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The Mentally Ill: Care In The Community

Volume 572: debated on Wednesday 15 May 1996

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6.1 p.m.

rose to call attention to the situation of the mentally ill under the care in the community programme, especially those requiring 24-hour nursed residential care; and to move for Papers.

The noble Lord said: My Lords, I framed this Motion to give an opportunity to take stock. The community care scheme has now been in effective operation for three years. The Griffiths Report was published in 1988; implementation was postponed from 1991 to 1993 and a new edifice has been or is being built. As with all large edifices, it could not be completed overnight. The building had to be occupied before it was fully finished and the work of completion and improvement is still going on. I hope that the Minister will regard any critical contributions this afternoon as intended to be constructive. Care of the mentally ill is not a party issue.

We gratefully acknowledge the fundamental transfer of emphasis from segregation in the vast old institutions to a network of services designed to integrate patients into their local communities, as far as possible linked to families and friends, for which the Government are responsible. But, as Sir Roy Griffiths indicated, there are inevitably problems and frictions where responsibility is divided. The Government must retain responsibility for health treatment as such; but local authorities are best qualified to provide most of the supporting services—accommodation and so forth. And many local authorities, as has been so vividly illustrated in some of the reports published in the past two years, had little or no familiarity with the needs of the mentally ill until five years ago.

A thick fog of ignorance and inertia of both councillors and officials had to be penetrated and replaced with enthusiastic interest and commitment. There is a limit to the extent that, after devolution of responsibility, departments can intervene beyond guidance, encouragement and funding. Much progress has been made on which the Government and local authorities deserve congratulation. But, as Ministers would be the first to acknowledge, much remains to be done before community care becomes a reality throughout the whole country, especially for the seriously ill.

I hope that, after three years, it is timely to take stock. The Motion does not embrace the whole constituency of community care. The Motion of the noble Lord, Lord Carter, in 1992 covered the whole field—the needs of the aged, the disabled and the handicapped, as well as the mentally ill. It is the latter alone with whom we are concerned today.

A vast number of sufferers, estimated at some 250,000 (and to those one must add the carers who bear such burdens and have such pain) form a huge segment of society. Most noble Lords have had some personal experience of the immense burden that this scourge inflicts. It is reassuring that some 25 per cent. of sufferers eventually, after a first attack, recover. But most relapse frequently and I understand that between 10 and 15 per cent. are permanently and gravely ill.

In the past year many different facets of the problem have been discussed in our debates on legislation and in Questions. Latterly, the main concern has inevitably been about homicides. Sensationalised by the media, they have given the public an entirely false impression of the prevalence of violence among schizophrenics. I am advised that aggression and violence are not symptoms of the illness as such. But negative coverage has increased the prejudice and anxieties of the public about relations with the mentally ill and that of course has been reflected in resistance to the opening of facilities in residential areas and generally tends to add to the difficulties of carers and professionals. The mentally ill need sympathy and inclusion in social life.

An important new recent development has been the improvement of drugs on which treatment largely depends. I am told that clozapine and risperdal apparently have much enhanced efficacy and have far fewer harmful side effects. But they are extremely expensive. There is evidence that fundholders responsible for budgets are resorting to rationing of the new drugs to save money. That is a problem that needs to be addressed. If the new drugs clear up the symptoms, they will save money on future treatment and be cost effective, as has apparently proved to be the case in Germany. Is this a matter that the Royal College of Psychiatrists can clarify?

The Government have taken many helpful new initiatives in the past three years. The most important recently has been the decision to provide additional nursed residential accommodation for 5,000 seriously ill patients. There have, as we well know, been repeated reassurances that the closure of old hospitals was being matched by modern replacements, but many of us have felt that in the real world this has often not been experienced. We welcome the new decision but a number of questions arise. Are the new units going to be of the required high standard? There is a graded scale of the degree of supervision, nursing, security, recreation, employment opportunities and so on that residential homes and hospitals require. It is above all important that they should not be too large. I believe the optimum for therapy is said to be 10 to 12 beds with ample sitting rooms and private gardens—all very expensive in terms of both staff and buildings. What is the timetable to be?

At present, closures are, I understand, continuing to proceed apace at the rate of some 4,000 to 5,000 beds a year. How long then will it be before the new nursed residential units are open? Surely there should be a moratorium on closures in any area in which there will not be replacement beds with nursing and medical services. I, for my part, have never been able to understand why the Government have been so inflexible on accelerating closures. Questions in both Houses of Parliament have signally failed ever to get a clear explanation. I must say that the absence of replies suggests to the uninitiated that the programme is dictated by prejudice against the old institutions.

All of us who have visited the old hospitals to see patients in them have initially been horrified by their awful appearance. That seems to dominate the perception of their quality—a quite different thing. I shared the initial reaction but I revised it. In spite of the forbidding old buildings and the isolation from the community which we deplore, these hospitals have provided, in the absence of suitable alternatives, good care, excellent treatment with all the skills available on the spot, companionship, decent food and a sense of protection. They can indeed come to be regarded as a home from home. No doubt there are difficulties in adjusting timetables but patients' care should not be subordinated to bureaucratic inertia.

The excellent reports on the successive homicides have vividly illustrated the dangers of discharge when there are no adequate services to take their place. But there is heavy pressure to discharge too early, especially in London and the big cities. Again, patients requiring beds and treatment are turned away because there is no room. I have illustrations of this which I shall not quote as I have not time.

A related problem of accommodation is the quality of the private sector homes. Some of your Lordships will have seen a rather sensational "Panorama" programme—not the first sensational programme by "Panorama". I do not necessarily suppose that this is a fair representation of what goes on generally in the private sector, but it indicates that there are cowboys about exploiting the taxpayers' readiness to fund residential accommodation and disregarding the responsibilities that go with the provision. The Audit Commission in 1994 found that no district surveyed had an adequate range of community services. There is a great problem of co-ordination. This is a problem that all concerned have to continue to address.

We much look forward to the maiden speeches of two contributors tonight. We shall be greatly interested in what they have to tell us. My Lords, I beg to move for Papers.

6.17 p.m.

My Lords, may I express an interest in the care and nursing of the sick? As a nurse I followed in the footsteps of my mother, Vera Tyrwhitt. She inherited the Berners Title but she did not take her seat. She trained as a nurse at Guy's Hospital in the 1920s, and died only four years ago at the age of 90. I trained in general nursing at the Radcliffe Infirmary, Oxford, just as penicillin was first being used on the wards. I think the skills at administering injections of antibiotics left much to be desired from the patient's point of view. I well remember one of my patients escaping through a window one night as the four-hourly dose-time approached. We just managed to prevent him from disappearing down the Woodstock Road.

What a huge change there has been in the various treatments and codes of practice in the nursing profession, not only since my mother's day but also from my day. It is quite staggering. Doubtless many changes came about due to the experiences and expediencies of the war. There has been vast funding and investment in research and in training for new disciplines to serve different concepts of treatment. There are special codes of practice for transplants, scans and high technology in every field of medicine—and certainly no more just bed rest.

Since my days of nursing many more skills are needed by nurses, so Project 2000 was devised to provide facilities to study for these new skills up to graduate standard. Many jobs previously done by junior doctors are now done by these nurses. Those who have the love of nursing in their blood but do not want university qualifications are happy to back up these skilled graduate nurses and they join the profession as health care assistants. A vast array of these people are needed not only in the hospitals but also for the delivery of the various packages put together for care in the community. This much-valued policy is for looking after people in their own homes where they are in familiar surroundings and can keep to their own routines as much as possible. This promotes the patient's own ability to stay the course with a little—or in some cases a lot—of help from nurses and friends. I am sure that this is also applicable to the mentally ill in a great many cases.

Memories and hearsay of those large institutions where people with every kind of mental illness were housed, often for life, in the first place, were necessary then. There was less effective treatment to control or cure their conditions. This is a thing of the past.

There are, of course, some people for whom secure accommodation is very necessary, like those who are known to be dangerous either to others or to themselves. Places for these patients do exist, as they do for the 24-hour nursing care for Alzheimer's patients and the demented.

I live near a very new unit for the acute mentally ill, built and run by the East Gloucestershire Health Trust. It also has a special assessment centre that sorts out, by careful tests, what would be the best on-going arrangements and treatments for people who are sent to it by hospitals and the general practitioners. In the same complex is an excellent, recently extended long-term care unit and convalescent hospital where my mother helped out for a while when they first moved to Cheltenham in the 1960s.

There are other places in Gloucestershire where help and support can be found, such as mental health resources centres. There are four of these fully staffed and working in conjunction with general practitioners and social services where people with mental problems can find understanding and sympathy together with professional help and advice.

I have a friend who works at an organic garden project in the Stroud valley that takes many young men and women with learning difficulties who come there from local hostels and homes. This project gives them, among other things, an interest—or fosters one that they already have—for growing things, looking after domestic animals and for the countryside. Bee-keeping and art are also practised there. They have a shop which they stock from the garden where they can learn to handle money.

They do have little problems now and again—like someone pulling up the week's supply of lettuces in a fit of pique at having to weed them—but this sort of enterprise in the community gives to an otherwise pointless and empty life something worthwhile to do and look forward to. It develops useful skills and involves them with people in everyday life.

So we are looking with hope and optimism to the future, but as we live in an imperfect world we do not see perfection yet. We must be vigilant and not complacent. The old instincts of cruelty and mistreatments, brought about by man's imperfections, must be watched for and condemned.

I have spoken of these huge changes during the past century, but what has not changed is the dedication and compassion of men and women who continue to nurse and care for us.

6.24 p.m.

My Lords, I am very grateful indeed to the noble Lord, Lord Thurlow, for initiating this debate on such a crucially important subject. I congratulate the noble Baroness, Lady Berners, on her excellent contribution to the debate. I assure her that the Radcliffe Infirmary is still an excellent hospital. It is very good that the noble Baroness will be able to bring her long practical experience to debates in this House. We look forward to hearing her again.

In the early 1960s as part of my training for Ordination I had the good fortune to work, under trained supervision, in a large mental hospital. Many of the patients had been there 10, 20, 30 or more years. They had become institutionalised. Against that background, the concept of care in the community is to be most warmly encouraged and welcomed. In 1955, there were more than 150,000 people in mental hospitals; now there are about 50,000. Because of changing attitudes to mental illness, increased levels of care and the advent of better drugs, many people are now living in the community who once would have been hospitalised and institutionalised. It is good that they are in the community and not outside it. It is good that as a society we recognise the need for care towards them by the community in which they live.

That said, it is crucial to recognise that we will continue to need psychiatric beds for people who are acutely ill. There are people who are a danger to themselves and to others. They need to be protected both from themselves and from those who might take advantage of them. The public needs to be protected from them. But there is at the moment an acute shortage of psychiatric beds. Recently people who have needed admission to a psychiatric unit in Oxford have had to travel as far as Stafford. Conversely, there have been occasions when people who have lived as far away as Greenwich have had to come to Oxford for the nearest vacant hospital bed in a psychiatric unit. When we consider how much those who are mentally ill need the support of their family and friends, such distances are quite unacceptable.

Most of these acutely ill people will eventually recover enough to return to the community. When they do they will continue to need, for their own sake and for the sake of others, skilled care. They may also need for a period to be in special accommodation offering supervision as well as care. It is vital that the resources to offer that care are in place, that there are clear lines of responsibility and accountability for offering it and close co-operation between the different agencies involved.

Alas, we know through a number of highly publicised cases recently that that has not always been the case. Jayne Zito, whose husband was murdered by Christopher Clunis, Sandra Sullivan and Wendy Robinson, both of whom lost their daughters, and Jane Newby, grandmother of Jonathan Newby who was murdered, are just some of those who have come together in the Zito Trust to try to ensure that these tragedies that they have experienced personally do not happen again. Even more recently, however, we have had the case of Darren Carr, a psychopath who was discharged from hospital and who ended up burning a mother and her two children to death. In the words of the Buchanan inquiry into an earlier case, discharging a person time after time is simply,
"an offence waiting to happen".
Two other aspects of these tragedies should not be overlooked. The publicity can engender a fear of mentally ill people which is totally unwarranted, as the noble Lord, Lord Thurlow, quite rightly emphasised. Furthermore, they call into question and undermine the whole concept of care in the community. In fact, it is unlikely that the number of murders committed by mentally ill people now is any greater than it was at times in the past; but, understandably, the publicity which such cases are given underlines the need for better provision.

I emphasise again as strongly as I can that care in the community is a thoroughly worthwhile concept and it must be made to work. It wants people to be in the community, taking responsibility for their lives so far as they can. But for it to work the ideals behind it must be met.

Those goals and standards are well set out in the community care plan for Oxfordshire, just to take one example where these words are written. First, there must be a systematic assessment of health and social care needs; secondly, nomination of a key worker to co-ordinate the package of care offered to the client; thirdly, a written care plan; fourthly, regular review of need; fifthly, inter-agency and inter-professional collaboration and care planning; sixthly, consultation with users and carers; and, seventhly, effective co-ordination of packages of care to support individuals in the county. It adds that care management is to be fully integrated into the care programme so that people will have only one key worker, and full joint paperwork is planned.

The question is whether those excellent standards are being met and whether there are the resources available to meet them. Mental illness is not a marginal problem in our society. To take just one example, Oxfordshire has a population of 372,300 people aged between 18 and 65; 1,514 of those are expected to suffer from a functional psychosis, which means admittance to hospital, at least on some occasions. The total number of people suffering from mental problems of one kind or another is 55,890. That means that one in seven of the population is likely to be affected at one time or another.

Among that large number of people there is one particular group to whom I should like to draw attention. I refer to the mentally ill among the homeless. A very high percentage of homeless people suffer from mental illness of one kind or another. Furthermore, an extraordinarily high percentage of people who are discharged from psychiatric units have nowhere to live; they are homeless. What more can be done to help that particularly vulnerable group of people? The Health Advisory Service report, People Who Are Homeless, pointed out that 60 per cent. of homeless people do not know where to seek help on health matters. They view health as a low priority, fear discrimination if they try to register with GPs and move frequently. Making mental health services accessible to the homeless, a high percentage of whom need them, is a continuing problem.

The wording of the Motion refers especially to people requiring 24-hour nursed residential care—that is, those who need long-term close supervision as well as care for up to 10 years. I find, both locally and from organisations like MIND, that there is a great deal of uncertainty about what this actually involves. It is not clear whether some of the people living in the 24-hour nursing residential places will be detained under the Mental Health Act 1983, nor how 24-hour nursed care will differ from hospital provision. There is also the further question of how this provision for 24-hour nursing care fits into the philosophy of care in the community which aims to prepare the residents for returning to live in the community and which therefore helps them to develop life skills. I know that many people will be looking to the Minister for further clarification on a number of points, as well as the assurance that such 24-hour nursed care for people with severe and enduring mental illness will not run counter to the care in the community programme.

I am also somewhat sceptical about whether the policy is financially feasible. Small homes for between eight and 20 people—ideally for 12 people—are being planned. On the Government's own estimate, there is a need for something like 5,000 places of that kind, which means more than 400 such homes. The cost of building them—let alone running them—will be very high. One wonders whether there is the political will to overcome those difficulties.

I only hope that those difficulties will not detract from other priorities. As I have already mentioned, there is a need for more beds in already established psychiatric units. When someone is taken acutely ill with a psychotic illness, that person needs prompt admission to a hospital in the locality and skilled medical attention. The great blessing today is that the majority of people afflicted in that way can, with prompt skilled attention, recover and return to their own home. But they may very well need continued care along the lines of the admirable guidelines to which I referred earlier.

Then there are those, a large number of whom (although no danger to themselves and others, except through neglect) need continuing support, perhaps through a hostel or warden-assisted accommodation. They too need the benefits of community care. It may be that if there are more beds in psychiatric units, and if community care achieves the standards it has set for itself, the need for 24-hour nursed residential care will be less than is predicted. I hope so—for none of us can relish the thought of people being in a new form of asylum for up to 10 years. Such homes, offering 24-hour nursed residential care, may prove a valuable component of the total spectrum of care in the community, but fewer such homes will be needed if there are adequate beds in psychiatric units and if the other components of care in the community are in place and working properly.

The ideal on which care in the community is based is thoroughly good. The directives which have been sent out recently, together with the care plans which have been drawn up by many authorities and the recommendations arising from inquiries into recent tragedies, have highlighted the practical steps that are necessary to ensure that skilled and professional care is, indeed, offered. But resources are needed for that. If severely mentally ill people are to receive the supervision and skilled medical care that they need and if all those suffering from mental health problems are to receive the help that they need, there must be enough skilled, trained personnel to do the task, as well as enough appropriate accommodation.

6.35 p.m.

My Lords, it is a privilege to take part in a debate initiated by the noble Lord, Lord Thurlow. I cannot help reflecting on the fact that the replies from the three Front Benches are to be made by three noble Baronesses and that we have just heard from another noble Baroness making her maiden speech. The wisdom of women is thus strongly represented. When one thinks that this House resisted the membership of women for 40 years after their arrival in the Commons—even then only four were allowed in—one realises that we are very lucky to live in this age and not earlier.

I must take this opportunity to congratulate the noble Baroness, Lady Berners, on her maiden speech. I always feel humbled when I hear a former nurse speaking in this House. The noble Baroness, Lady Cox, usually sits close to the place occupied by the noble Baroness, and the noble Baroness, Lady Cumberlege, is to reply on behalf of the Government. If one goes round like I do, poking my nose into all sorts of awkward situations, one realises how very much easier it is to do that than to work in a hospital, to see the job through and to do that job for, say, 24 hours a day. I salute the noble Baroness and all nurses.

When I heard the right reverend Prelate the Bishop of Oxford deliver his expert address, my mind went back to my time in Oxford when I was a councillor for Cowley. I had already become interested in prisoners. When one young man, an arsonist, was convicted he was sometimes sent to prison and sometimes to Littlemoor Hospital. From that moment onwards—that happened over 50 years ago—I realised the extraordinary and delicate line that has to be drawn between illness and crime.

I rise tonight to put one simple question, of which I have given notice, to the noble Baroness, Lady Cumberlege, who is probably better qualified to speak on these matters than any health spokesman in my time in this House. I hope that that compliment will soften her heart and ensure the right kind of response from her. I know that it would if the noble Baroness were in total command of the situation, but she is part of a government team. Some time ago— during the war in fact—Mr. Duff Cooper, then Minister of Information, told the public that if they heard any defeatist talk they were to go up to the person in question and ask, "Are you a paid or unpaid agent of Hitler?" In the past I have been inclined to say that I was neither a paid nor an unpaid agent of the Matthew Trust. Now that I have had the great honour of becoming its president, I suppose that it is appropriate to say that I am an unpaid agent of the Matthew Trust. However, I do not rise tonight only to speak on behalf of the Matthew Trust.

The Matthew Trust was begun—and has always been inspired by—Mr. Peter Thompson, a remarkable man. He left Broadmoor with nothing in the world except the discredit which in those days came from being in Broadmoor. He has built up the Matthew Trust to its present great performance. I speak today not only of the Matthew Trust, which is a medium-size organisation, and the work it has done for ex-mental patients, but many smaller organisations. Peter Thompson of the Matthew Trust has taken the initiative in starting a federation of smaller mental health organisations. Preliminary meetings have already taken place, and they are on the way to formation. The only reason I rise tonight is to ask the Government whether they are ready to recognise and encourage in the most appropriate fashion this new federation.

I refer to a leading member of a small organisation called Consumer Forum. He was at Eton. That counts in his favour in my mind; but I hope that it does not count against him in anyone else's mind. That old Etonian found things difficult for a time but, like Peter Thompson, he rose above it all. Currently, he and a colleague see 50 ex-mental patients per day. That is just one example of the work of these smaller organisations. Already 160 of them are interested in the federation. I am told that there are at least as many who are waiting to be asked to join. I put to the noble Baroness the simple question: are the Government ready to back the federation of smaller mental health organisations not only by word but by deed?

6.42 p.m.

My Lords, it is a great honour to be able to speak in your Lordships' House, particularly on a subject of such great importance and one so close to my heart. I do so for the first time with great diffidence. In a mental illness survey in 1994 95 per cent. of the general population agreed with the statement that,

"we have a responsibility to provide the best possible care for people with mental illness".
I fully agree. Anyone who has grappled with the issue of how best to care for someone who is seriously mentally ill—in particular, whether or not to commit that person to full-time care outside the home—knows what a complex matter it is. My first experience of this issue arose at a relatively early age when I was asked to commit my late father. On a rather lighter note, some years ago I visited two cousins who were both in the same institution. I asked the guard whether I could have two passes to see them at the same time. He said that I could not and I had to see one, exit and then return. By the time I exited a different guard was on duty. He asked whether I had just been in and I said yes. He asked whom I had come to see and I told him. Then he asked whether I was a relative, to which I said yes. He looked at me and said, "Sir, have you ever been with us?"

I count myself extremely fortunate to be living in an era when changes in attitudes towards mental health and advances in medicine have combined to produce a more hopeful picture for sufferers and their companions. I speak from my experience of having seen the quality of life of those close to me improve dramatically following treatment, and my experience in business where incapacitated employees have returned to productive work. On the negative side, the dramatic effect of costs in this area was made clear to me several years ago in the United States where I was running a business. In that year the healthcare costs of that business formed the expense category with the largest growth (approximately 40 per cent.). The largest growth segment in that category was the mental healthcare cost for employees and their families. We believed that one of the best ways to recoup the expense was to provide treatment to restore worker productivity.

It is hoped that for sufferers of serious mental illness the days of being consigned to the "bin" are over. Recently, I was told by a well respected professional in the healthcare field that 95 per cent. of cases relegated to care in asylums 30 years ago could now be treated and those people could hope to lead productive lives in society outside hospitals. That is good news. The shift from old hospitals to the new programme of integration into the community is both welcome and warranted. Not only is that possible due to advances in treatment, but it holds the promise of lower expenditure. Recent experience in the United States indicates that long-term hospitalisation is approximately four times as expensive as home group living, and that living in a productive community can further reduce costs. I hope that we can also have that experience here.

A major issue today is: what is the quality of the care that is being provided in the community? I suggest that during the transition from the old system to the new several areas deserve greater focus. The first is the creation of supportive communities. The care programme approach adopted in 1990 had as its aim,
"to provide a network of care in the community for people with severe mental illness, which would minimise the risk that they would lose contact with services".
I respectfully suggest that there may be an error in logic, in that a key assumption is that a "community" exists. The truth is that for many patients who are released into the community a network of family members, neighbours, religious organisations and others with the wherewithal to support these people does not exist. If it does exist, it exists only in a limited form. People who try to avoid poverty and isolation are often placed in situations that are characterised by these traits. This dynamic is further exacerbated by the greater prevalence of serious mental illness—schizophrenia—among those from lower socio-economic classes.

We must focus on how best to create supportive communities—some of which already exist as a result of private sector initiatives—and perhaps to assist them with funding. We must continue to create an environment where the mentally ill members of the community feel at home and are supported and encouraged to become productive members of society. Unless we do that, many will continue to wish that they were back in the hospitals where they felt safer. This requires more than the purchase of professional health services and the provision of financial support. It asks that we ensure that an appropriate living community exists for those for whom we have taken responsibility.

Recently, I visited the headquarters of Fountain House in New York. It is a club house which provides healing and hope for men and women who are recovering from mental illness. All individuals are members and build on their strengths and capabilities to move from isolation and dependence to self-reliance and productivity. Members work together. They work in transitional employment, and the club provides housing. The atmosphere is happy. Fountain House has produced very impressive results in returning people to normal life and reducing the rate of relapse. There are some 300 Fountain House clubs worldwide, and I am pleased to say that 14 are open in this country. Local authorities have helped to fund these wonderful facilities and are interested in their non-medical approach. They have no throughput requirements. Membership is for life. The ideal is to return the members to independence and to be there for them if they wish to come back. We need more of these types of support mechanisms.

I believe that the second area of focus is the inventory of beds. The rate at which the old hospitals are discharging patients as a result of closures exceeds the rate at which the new communities can absorb them. As the mechanics of housing and caring for the severely mentally ill who are in transition, relapsing, moving and so forth are being fine-tuned, we have a situation in which our resources are being misallocated. People who are being relocated are occupying acute care beds and those who need them are not being accommodated. It would seem that one way to improve that situation would be to slow or even to reverse the rate of closing and discharge pending the community's readiness.

I suggest that the third area of focus is dealing with the hard cases; those needing incarceration. As recent events have demonstrated, there are some mentally ill patients who should not be released into the community because of the dangers they create for themselves or for others. We must continually review the status of such individuals and accept that there is a group for whom the best place is a contained environment. We must also develop and implement strict guidelines as regards those who must be institutionalised for the long term. We should strive to create communities for them under the most humane conditions possible but we must recognise that this group may need to live in an insulated community.

Finally, I suggest that a full accounting of the effects of changing from the old system to the new would be very useful. It would allow us to follow the pound saved by closing the old hospital through to its expenditure in the community under the new system. We will then be able better to ascertain the financial ramifications of the changes made and improve our prospective decisions.

One characteristic of mental health is said to be flexible thinking. We may need just that as we evaluate and perhaps change existing policy. In that regard, I am hopeful that this debate will assist in improving the quality of life of the seriously mentally ill.

6.52 p.m.

My Lords, it is indeed a privilege for me to congratulate the noble Lord, Lord Gerard, on an outstanding maiden speech. It was delivered so well with such humour and did not upset anyone, including my noble friend the Minister, so far as I could tell. It could not have been a better maiden speech. I notice that his address is in New York. I hope that we shall see a great deal of him in this House and that he will frequently come over from the States, if that is where he is to continue to live, and give us the benefit of his very wise remarks.

I thank the noble Lord—I nearly said my noble friend but I should not—Lord Thurlow, for initiating the debate. It is some time since we had a similar debate. I also thank him for laying emphasis on the 24-hour nursed residential care. He is so right in considering that this is a suitable time to take stock of community care. It is the right moment and I believe that the programme is getting underway at last.

The debate gives me the opportunity to thank in particular my honourable friend Mr. John Bowis, the Minister responsible for mental health, my noble friend Lady Cumberlege and their Secretary of State for the financial help that they have given to the Isle of Wight health authority during the past few months. I wish to thank John Bowis for his most thoughtful reply to a letter that I wrote to him last March about some of the outstanding problems that I saw in providing care both in and out of the community in the years to come. The financial help and part of the correspondence relate to the subject of this debate. The Minister provided assistance to the Isle of Wight to recover stability in its health funding, which was badly out of control, and has awarded £305,000 from the Mental Health Challenge Fund, which his Secretary of State initiated last December. We on the island are indeed grateful to all concerned in the Department of Health for their assistance on those two issues.

One of the points that I made more than once in my March letter to John Bowis was the fact that, when determining help needed by the mentally ill, there was initially, a requirement to assess that help without consideration of its possible cost. That gives at least one true picture of what really is wanted. Of course, the question of what can be afforded must always be faced, but I suggested that that should be done only after seeing the true picture.

The Minister in reply stated that that did indeed happen. But I must confess that in the past 13 years that I have been concerned with this subject it has never been obvious to me that it has. It is nice to think that at least the Government believe they are doing that, and long may it continue.

As your Lordships will know, during the past 35 years, since Enoch Powell first started shutting down mental hospital beds, people on the ground, such as members of the National Schizophrenia Fellowship, have been saying to successive governments, "Please don't do that too quickly". The noble Lord, Lord Gerard, said just the same thing and, as far as I could tell, was saying that it was as applicable to the United States as it was to us. It is interesting to note that that should be the view.

My impression during the past 13 years, since I was first introduced to the NSF, has been that governments, health regions and districts reporting to them were so keen on the civil liberties of sufferers and on saving money that they never waited to find out what was really needed before reducing beds. However, in the case of the Isle of Wight the exercise of assessing needs initially without regard to resources has been done as a preliminary to applying for the award to which I have referred.

During the course of 1995 a project worker undertook a detailed survey of the needs of 360 island residents with serious mental illness. Perhaps I should say in passing that that number is approximately what one would expect from a community of 125,000 at a particular moment. As has been said by other noble Lords, there are probably more such cases in a lifetime but at a particular moment that is probably just about the right number. The project worker discovered that, in the opinion of the key workers looking after the clients, as they described them, about 250 people were appropriately placed. Roughly half of the remaining 110 people needed more intensive care and those tended to be in the more independent accommodation. The other half of the 110 needed less intensive care and those tended to be in the more secure accommodation.

From that survey, the Isle of Wight Health Commission deduced that it needed, first, the provision of a 24-hour crisis intervention service; secondly, an increase in the provision of 24-hour staffed accommodation; thirdly, an increase in the provision of crisis beds; fourthly, more facilities for clients supported in housing association accommodation; fifthly, fewer inappropriate admissions to acute in-patient beds; and, sixthly, fewer mainland placements, that being achieved by the increase in the 24-hour staffed accommodation. I should explain to your Lordships that when we talk about mainland accommodation we refer to people who have to be taken across the water from the Isle of Wight because we do not have the necessary secure accommodation for them. That is one of the aims that we are hoping to achieve. The award from the Mental Health Challenge Fund will enable the health authority to achieve those aims.

Until now, many people felt that more beds were needed until community care was developed fully. For the Isle of Wight, it seems that it is more the case that we need an increase in secure beds and the 24-hour crisis intervention service and more care in hostels rather than hospitals. If the number of beds are added together, there is the right number but you cannot get the right people into them. That is what needs to be adjusted. We are on the way there and much more quickly than I had expected. I hope that poor old England will catch up later.

In conclusion, I am told that there is growing concern that general practitioners are beginning to press that some of the money allocated for the severely mentally ill, who are out of GPs' hands, should be diverted to the care of people in mental distress for whom the GPs care. I suggest that that needs to be watched because we must not lose what has been won for the severely mentally ill.

There also seems to be a national shortage of psychiatrists and specialised support staff. I should be extremely grateful if, in her reply to the debate, the Minister could comment on those two points. I hope that she received my letter asking her to do so. I hope that she will give some idea of how the Government are tackling those problems.

Thanks to what I have been able to recount to your Lordships this evening, I am able to conclude this speech in a much more hopeful manner for the future than I have in many other debates during the past 13 years in which I have been involved. I believe that we are reaching a point at which many of the facilities for which we have been crying out are coming into existence. I hope that there is no hold-up in developing that further. Perhaps the best solution to the whole problem would be to divert all the National Lottery money to looking after the mentally ill.

7.2 p.m.

My Lords, I thank my noble friend Lord Thurlow for giving us the opportunity to discuss this vital subject. I congratulate also the two maiden speakers. Some of my remarks will give examples of deficiency in the service but others will demonstrate positive aspects of excellent projects which have been established by dedicated people providing a much improved service.

I served on the Yorkshire Regional Health Authority when discussions were taking place about closing many of the long-stay hospitals for the mentally ill. My voice was one of several which said that that would not be a cheap option. I warned that it was wrong to close beds until acceptable improved facilities were put in place. I said then and still say today that severely mentally ill people are the most difficult and unpredictable group to be dealt with. If they fall between health, social services, the voluntary sector, the prison service, the police and the probation service, which many seem to do, they themselves and society at large may be put at risk.

There needs to be co-operation and communication among all the agencies, with adequate training about mental illness. Family members or friends who may be helping with individuals who have a mental illness need to be listened to and not fobbed off by the professionals, who so often seem to think that they know best. They often do not know what goes on behind closed doors in people's homes.

I visited Brixton Prison with the all-party Penal Affairs Group. There, we saw a ward which was filled with 100 per cent. of prisoners suffering from schizophrenia. When those people are released back into the community, it is vital that satisfactory aftercare facilities are in place for them.

I should like to quote from a report commissioned by the Department of Health on 24-hour nursed care. The report states:
"There is accumulating evidence of a need for residential nursing care for a relatively small group of so-called new long-stay clients".
How will the Government ensure that health authorities provide for that need? What will happen if they turn to the Government and say that they do not have the money to pay for the nursing staff who provide such a service? Will ring-fenced money be given for that specific 24-hour care?

People who misuse drugs and alcohol are much more likely to be violent than those with a major mental disorder. But alcohol and drug misuse increase the risks for patients with a major mental illness. However, emerging findings of a strong association between violent behaviour and times at which the symptoms of severe mental illness are active rather than in remission have major implications for future healthcare policies. That was stated in Volume 312 of the BMJ on 13th April 1996.

On 21st April, I received a letter about a hostel for discharged psychiatric patients in Southwark. The letter states:
"The occupants are woken about 6 am. and given a meagre breakfast and then sent out for the rest of the morning until their midday meal at 11.30 am. which lasts for half-an-hour. After this they are discharged again into the streets to wander about until their last meal at 5.30 p.m. and sent to bed at 6 p.m. They do not have any of the amenities of present day life, such as television and so on. They can be seen wandering about Vauxhall Park performing ridiculous tasks, such as imagining they are collecting litter, and so on. They are sent out of the hostel regardless of the weather. Their clothes or some of them are in a poor condition. I send you this account in the hope that your Ladyship may be able to alter these conditions which probably prevail in other such institutions".
I ask the Minister who monitors those hostels and who cares what happens.

I should like to pay tribute to Bill Kilgallon, who served with me on the Yorkshire Regional Health Authority. He has been a past Lord Mayor of Leeds and chairman of the city council housing committee. His brainchild has been St. Ann's Centre for the Homeless, which includes people with mental illness who otherwise would have been in hospital or on the streets. They have a flat to live in and support services are available.

Another splendid project is the recently opened unit for severe sufferers of Alzheimer's disease at the Hospital of St. John of God at Scorton in North Yorkshire. That is an independent hospital. The unit caters for people who can no longer live at home and who need 24-hour nursing care. The patients have extremely comfortable accommodation with a garden. It was full before it was officially opened. It has nursing home status.

Throughout the country there are some excellent facilities for mentally ill sufferers with caring staff. There are also some deplorable ones, with people doing the job just for the money. There should always be a minimum standard.

AIDS dementia, also known as HIV encephalopathy, HIV-associated dementia and HIV brain impairment are most distressing conditions. They affect between 10 and 15 per cent. of the known HIV population. The incidence of AIDS dementia doubled in 1993–94 compared with cases studied in 1991 to 1994. Patients with that diagnosis require higher levels of supervised care, often for 24 hours. The only residential facility dedicated to that group of people is a four-bedded unit in Hammersmith. Therefore, care managers are in the difficult position of arranging a costly 24-hour package of care for individuals in order to maintain them safely in the community.

Care packages are often extremely time-consuming to prepare for the managers. I shall give your Lordships an example. A man of 38, a former academic lecturer, with severe AIDS dementia has been discharged to his one-bedroom flat, unable to care for himself in any sense. He cannot prepare himself a meal or walk safely on the road. He was recently conned out of a large amount of money by unscrupulous workmen. He smokes constantly, without paying attention to where he holds his cigarette and is, therefore, a health hazard. In the flat above him lives a family with young children. He needs 24-hour care. His mother, while willing to help, is herself elderly and frail and is frightened of him at times when he gets aggressive. She is unable to restrain him if he wants to go out in the middle of the night or to lift him if he falls. He has a number of different agency staff sent in to care for him but he is aggressive with those whom he does not know and sometimes refuses to let them in. As many of them have no particular training in how to deal with such clients, they cannot always manage to gain admittance. He has moments of insight. In one such moment he recently wrote a short note saying:
"I am not myself now. Apologies for the inconvenience caused".
Care managers based at St. Mary's Hospital, Paddington, are currently trying to arrange for the community care of 30 AIDS patients with dementia in the community.

I hope that the Minister will help, through her department, to promote services for this very unfortunate patient group with dementia. The needs are more training and facilities with 24-hour care, combining psychiatrically trained staff and psychological input familiar with AIDS dementia, including professional and informal carers; an increased emphasis on early assessment and diagnosis so that adequate planning can occur before a crisis breaks out; and joint funding between health and local authorities for community care and hospice-type provision. There is a recently formed HIV brain impairment forum which should help to centralise research and planning. There seem to be so many pressing needs for the many different mentally ill groups.

7.13 p.m.

My Lords, I am most grateful to the noble Lord, Lord Thurlow, for introducing this most important debate with such a very fine speech. I must declare an interest in that I am a patron of MIND's Golden Jubilee Appeal. In its 1994 report entitled, Finding a Place: A Review of Mental Health Services for Adults, the Audit Commission stressed that two thirds of expenditure on mental health services is still tied up in hospitals and hence is unavailable for care in the community.

At paragraph 27 of the report, the Audit Commission graphically portrayed the current vicious circle: most funds are tied up in providing hospital beds; thus there is no spare capacity to develop community services; thus people are unsupported in community and so are admitted to hospital; and thus hospital beds are full. The Audit Commission called on all authorities to plan on how to break out of that circle. An important scheme towards which their thinking ought to be directed is MIND's model of a 24-hour crisis service.

After consulting its own network of local groups and people who use its services, MIND points to the need for community-based crisis services. Their role would be to respond rapidly to people having mental crises; to offer support until their acute problems are resolved; and to link people to longer term care and support when that is wanted.

A crisis service ought to be available around the clock and would consist of a variety of features. A crisis telephone helpline specialising in mental health problems needs to be developed and given wide publicity. People in mental distress could turn to the telephone for immediate assistance. The helpers would listen to the problems, give an outside view and advise on how to get further assistance, if necessary. Southampton's MIND runs a most successful crisis point which combines such a telephone line with a "Drop in" on Friday and Saturday nights from 10 p.m. to 8.30 a.m.

A crisis counselling service would be a non-medical service providing immediate short term help to people in mental distress. That service would give the advice and aid necessary to assist people to cope; for example, the Leeds crisis service provides counselling on a seven-day basis, from 10 a.m. to 10.30 p.m., with the possibility of an overnight stay.

Crisis houses would be non-medical, safe houses which would give people a sense of security, enabling them to get away from their problems and—it is to be hoped—get through their severe distress. Those houses might be set up for particular needs; for example, women-only houses for women who have been sexually abused. Wokingham and District MIND runs a most successful crisis house along those lines.

The core service for people in acute distress would be home treatment. A range of mental health specialists would staff the service: social workers, housing workers, community psychiatric nurses, psychiatrists and community support workers. That team would treat people at home whenever possible, with a 24 hour on-call cover. The team would have a sensible case load enabling frequent contact with the patients.

The West Birmingham home treatment service offers an excellent example. The team provides acute, intensive medical health care at home on a 24-hour, seven-days-a-week, basis. Home treatment is most effective when there is 24-hour cover. That can be achieved by enabling patients to telephone a team member at any time of day or night. After the introduction of such an on-call system in Sparkbrook, Birmingham, the proportion of users who could be treated entirely at home rose from 41 per cent. to 65 per cent.

If, for some reason, it is undesirable for the person in severe distress to stay at home, the team would require alternative accommodation. Bassetlaw health district uses an unstaffed flat with a telephone link to an acute ward for both crisis and rehabilitation purposes. As some noble Lords have already said, for those people who cannot be supported by those services, highly staffed acute residential accommodation will continue to be essential. Some will be hospital based, and some medium secure or high secure for those who pose a risk. However, some acute units need not be in a typical district general complex. For example, the Grange in Newcastle is an acute unit in a large house with nine residential places and capacity for 13 patients to attend by day.

National standards for such a 24-hour crisis service would be essential. Community Care at the moment is a lottery depending on where people live. As the noble Lord, Lord Mottistone, has told us, the Isle of Wight is doing rather well in that part of the lottery. The Government should set national standards which would insist on a minimum level in each health authority area. In setting the standards, the Government might do well to look at some examples of existing home treatment services.

In the first two years of the West Birmingham home treatment services, only 15 per cent. of the people seen needed to be admitted to hospital, while in south London the Daily Living Programme, which gives home care to people facing emergency admission to hospital, reduced their time spent in hospital by no less than 80 per cent.

All the examples I have cited show that every different feature of MIND's model of a 24-hour crisis service is eminently practical.

On 19th February the chief executive of the National Health Service wrote to all district health authorities and mental health trusts about the planned patients' charter and mental health services. In the letter he declared:
"Over time, direct 24 hour access to services should become the standard for people with serious mental illness everywhere".
This is a fine expression of government intent, but what is needed is money. As the Royal College of Nursing aptly states in its briefing:
"Health authorities and boards should be given money which must be spent on the double running costs of developing a full range of community services whilst phasing out hospital services. Bridging money over a two to three year period is essential if trusts are to develop realistic alternatives to hospital admission".
MIND estimates that something like £300 million of new money is required to provide nationwide crisis care in the community for people with serious mental health problems. That is a large sum of money, but then this is a huge problem affecting many people, as the noble Lord, Lord Thurlow, and the right reverend Prelate described so well.

The question is: when will 24-hour crisis services in the community really happen on a nationwide and satisfactory basis? They will not happen until the Government provide that £300 million. They will not happen until the crisis services are actually set up and are running. It is for the Government to lead the way out of the vicious circle by providing that £300 million.

7.22 p.m.

My Lords, I am very pleased to support my noble friend Lord Thurlow on the very important subject of his debate. Many mentally ill people can be treated by their GPs; they never see a psychiatrist and never go into a psychiatric hospital. The remainder, however, need to be referred to a psychiatrist and need to be admitted to hospital. Recovery, a return home and to work is a possibility for some of the first group. The remainder probably need long-term treatment and care.

The Government's initiative for 24-hour nursed residential care for 5,000 is welcomed by the National Schizophrenia Fellowship among others. The acceptance of patients awaiting discharge for accommodation funded by social services departments can apparently take up to three months, and no wonder as it can entail over 100 pages of forms and reports. Can the Minister say whether this is so and whether they are all really necessary?

The waiting can apparently lead to the blockage of acute beds, which can be exacerbated by the lack of highly staffed residential care and leads to problems with admissions, and possibly too speedy discharge for some to free spaces.

Mencap confirmed—when I asked it—that those with learning disabilities can suffer from mental illness as well. This can create problems in diagnosing their special needs, and it is important not to lose track of the need for special skills in dealing with people who have both conditions: the dual diagnosis. Perhaps the services for learning disabilities and mental health services should work together. This is often done where there are psychiatric hospitals in the vicinity, but not so much where they are more scattered and away from services. This would help to ensure that people get the best of both worlds and not the worst of both, or risk falling between the two services. Perhaps the Minister could look at this problem, please?

The brain changes in people as they age who suffer from Down's syndrome are known about, but much less is known about people with Down's syndrome who suffer from dementia, which I understand is by no means the same thing. It is important that the minority who suffer from mental disability and mental illness are catered for and not disregarded as difficult, because they may not be able to speak to help others to help them. There are some who may not use words much and some who may not use words at all, thus it may be difficult to assess their needs and their condition. The Royal College of Nursing feels that, although there is a series of policy initiatives such as the care programme, approach management for supervised discharge and a mental health charter, this cannot be fully implemented without further investment in specialist nursing services. This really means an increase in the numbers of community psychiatric nurses.

The Government have this year accepted a review of mental health services and outlined a package of measures. The Government have also accepted the results of a report on the need for 24-hour nursed care, commissioned by the Department of Health, which found accumulating evidence of a need for residential care for a relatively small group of people who need long-term care who suffer from severe and enduring mental illness. It is to be welcomed that the Government have accepted that there is a need for this kind of care, and may we hope that they will be able to increase the number of community psychiatric nurses to help with these new measures, and so help to relieve the pressure on the nurses already working in the community?

May I ask the Minister if she has seen the article in the Psychiatric Bulletin of May 1996 by Dr. Tony Whitehead of Brighton General Hospital in which he describes his acquaintanceship over many years with psychiatric hospitals? He says that,
"Most psychiatrists have spent their lives battling against institutionalism and over the years have created, with the help and enthusiasm of nurses and other professionals within the psychiatric service, inpatient regimes that discouraged institutionalism and encouraged the establishment of care in the community".
Let me hope that those I have just mentioned will see their hopes fulfilled in the future of care in the community.

There is some concern felt that even small residential care places are not necessarily places of freedom but could become institutionalised if they are based too far from services. As a result they can suffer from discrimination and stigma. As my noble friend Lord Thurlow said in opening this debate, although the old hospitals were isolated, they supplied nursing, feeding and above all companionship. Although we all welcome the new small residential homes, no beds in the old hospitals, which should provide the highest quality of care, must be closed until care is in place in the community or meets or exceeds those standards of care. There needs to be proper management training and more trained psychiatric nurses working in the community, and I wish the future of care in the community success.

7.28 p.m.

My Lords, I rise to speak because I have been asked by a number of your Lordships why on earth I am not speaking in a debate on community care. The reason is quite straightforward, as I am sure your Lordships recognise. I am the chairman of Mencap, which deals with people with a learning disability or mental handicap. That is a different problem from those facing people with a mental illness. A learning disability is lifelong; it is something with which one is generally born and from which one does not recover until death, as it were. But, on the other hand, mental illness can occur to any of us present in your Lordships' House or those outside. But, thank goodness, it is possible to cure it in many cases. However, that is not the case with learning disability.

Reference was made by my noble friend Lady Kinloss to the fact that people with a learning disability can also suffer from mental illness. That is true. On the other hand, in the Department of Health's series entitled The Health of the Nation, a booklet entitled A strategy for people with learning disabilities has a useful section on the mental health problems of people with learning disabilities and how to deal with those problems.

Without wishing to add to confusion between mental illness and learning disability—it is a confusion that is always put forward by the media; we see glaring headlines which confuse mental illness, mental handicap and learning disability time after time—I wish to make it clear that people with a learning disability can suffer from mental illness as well. Therefore, our mental health strategy must cater sensitively and appropriately for that minority of people with learning disabilities who also have mental health problems. We have too often failed them in the past; and now we have the opportunity to do better in the future.

7.30 p.m.

My Lords, I, too, wish to thank the noble Lord, Lord Thurlow, for introducing the debate today, in particular as he has chosen to concentrate on one aspect of community care. I feel privileged to have listened to two maiden speeches on a subject close to my heart. It has demonstrated that the two new Members of this House will be able to contribute enormously to future discussions in this Chamber. We look forward to hearing them.

The care in the community programme has come under considerable criticism as failing to provide an adequate safety net for those with mental health needs. The right reverend Prelate the Bishop of Oxford gave us some outstanding examples of where the community care programme has failed. But we have been privileged also to listen to the noble Lord, Lord Acton, and the noble Lord, Lord Gerard, who were able to tell us about the wonderful achievements of voluntary organisations from which I believe that we can learn a great deal. However, everyone, even the Minister, has to admit that the community care programme has not yet achieved all that we had hoped.

Both the Royal College of Psychiatrists and the Royal College of Nursing are concerned that most health authorities still have to spend too much of their resources on in-patient beds because of the high demands for those beds. In London, for instance, one-third of in-patients on admission units—those beds intended for short stay—have been there for more than three months and some for as long as six months. Health authorities in some other parts of the country are having to spend millions of pounds admitting people to distant hospitals as extra contractual referrals. That not only involves costs but misery for the patient who is removed far from his own community.

The Royal College of Psychiatrists is concerned that despite a continued fall in bed numbers, there are more people aged 15 to 44 in psychiatric hospitals than there were 10 years ago. The increase in hospital episodes is most pronounced in young men, who account for over 40 per cent. more episodes than they did a decade ago.

Very few hospital beds have been replaced by other residential provision in the community and there is now only one-third of the residential places (hospital or community) that were available 40 years ago.

The tragedy is that, despite the great reduction in the number of hospital beds, they still account for about 75 per cent. of expenditure on National Health Service psychiatric services. This is largely due to the increase in unit costs of caring for a disturbed group of patients concentrated in psychiatric beds, and chief executives express little hope that further closures will make a substantial contribution to the funding of community services in the future.

Many of these units report that, because they are permanently occupied 100 per cent., they have to discharge people prematurely to make way for new admissions. As a result of these problems, disturbed people in the community are not receiving the care that they are entitled to expect. In inner London, mental health teams found that 46 per cent. of council tenants, for example, received no day-to-day support and 40 per cent. suffered social isolation. With the best of intentions, social workers and NHS support provide only a few hours of contact each week to many patients in need.

Despite a series of policy initiatives—such as the care programme approach, arrangements for supervised discharge and a mental health charter—it is clear that mental health needs in the community will not be met without further investment.

I believe that three things are required. First, there needs to be additional support for general practitioners, whose workload has increased as a result of the care in the community initiative. Secondly, policies for mentally ill people cannot be implemented without adequate numbers of appropriately trained community psychiatric nurses. Yet there is currently a shortage crisis in mental health nursing. For example, GPs find it difficult when calling on community psychiatric nurses for help with their patients. Those nurses are unable to take on a patient for perhaps as long as three, four or five weeks. That is too long for such patients to have to wait.

Only one in five people diagnosed as suffering from schizophrenia currently has access to a community psychiatric nurse. The Royal College of Nursing estimates that the number of community psychiatric nurses needs to be doubled to around 10,000 in the United Kingdom. We also need an increase in the social services which provide the back-up in the community for people who are able to live on their own in the community.

As has been said, the Secretary of State for Health has accepted the results of a report on the need for 24-hour nursed care for a number of patients who are not in need of full hospital care but who nevertheless need 24-hour supervision. We welcome that initiative, but the resource implications must be addressed. That is the greatest hurdle. According to the health authorities, we cannot save the money on the psychiatric hospitals. Therefore, the Government must consider the resource implications. We welcome the introduction of 24-hour nursed care establishments because they must inevitably create a better atmosphere for the patient than being in an institution.

The National Health Service executive has itself estimated that some 5,000 people may need access to this accommodation. It has been estimated that £300 million will be needed to provide the accommodation, as well as a further increase in the number of psychiatric nurses. Perhaps I may say to the noble Lord, Lord Acton, that the sum of £300 million seems to be needed in more than one field relating to this problem. Will the Minister also tell the House how medical cover is to be provided for residential homes? I have heard concern expressed by general practitioners who feel that it may fall to them to be responsible for medical cover, especially increased night cover, thus adding to their workloads.

One problem on which we and the health service providers should concentrate is the need for better communication between hospitals, the community psychiatric nursing services, social workers and general practitioners. Too often, general practitioners who carry much of the burden are not informed before a patient is discharged back into the community. I was talking to a general practitioner in Wales who was called in by the local psychiatric consultant to assist in the committal of one of his patients. Six weeks later, the patient turned up in his surgery, having been discharged. The GP had not been informed of her discharge, which was quite unforgivable.

I believe that all those problems can be overcome. Communication difficulties can be overcome with good will. But in order to do so, the service as a whole needs to feel that it is financially supported by the Government. I hope that the Government will do their best.

7.41 p.m.

My Lords, I wish to thank the noble Lord, Lord Thurlow, warmly for introducing the debate. He has given the House an opportunity to discuss again an issue which has become of serious concern to noble Lords on all sides of the House. As he said in his introduction, we have discussed many facets of the problem over the past year, but I do not believe we can do so too often. I am grateful to him for giving us the chance.

I wish too to congratulate the noble Baroness, Lady Berners, and the noble Lord, Lord Gerard, on their maiden speeches. I look forward to hearing them again, as I am sure we shall return to this vexed question on many occasions. They will both be able to add to the great authority on the subject which is available in your Lordships' House.

Tonight it is worth while and useful once again to restate that there is general agreement that community care for the mentally ill is a policy to which we all aspire. Everyone subscribes to the community care policy, at least in theory. In practice, the acute problem which faces everyone who is concerned about it is that community care for the mentally ill is failing. There are growing numbers of mentally ill people in the country and their care is causing great anxiety to the professional and informal carers who try to look after them; anxiety to ordinary citizens who are sometimes disturbed and also threatened by the presence of seriously mentally ill people in their midst; and above all, anxiety to the patients themselves, in whom care in the community often leads to a feeling of isolation and helplessness.

Today, sadly, it can be common to see mentally ill people aimlessly wandering the streets, apparently without proper support and treatment. As has been described by several speakers in the debate, their present plight is a direct result of the failure to develop adequate community care services to substitute for the old-fashioned long-stay residential institutions—the asylums. Too many psychiatric beds in hospitals have been closed too quickly. That is something to which several noble Lords referred tonight.

The noble Lord, Lord Thurlow, described the Government's attitude as "inflexible". Suffice it to say that nearly half the beds in hospitals have been cut since 1980 and the patients who occupied them have been discharged, largely to fend for themselves. As your Lordships have heard, in February the Government announced the review of the mental health services provided by local health authorities and a package of proposals for improving care. Many of the questions and points which have been raised today are the same as those which were raised when the proposals were announced three months ago. I am particularly glad that the noble Lord, Lord Thurlow, drew special attention to the document on 24-hour nursed care which was published as part of the so-called "Spectrum of Care" introduced on 20th February.

The document on 24-hour nursed care addresses absolutely head on the issue of residential care, of beds for psychiatric patients. It seeks to find ways of filling the gap which has been left by the too rapid closure of psychiatric beds. The real situation is that there are just not enough appropriate beds for patients when they need them. The right reverend Prelate the Bishop of Oxford gave us vivid examples of the difficulties which arise in different instances. After all, not all mentally ill people can be cared for at all times in a community setting, however good that community setting may be. Indeed, the very nature of episodic mental illness may mean that there will always be demands on acute beds. So sanctuary of some kind is vital—not least, it has to be said, for the relatives of those suffering from episodes of acute mental illness.

Access to that sanctuary is being denied in part because acute beds are being blocked due to a shortage of appropriate community facilities for mentally ill people. The noble Lord, Lord Acton, referred to the Audit Commission's report, Finding a Place. To quote again from it, it mentions one research study which found that up to two-thirds of admissions could have been avoided had better community support been available.

In those circumstances it is common sense to welcome the ideas behind the proposals for 24-hour nursed care. But like other noble Lords who have spoken, I wonder how they will ever be implemented. The record on radical community care programmes is not encouraging. I remind the House of the care programme approach which was supposed to form the basis of all community care for mentally ill patients and would probably be the framework within which 24-hour nursed care would be operated. That had still not been fully implemented when the new proposals were introduced in February, although it was intended to be in place five years ago, in 1991.

When the Minister introduced the new proposals in your Lordships' House on 20th February, the Statement said that the care programme approach would be universal by 1st April this year. I hope that when she replies tonight, the Minister will be able to tell us that that has happened.

I also remind the House that the Government's own review of the mental health service which was published in February noted that two-thirds of all health authorities did not expect to be able, even with additional help, to offer comprehensive services by the end of this year, as had been intended. In the North Thames region, no health authorities at all are expected to be able to deliver their programmes. Incidentally, I should mention that I spoke this morning to the chief executive of one of the health authorities in the North Thames region. Although the document on 24-hour nursed care gives special emphasis to the lead role required by purchasing authorities, the chief executive—certainly not someone who is lax or lazy—had not even seen the report.

The question of resources has been raised at different points around the House. I join the right reverend Prelate in describing my attitude to it as "sceptical". The new expenditure on 24-hour nursed care is reckoned to be about £275 million, with capital costs at over £1 million for each unit which will be provided; and revenue costs which would be anything from £35,000 to £50,000 per place in one of the new units.

When the package of proposals was introduced in February, we were told that there would be £95 million additional money to contribute to the new programmes. We raised doubts at that time about whether it would be new money. Helpfully, the National Association of Health Authorities and Trusts in its March briefing broke down the £95 million in a way which did not suggest that we were getting new and amazing largesse from the Government.

The briefing document said that, of the £95 million package, £53 million had been previously earmarked by health authorities; £10 million would come from the Government's new Mental Health Challenge Fund, with a matching £10 million contribution from health authorities; and £20 million from the mental illness specific grant, with a matching £2 million from local authorities. In that context, the figures suggested by several noble Lords this evening, including at the top end, as it were, the figure quoted by the noble Lord, Lord Acton, of £300 million, are very wide of the mark.

I hope that we shall not be told by the Minister in replying that this is an opportunity for the Private Finance Initiative. The House will have a chance, of which I hope we shall all take full advantage, to debate the Private Finance Initiative in the National Health Service next week. I certainly do not want to go into that troubled history in detail tonight. However, it would be particularly unfortunate if an important initiative such as 24-hour nursed care were to be at the mercy of the Private Finance Initiative.

My briefing from the financial experts suggests that, already, consultancy fees and management time have been estimated by NHS trust chief executives at around £200,000 per scheme, and that in the mental health field no firm agreement has been made on any provision of any substantial kind. I believe there is concern and interest now in the possibility of perhaps explicitly exempting mental health schemes from the PFI. It would be a very welcome suggestion if that were so.

In the meantime, while the arcane financial and institutional debates continue, many people with mental illness struggling to survive in the community will continue to be in need. The 5,000 or so patients with severe enduring mental illness are in special need of course. In the past few months we have seen yet more tragic examples of violent incidents involving mentally ill people released into the community. We know that these people are exceptions and that the severely mentally ill are more likely to harm themselves than anyone else. Nevertheless, high profile cases such as that of Jason Mitchell—reported on in March by Sir Louis Blom-Cooper—who murdered three people while living in a hostel undermine public confidence in community care programmes.

An earlier report on the Christopher Clunis case is quoted in the document on 24-hour residential care. It states:
"If the needs of that small group [the severely and enduringly mentally ill] are not met, care in the community will be discredited and … perceived as a policy which has failed. We do not think that as a society we can afford to let this happen … and we have no wish to return to the days of locked, impersonal, dehumanising and undignified institutional care".
We can all agree with that. But if we are realistic, we must surely also be sceptical that health authorities will be able to provide 24-hour nursed care to alleviate the problem, at least in the short term.

There are other practical solutions. I urge the Government to halt further psychiatric bed closures until appropriate community services have been developed; to take action to address the staff shortages referred to by several noble Lords, particularly the problem of community psychiatric nurses; and, particularly important, to implement immediately the care programme approach—a priority in all parts of the country and in every health authority.

Once again, I thank the noble Lord, Lord Thurlow, for introducing this timely debate. I hope that the Minister will be able to give him a positive response and that she will be able to respond positively to my proposals when she replies.

7.53 p.m.

The Parliamentary Under-Secretary of State, Department of Health
(Baroness Cumberlege)

My Lords, in thanking the noble Lord, Lord Thurlow, for securing this debate, not only do I congratulate him because I know of the fierce pressures on parliamentary time, but I would like to make three points. First, it is gratifying to have a debate led by a noble Lord who has such a depth of knowledge and insight into this very difficult and sensitive subject. Secondly, it has attracted two excellent and interesting maiden speeches. I hope that we shall hear more from these two particular maidens on this and other subjects.

I should like to say how pleased I am that the noble Baroness, Lady Berners, did not follow in her mother's footsteps and has taken her place in this House. Her experience as a nurse will inform and enlighten our debates. Clearly, she is one to keep her knowledge up to date.

The noble Lord, Lord Gerard, is also extremely knowledgeable. I am grateful to him for his perceptive speech, his transatlantic experience, and his welcome for community care.

Thirdly, I am pleased that this should be a Cross-Bench debate, not only neutral as the noble Lord, Lord Thurlow pointed out in terms of party politics, but on a subject which I believe is getting a higher profile and, for a variety of reasons, some positive, some less so. I believe it is time that this Cinderella service leaves the hearth, and, if not quite reaching the ball, at least comes into the limelight and receives the recognition due.

The Government have made mental illness a priority for the NHS and have awarded considerable resources to back their medium-term strategy, a "Spectrum of Care". Listening to the contributions made in this House, and knowing of the personal commitment of Ministers, not least my right honourable friend the Secretary of State for Health, I believe that that recognition is now with us.

As noble Lords are aware, mental health problems are common. At any time, around one in seven adults has a significant mental health problem. As the noble Lord, Lord Thurlow, said, these problems cause real distress, not only to the individuals themselves but to their families. It is vital that we identify these problems early and provide effective treatment. That may involve drug treatment or psychotherapy, or both, and is usually provided through the primary care team.

But, as the noble Baroness, Lady Jay, said, the focus of this afternoon's debate is not on the generality of mental illness but on those who need more constant care. I start by asking your Lordships to consider a young man, Paul Weston, who 25 years ago was diagnosed as having acute schizophrenia and considered to be a danger not only to himself but to others. He was admitted to a 1,000-bed hospital, 30 miles and over an hour's journey from his family home. He lived in a dormitory of 30 patients, where the only privacy was a curtain round his bed. He wore ill-fitting, secondhand trousers and shared a bathroom with 15 other patients. He was able to walk in the grounds of the hospital, although there was little else to occupy his time besides short shifts packing ballpoint pens into plastic packs, earning just enough money to buy cigarettes. In summer he would be in bed before dark, complying with a hospital regime which took little account of the needs of individuals but was more concerned with systems necessary to run a large institution. Over the years, Paul became passive and dependent, and had no contact with his family or friends from home.

Paul is a fictitious character, but one which those who have experience of this service will recognise. But what if Paul Weston's mental health problems had been identified this year? Through the Care Programme Approach, he would have been assessed, either at home or in a local hospital, by the specialist mental health team who would have arranged the care that he needed. That would include a home to live in, people to talk to, something to do, whether it be a job, work around the house or social activities, and an adequate income—together with the help needed to organise and sustain his unremarkable lifestyle.

He would also receive effective treatment, including drug treatment and psychotherapy. His progress would be monitored and a specialist team involving his family would reach a view about how to continue to support him. One option would be intensive support at home; another would be 24-hour nursed care.

It is our intention to provide a "Spectrum of Care", for we know that different individuals have differing needs. Twenty-four hour nursed care is one component. It is intended for the small number of people with severe and enduring mental illness who, like the Paul Weston of 25 years ago, require a high level of support, often over a long period of time, in a safe, non-institutional setting. Without 24-hour nursed care these patients have often stayed for too long in an acute hospital where it is impossible to provide the range of facilities and the rehabilitation that they need. Twenty-four hour nursed care offers greater intensity of care than can be provided at home and, by facilitating discharge from hospital, ensures that acute beds are available for those patients who need short-term intensive treatment.

The noble Lord, Lord Thurlow, raised the issue of the timetable for building 24-hour beds, or at least creating them. We have not given a timetable on the establishment of 24-hour nursed beds; but we are encouraging their provision as part of the local "Spectrum of Care". Indeed, some are already in existence. I refer noble Lords to the very good, independent report that we commissioned on 24-hour nursed care which sets out some of the examples and the aims of this particular policy. We intend partly to finance that through bids via the Mental Health Challenge Fund money. We know that some authorities are using that and some are finding resources from other sources.

The noble Lord also questioned the quality of private sector homes. That is important because we foresee that some of those 24-hour nursed beds will be provided by the independent and private sectors. I understand his anxiety and that of the noble Baroness, Lady Masham, that all homes for mentally ill people should be adequate. Of course, we try to achieve that, not only through regulation but through regular inspection. Indeed, we know of many cases now in which social services have taken action when deficiencies have been brought to their notice.

Perhaps I could look into the instance raised by the noble Baroness, Lady Masham, and come back to her in due course.

Should Paul Weston be identified by the team as at risk of harming himself or others, he will be included today on the supervision register, which is another component in the spectrum of care. The register will ensure that, as a particularly vulnerable patient, he will continue to receive the care that he so badly needs. Details of the circumstances in which he would be at greatest risk will be included on that register, so that his key worker can make sure that preventive action is taken should any of those risks occur.

If Paul Weston had been detained in hospital under the Mental Health Act and was considered to present a substantial risk of serious harm to himself or others unless his aftercare were supervised, he would now be eligible for supervised discharge—a third component. That new power, introduced on 1st April, would mean that if he failed to agree with the agreed care plan, it would lead to an immediate review of his care and, if necessary, readmission to hospital. But that may not be needed. An adjustment to his care plan may be sufficient. More often, it will involve the local authorities. As the noble Lord, Lord Thurlow, said, it requires local authorities and health authorities to work together. We have been encouraging that, not only through local workshops and study days but also with our guidance booklet, Building Bridges, which sets out good practice on inter-agency working and has been welcomed by both services.

I am aware that what I have described is the ideal. It is what the Government, through the NHS and social services, wish to deliver. But we recognise that the spectrum of care providing services designed to meet individual needs in the most suitable environment requires targeted resources. Specialist mental health services must focus on those with severe mental illness, and that is being achieved through the care programme approach supplemented by the supervision register and supervised discharge when those measures are appropriate.

The right reverend Prelate the Bishop of Oxford, the noble Lord, Lord Gerard, and the noble Baroness, Lady Masham, raised the issue of cost, particularly in relation to 24-hour nursed beds. Again, I draw attention to the document commissioned by the NHS Executive. With regard to resources it states that more work is needed to cost 24-hour nursed care compared with other forms of care for this client group. Nonetheless, it is clear that the cost per resident, though high, does not compare unfavourably with the cost for current alternative provision for this client group. More importantly, in our view, it represents much more cost-effective provision when the wider benefits to the mental healthcare system as a whole are considered.

We currently spend £2.35 billion on NHS hospital and community mental health services. A review of mental health purchasing carried out in the autumn indicated that health authorities planned additional investment in mental health services in the present financial year. Your Lordships will recall that on 20th February in this House I repeated the Statement made by my right honourable friend the Secretary of State for Health announcing several new initiatives. Those included a new Mental Health Challenge Fund, an additional £10 million matched by health authorities pound for pound which has been allocated to a range of developments, including an expansion of 24-hour care, strengthening of community mental health teams and provision of a crisis service for people with acute mental health problems. At the same time we announced that the mental illness specific grant allocated to local authorities would be extended into its fifth year and increased by £11 million to a total of £58.3 million. That grant has already supported 1,200 projects, helping over 100,000 people since it was introduced in 1991.

The noble Lord, Lord Thurlow, referred to violent patients, as did the noble Baroness, Lady Berners. We understand the concern about violent behaviour. However, there is no evidence to suggest that homicides by mentally ill people are on the increase. Convictions for homicide under Section 2 of the Homicide Act 1957—which provides the best available indicator of the number of homicides committed by mentally ill people—are no higher now than they were 20 years ago, though the total number of homicide convictions has increased substantially. It should be remembered that severely mentally ill people are far more likely to harm themselves than to harm others.

Before addressing the points raised by the right reverend Prelate, I should like to mention my sincere bereavement. Due to a decision made by the BBC, we shall in future be deprived of the right reverend Prelate's "Thought for the Day". I am truly saddened by that. However, this afternoon we have not been denied his thoughts on mental health, some of them from first-hand experience. I am delighted by his warm welcome for community care, although I understand his view that it needs to be made to work.

The right reverend Prelate particularly addressed the issue of homeless mentally ill people. They are a group which has concerned the Government for a considerable time. Your Lordships will know that in 1990 we launched the Homeless Mentally Ill Initiative in response to those concerns, particularly about people sleeping rough in London. That scheme aims to introduce mentally ill people to mainstream services by encouraging them into temporary accommodation, where they can receive appropriate care and assistance before moving on into the community. The initiative funds five multi-disciplinary community psychiatric Outreach teams and nearly 150 temporary hostel places. We have spent over £20 million on the initiative so far and this year a further £2 million has been top sliced from the mental illness specific grant to extend the initiative into other areas because we know from our experience that this scheme has brought real dividends to that vulnerable group.

The noble Earl, Lord Longford, sought to soften my heart. He does not have to try too hard. Apart from his charm, the noble Earl has the respect of this House for a long and very distinguished career in politics, having held an array of offices of state. Latterly we know of his determination and commitment to improve the care particularly of those involved in both health services and the penal system. Perhaps I may say that I found his book Prisoner or Patient very enlightening.

The noble Earl particularly mentioned the Matthew Trust and also a new body that is being set up to represent a number of small aftercare bodies in the field of mental aftercare. I learned of that only recently. In fact the noble Earl courteously told me about it yesterday. I understand that that body has not yet been fully established. But, along with other voluntary organisations, such as the Mental After Care Association, which we already support through the Section 64 scheme, we should want to keep a close eye on it as it develops. I am sure that the noble Earl will keep me in touch with its progress.

I should like to thank my noble friend Lord Mottistone for his generous remarks to both my honourable friend and colleague John Bowis and myself. We have listened to my noble friend over time both with regard to issues concerning the particular needs of the Isle of Wight and to his reservations concerning the speed of moves toward community care. I know that the organisation for which he has been a champion—the National Schizophrenia Fellowship—has campaigned for some time now for a 24-hour nursing service, albeit it names it differently. It has also campaigned for greater powers to ensure that those suffering from schizophrenia are not neglected and fail to take their medication. That is an issue which we have addressed through supervision orders.

But tonight my noble friend particularly wished to mention the responsibilities of GPs as did the noble Baroness, Lady Robson. We accept that there are tensions between the need to focus services on severely mentally ill people while helping primary mental healthcare teams to cope with their patients who have more minor forms of mental illness.

In February this year we announced a two-year project to allow fundholders to purchase not only community mental health service and out-patient care, but also to purchase in-patient care. The 27 fundholders taking part in the pilot scheme will be contributing to agreed strategies for local services and will aim to strengthen their links between community mental health teams and primary healthcare teams in order to offer better support to their patients in the community and to prevent unnecessary admissions. We will therefore be monitoring the initiative carefully.

The noble Baroness, Lady Robson, also wanted to discuss the issue of medical cover for 24-hour nursed care and was concerned that that would again fall onto GPs. We expect either local authorities or the relevant professions to forewarn the GP that a patient is about to be discharged from hospital as part of the care plan to be drawn up before the patient leaves hospital. Again, that is something we shall be monitoring closely.

My noble friend Lord Mottistone also wanted to draw attention to the shortage of psychiatrists. He is right to do so. We are addressing that issue and recently announced an increase of 114 specialist registrars in general psychiatry, forensic psychiatry and old-age psychiatry. In addition, a joint working party from the Department of Health and the Royal College of Psychiatrists is looking at workforce issues.

The noble Lords, Lord Gerard and Lord Thurlow, expressed concern about hospital closures and discharges. I can assure your Lordships that permission is not granted for the closure of long-stay hospitals unless adequate provision is available in the community. In addition, we issued guidance about the discharge of patients into the community to balance both their own needs and that of the community. Of course, the care programme approach should ensure that.

The noble Lord, Lord Acton, and the noble Baroness, Lady Robson, expressed the view that too much money is still tied up in hospitals. As the number of patients in long-stay institutions decreases, so the unit costs of those remaining increase, which was a point made by the noble Baroness. Those patients remaining are likely to be more severely mentally ill than those initially discharged into the community. We are encouraging health authorities to develop comprehensive reprovision strategies covering services and resources. Again, with the undertakings we have given about non-closures, I am told that there are facilities available. We believe that is the way forward.

The noble Baroness, Lady Masham, urged us to listen to carers. In our consultation document, Mental Health Services: The Patients Charter, we set out a number of rights and expectations which both users and carers should expect in the delivery of care and treatment. We look forward to the results of those consultations.

I am grateful to the noble Lord, Lord Acton, for outlining existing services which support families when they and their mentally ill relatives are at crisis point. He is right that we need a spectrum of care, a variety of services, especially those based in the community, to deal with crises. He may be encouraged to know that through the Challenge Fund 12 new crisis services have already been set up.

A number of other issues were raised. I shall pick them out in Hansard and write to noble Lords. But perhaps I may mention one or two points raised by the noble Lady, Lady Kinloss, who was concerned about the matter of psychiatric nurses. Again, that is an issue that we have addressed. Indeed, in the current year we increased the training numbers by 17 per cent. But the growth in the number of community psychiatric nurses has been considerable. Clearly, however, there is an increasing demand and it is something with which we have to keep pace.

The noble Lady also raised the issue of people with a mental illness and a learning disability. There are various views concerning that, as outlined by the noble Lord, Lord Rix. I do not want to enter that debate tonight, except to say, as the noble Lord said, that we are sending out guidance in terms of a booklet. Perhaps it is an issue that we shall come back to on another day.

On the question of form filling, I can assure the noble Lady that we are in the midst of an efficiency scrutiny and are examining what forms are unnecessary.

Although I understand that the role of the Opposition is to oppose, it is a pity that the noble Baroness, Lady Jay, did not acknowledge the huge strides that have been made. All districts now have the care programme approach in place and only a few have not applied it to all their patients in contact with specialist psychiatric services. The NHS Executive is pursuing those authorities which have not met the target date of April 1996. I understand that they will have achieved full implementation by the end of June this year.

As the noble Lord, Lord Thurlow, stated, the Griffiths proposals have only recently been introduced. I am sure the majority of your Lordships will agree that the care which can be provided for Paul Weston in 1996 is far better than that available 25 years ago. We owe it to Paul Weston and to everyone else with severe mental illness to ensure that care of that quality is available for every person with a severe mental illness. Real progress has been made and the policy to establish a spectrum of comprehensive services is not in doubt. The prize will be to enable those with severe mental illness to live among us, supported by the care which they need, leading safe and fulfilling lives and contributing to the community to which they and all of us belong.

8.16 p.m.

My Lords, I thank all those who have contributed this evening from their considerable personal experience. In this House we enjoy the advantage of being able to draw upon great knowledge and experience in so many fields, and that certainly applies to the field of mental illness.

I hope that the Minister will feel that the contributions were made with a constructive intent. It has been a constructive debate. As I suggested at the start and as the Minister emphasised, the edifice proposed by Griffiths is still young; it is still being built and it would be entirely unrealistic to have expected a perfected building to be available yet. However, it has been encouraging this evening to hear of the remarkable strides that have been made in achieving the reality of community care to a much greater extent.

That does not mean to say, as your Lordships have not been slow to point out, that there are not serious continuing gaps, and at present it is difficult to envisage how they will be filled without new initiatives. One gap in particular that was mentioned in relation to the problems of local authorities points to the need for some kind of new training blitz to help councillors in local authorities to understand some of the problems better, as well as the medical and legal framework.

Like others, I too congratulate our two maiden speakers. Though the noble Baroness, Lady Berners, had to leave, it is a great advantage to have another nurse in our ranks, especially, as your Lordships emphasised, with the critical situation that exists in the supply of CPNs.

I was interested by some of the new ideas that arose in the course of the debate. I was not surprised to learn a lot. The noble Lord, Lord Gerard, told us of the interesting Fountain House project which is being extended throughout the country. That seems to provide a wonderful instance of how ordinary members of the community can help to back up the professionals and others in this field.

My main impression of the debate is on the whole in line with that of the noble Lord, Lord Mottistone, that the trend has been encouraging and is encouraging. Much remains to be done but we must be grateful to all concerned for the progress made. I beg leave to withdraw the Motion.

Motion for Papers, by leave, withdrawn.