As soon as it became clear that the court required a bed to be available, both a place and the necessary funding were made available.
The Reed review was a watershed both in ideas about mentally disordered offenders and in practical action to help them. In the two years since it completed its main task we have continued to act energetically on the issues it raised.
In July this year we published two reports on the important and difficult issues of high security psychiatric services and psychopathic disorder. The latter was issued for consultation and we shall be looking very carefully at the comments we receive on the proposals, which are due by the end of this month.
As to high security services, which are at present concentrated in the three special hospitals, it is very important that decisions about their future take proper account of the important issues they raise about public safety and the relationship of the services with the rest of psychiatry. We have commissioned further work by officials who will be reporting back in January next year. My right honourable friend the Secretary of State will consider the future development and organisation of the services, including questions about the size of the present special hospitals, in the light of this assessment.
I should also briefly like to mention two further reports on race, gender and equal opportunities, and services for people with learning disabilities or with autism which we published in February this year. These represent the final phase of the Reed review proper but to keep us on our toes we have set up an advisory committee for mentally disordered offenders to advise Ministers in the Department of Health and Home Office on taking forward the recommendations of the Reed review. The committee is made up of distinguished outside people involved in work with mentally disordered offenders. Although, I appreciate, it falls short of the proposal for a Cabinet committee, suggested by the noble Earl, it plays a very valuable role in ensuring that these issues remain a high priority for both departments.
I know of the noble Earl's continuing interest in the Matthew Trust and I should like to pay tribute to the practical support the trust is able to give to individuals in crisis situations and for its other work. As the noble Earl is aware, we have to apply strict criteria to the grants we give to voluntary bodies and I am afraid that the work of the trust, valuable though it certainly is, does not meet these. Rather than take up your 918 Lordships' time with a detailed explanation perhaps I could write to the noble Earl and also place a copy of the letter in the Library.
The debate this evening has been pertinent, relevant and productive. It has demonstrated the considerable interest, depth of understanding and expertise among Members of your Lordships' House. Work in this field will never be easy; there are no simple answers. But I am encouraged by the momentum of current developments and pay tribute to those in health, social services and voluntary organisations who have worked so hard to achieve real improvements in the care of mentally disordered offenders. We also owe much to the noble Earl, Lord Longford, whose ever watchful eye ensures that the needs of mentally disordered offenders remain high on the Government's agenda.
§ 8.50 p.m.
§ The Earl of Longford
My Lords, after many years I have at last discovered that tabling a Motion instead of an Unstarred Question means that I get the last word. It took me 49 years in this House to learn that and I nearly missed it. But I can assure everyone that my final remarks will not only be short, but also friendly.
We are bound to be impressed by the reply from the Minister. It needs careful study. However, anyone who is deeply involved in these matters—as we all are tonight—must feel that not only is an immense amount of work being done on this issue, but also that in the Minister those with mental disorders have a real champion. I am sure that she would gladly do much more for them than government finances appear to permit.
I forecast that we should have a debate of high quality. I even ventured to imply that it would be of a higher quality than that preceding it. As I did not listen to that debate I cannot make a comparison. However, I can surmise that our debate came out better. No doubt if I had listened to the first debate I should not be so confident.
I am glad that I was followed by a spokesman for youth. People sometimes talk of this House as being a place for oldies. In the noble Lord, Lord Addington, we have a spokesman for youth. As far as I am concerned, anybody who is still playing first class rugger must be regarded as a young man and I was particularly glad to hear from the noble Lord.
I am sure that everybody present tonight realises that in my noble friend Lady Farrington the House has acquired an exceptional addition to its number. She speaks with the authority of real distinction in local government. I may be wrong but I am not sure that any other Member of your Lordships' House has ever been the chairman of the Association of County Councils. I am told that one has been; but that one has long since been forgotten, at any rate by me. So far as I am concerned, therefore, my noble friend is unique.
My noble friend Lord Ennals was so kind about me that it may be thought that there is some kind of mutual arrangement between us whereby I repay the compliment. But my noble friend too is unique. Not only has he directed MIND, but he is now its president. I do not believe that anybody has ever run a large 919 charitable organisation and become a Cabinet Minister—if anyone tells me otherwise, I shall not believe it—and that certainly makes him unique. I am sure, therefore, that my noble friend is unrivalled in that way and we listen to him with special respect.
My noble friend Lord Rea is a doctor and doctors are the people we rely on in the end. We turn to them and ask whether a man is mentally ill or otherwise. It is people like my noble friend Lord Rea who make those terrible decisions and from what he said tonight we understand that he is well qualified to make them.
920 I am grateful to all the speakers. I hope that somehow or other the suggestions will bear fruit. I can see from what the Minister tells us that a tremendous amount is being done. And if we can obtain the extra resources there will be something like triumph at the end. I beg leave to withdraw the Motion.
§ Motion for Papers, by leave, withdrawn.