§ Order for Second Reading read.
§ The MINISTER OF HEALTH (Mr. Arthur Greenwood)
I beg to move, "That the Bill be now read a Second time."
In rising to move this Motion, I invite the co-operation of all sections of the House in a Measure which does not involve narrow party political considerations, but which, nevertheless, in its intrinsic importance, is one which is entitled to the careful attention of all Members of this House. I do not think there can be any worse human tragedy than that of the man or woman wandering in the no-man's land between sanity and insanity, or the case of the person temporary deranged who, through lack of early care or adequate care, is plunged into permanent insanity, with all the phantasms that populate the world of people whose minds have lost their equilibrium. Anything that this House can do to deal with that problem, and anything that this House can do to popularise a new conception of mental disease, is work which it ought to do. It will be within the recollection of the House that five years ago I announced, in the Labour Government of 1924, that a Royal Commission on Lunacy was to be appointed, to be presided over by Mr. Hugh Macmillan, as he then was—a Commission of distinguished persons, including representatives of this House. Two years later the Commission issued its report.
The purpose of this Bill is to carry into law the less controversial proposals in that report, and to deal particularly with urgently needed reform. The reception which the Bill had in another place, and the discussions which took place there, lead me to believe that essentially the Bill can be treated on a non-party basis. During its passage through the other House certain Amendments were made, and during its passage through the Commons, the Government will be willing to consider sympathetically any Amendments which may be forthcoming which will improve the Bill, 958 but which are not inconsistent with the main principles of the Bill. The main emphasis of the Report of the Royal-Commission is upon the need for a new conception of mental disorder and its treatment. There is emphasised the view that there should be early treatment, and that mental disease should be viewed much in the same way as we now view physical disease. I will, if I may, quote one or two passages from the Report of the Royal Commission which, I think, express admirably the modern attitude towards the treatment of mental diseases:The keynote of the past has been detention. The keynote of the future should be prevention and treatment.Again,Contrary to the accepted canons of preventive medicine, the mental patient is not admissible to most of the institutions provided for his treatment until his disease has progressed so far that he has become a certifiable lunatic. Then, and then only, is he eligible for treatment.But they said—and here, I think, the overwhelming feeling of the House will be with the Commission—Certification should be the last resort in treatment, not the pre-requisite of treatment.Another quotation—and I think it is important that the House should realise exactly what we are trying to do in this way—With the advance of medical science and the growth of more enlightened views, insanity is coming to be regarded from an entirely different standpoint. It is being perceived that insanity is, after all, only a disease like other diseases, though with distinctive symptoms of its own, and that a mind diseased can be ministered to no less effectively than a body diseased.It is on that basis that the Bill has been founded. If we accept that view of mental disease, not as a visitation of Providence, not as something indecent, about which we ought not to talk in public, but as something in the same category as other forms of human ailment, then it becomes quite clear that the community ought to organise its resources to enable us to carry out preventive measures and early treatment. In the Bill provision is made for two categories of treatment: First, those who themselves recognise the instability of their condition, and who realise the desirability of taking early preventive measures; and, secondly, cases of people who themselves are no 959 longer able to realise their condition, but who, nevertheless, may be curable, and who ought to receive treatment different from that of the certified lunatic. The first Clauses of the Bill deal with those two categories of cases—the voluntary boarder who goes in of his own freewill fearing a mental breakdown, and what is called in the Bill the non-volitional patient, who enters for temporary treatment.
With regard to the voluntary boarder, at present in England and Wales voluntary boarders can be received only in certain institutions: in licensed houses and registered hospitals under the Lunacy Acts, and only in two public institutions where, as a result of special legislation, it is possible for voluntary boarders to be accommodated. They are the Maudsley Hospital under the London County Council and the City of London Mental Hospital at Dartford. It follows, I think, from that, that with very few exceptions treatment of the voluntary boarder is available only for people who are fortunate enough to be able to pay the fees for entry into these places. That, obviously, cannot in these days be defended. There are few free beds in the licensed houses and registered hospitals. There are 14 only of them and only 4,700 beds. The big bulk of the public hospitals are not entitled to take in voluntary boarders, and the result, therefore, is that the vast number of people for whom treatment as voluntary patients would be desirable are in fact debarred from that treatment. Of the 115,000 beds in our mental institutions, there are none that are available for persons who want to go in in the first stages. They are there only for those people who have gone in with the badge of the certified lunatic in their possession.
The object of the first four Clauses is to make more extended provision for voluntary boarders and to provide that such boarders may be received into the other types of public institution whose doors to-day are closed against them. In order that we may get a coherent and logical code with regard to voluntary patients, the opportunity has been taken in the early Clauses to repeal certain of the existing provisions and to re-enact them and bring them together in the first four Clauses as a definite and complete 960 code for voluntary boarders. It is, of course, clear that in cases of this kind, I think in most instances where the individual goes in of his own free will, there must be some measure of protection. The real distinction between physical and mental disease is that, in the case of mental disease the will of the individual does not consciously operate, and it is necessary, therefore, to have some measure of protection in the interests of people who enter these institutions. While provision is made to permit a person of less than adult years to become a voluntary boarder in an institution on the application of a parent or guardian, safeguards have been introduced requiring the support of definite medical evidence as to the desirability of the young person undergoing treatment, and a provision for the intervention of the central authority if the parent or guardian does not appear to be carrying out his duties after the minor has been placed in the care of the institution.
The next problem of the voluntary boarder is as to his release. It is clear that, if a person voluntarily enters an institution for treatment, he cannot be permitted to leave just exactly when he likes and, as the law stands now, notice of 24 hours is required. In the Bill, we are proposing that voluntary boarders should be entitled to release on giving 72 hours' notice. That is not because of anyone's desire to retain people against their will, but in order that there shall be sufficient time to communicate with friends or relatives and to make effective arrangements for their care when they are released, because it is obvious that in certain cases, unless proper steps are taken for the care of a patient who is discharged, some serious harm may come to him. I think it will be generally agreed, so far anyhow, that we are on right lines in opening more doors and in making more extensive provision for voluntary treatment. That provision is made in the first four clauses of the Bill.
In Clause 5, where there has been a certain amount of doubt expressed, we are dealing with the person who has gone a little too far to appreciate that he is a victim of incipient mental disorder and who, whilst not being the resistant type of case which calls for certification, ought to receive some method of treat- 961 ment. The cases we have particularly in mind are the cases of the man whose mind has been temporarily broken by overwork, the cases of the woman in childbed who suffers from puerperal mania, and cases where with proper treatment fairly early recovery might be expected. Think of the woman after confinement whose mind becomes temporarily unhinged and who is branded with the stigma not only of the Poor Law but of certification ! The stigma of certification is a real thing which has kept from proper institutional treatment many people who might well have benefited. I am not sure that in many working-class homes the stigma of judicial certification does not stab deeper even than the stigma of the Poor Law and it is, therefore, essential, if we are to do common justice to people who in time will be as normal as the rest of their fellows, that we should do something to get adequate treatment for them without putting upon them this brand of certification.
It raises very large and difficult questions. We know that a substantial proportion of the people who enter institutions duly certified recover and, in the report of the Royal Commission, a number of statistics are quoted of various mental hospitals showing that quite a substantial proportion of people who enter our mental institutions are released in a relatively short space of time. One of the best instances, perhaps—because the figures cover four years—is that of the Claybury Mental Hospital, where it is shown that out of 792 recoveries of sanity, 11 patients recovered between the first or second month, 40 between the second and third, 71 between the third and fourth, 76 between the fourth and fifth, and 83 between the fifth and sixth month. In other words, over a quarter of those recoveries took place within six months, and we are proposing, in the first instance, that, subject to safeguards, these people should be subject to a period of treatment not exceeding six months. In the cases I have quoted, over a quarter of all the people who recovered in that asylum would, under Clause 5, never have had to undergo judicial certification. It is clear that, if we had more and early treatment of this kind, more cases would recover. Even at the end of six months I do not think 962 we are justified in assuming that the patient who still remains needs certification, and, therefore, provision is made for the continuance of the treatment for a period not exceeding a further six months.
Here I feel that I must explain that the Government have departed from the recommendations of the Royal Commission. It is done after very careful and mature consideration. The Royal Commission, while anxious to differentiate cases which should be certified from those which need not be certified in the first instance, cast about for a procedure which would be different from that of certification, and they devised the plan of a Provisional Treatment Order, and they proposed, with reluctance—I use their own words—that the Order should be signed by a magistrate, though it is clear from the whole tenour of their report that they would be glad to get away from judicial interference. When we came, however, to work out what the Provisional Treatment Order would, in fact, be, it was clear that to the ordinary mind it could not have been distinguished from ordinary certification. I feel very strongly that, if the principle of Clause 5 as it stands now is destroyed, the heart will have gone out of the Bill. One wants, therefore, to devise a machinery which is distinguishable from certification. That is the whole point of the Clause, to get treatment for the non-volitional case without having to resort to the interference of the magistrate and all that that means.
But, of course, there must be safeguards, and we have inserted a number of safeguards which, I think, will be an adequate protection for the non-volitional patient. First, there must be two medical recommendations to support the application made on behalf of a non-volitional patient, one signed by a medical practitioner specially approved by the State, and the other, if practicable, by the usual medical attendant of the patient. There is a double safeguard without the intervention of a Justice of the Peace. Such a patient may be received into an institution provided by a local authority or into a registered hospital; that is to say, a charitably-provided hospital registered under the Lunacy Acts. He can only be received into any other institution, hospital, or 963 nursing home if that place has previously been approved by the Board of Control as being suitable for the reception of these cases. That is a further safeguard, because it means, in effect, that these cases can only go to institutions which are under the public eye and under a measure of public control. Moreover, on the reception of a patient, notice, with the full details, with a copy of the application, with the medical recommendation and so on, must within one clear day be sent for scrutiny to the Board of Control.
Further, arrangements are made in Clause 5 of the Bill for fairly frequent visitation, and, in addition, there will be the periodical visitation of the central authority itself. Arrangements for discharge will be as under the Lunacy Acts, and, in addition, it is laid down that a patient must be discharged in any event within 28 days of recovering volition. It is difficult to say now what time that should be, because cases may relapse and become worse, but it is clear that we should have a period of time in the Bill at the end of which the person who has recovered shall be automatically released. There are other safeguards, but what we have tried very sincerely to do is to protect the individual and at the same time not to introduce the process which is commonly associated with entry into a mental institution.
I believe that this Clause will mark a great advance in the treatment of incipient mental disorders, but I am equally sure that the intervention of the magistrate in these cases would destroy the whole value of it. We are faced with a complete dilemma. Parliament can agree to Clause 5 without magisterial intervention and to that extent permit the treatment of incipient mental disorder to be approximated to the treatment of physical disease, or they may leave the present legal machinery as it stands now and condemn these people to certification. If you do the latter, you will not get the early treatment which we all desire to bring about, and the great purpose of this Clause, and indeed one of the main purposes of the Bill, will have been defeated.
Medical opinion certainly, and I think a large volume of enlightened public opinion are prepared to support this 964 Measure and to get rid of what has been caled the stigma of judicial interference I may claim that we have in this matter the vast majority of the medical profession behind us. Certainly, Lord Dawson in another place spoke warmly in support of the Bill. The lawyers, to whom we are entitled to look for the protection of the individual, as; profession, have always stood by the liberty of the subject, and it is significant that when in another place an effort was made to provide for the intervention of the magistrate, two of the Law Lords opposed that view and supported the Bill. I think we may say that in the other House this Clause received support from all three political parties. It is unite clear that, if we are going to look forward to expanding the provisions for the treatment either of voluntary patients or of non-volitional patients, we must develop and re-fashion our local and central machinery.
In Clause 6 and the following Clauses we deal with the provisions as regards local authorities. Clause 6 enlarges the powers and duties of local authorities and enables them to do more in the way of provision of facilities for treatment. It imposes an obligation upon them to provide suitable accommodation for temporary patients under Clause 5 as was recommended by the Royal Commission. They are given powers which, I believe, will prove to be of the utmost value, powers to provide out-patient clinics—for I see no reason why every temporarily unbalanced person should be put into an institution—powers to undertake aftercare—and. if after-care were effective, many of the recurrent cases would not go back-and powers to undertake research. These powers are subject to the approval of the Board of Control and are so drawn on the specific recommendation of the Royal Commission.
§ Mr. STEPHEN
In view of those additional obligations which are being put on the local authorities, is there any additional national finance being provided to relieve the local authorities?
§ Mr. GREENWOOD
I am not sure whether the hon. Member quite understands what is the position to-day. We are dealing with people who to-day are certified, and to-day it is the duty on the part of local authorities to undertake the treatment of those people. We are 965 asking now, not that they are to undertake entirely new duties, but to undertake the duties which have been performed hitherto under certification in a different way.
§ Sir DOUGLAS NEWTON
Will the right hon. Gentleman permit me to say that, under present conditions, a grant is given by the State, and that I shall be glad if the right hon. Gentleman can make it quite clear whether it is the intention to give a grant in future for these additional patients.
§ Mr. GREENWOOD
The grant which is given to-day in respect entirely, I think, of Poor Law patients is a small grant. That grant was largely destroyed, not by me but by the late Government. When the block grant was introduced last year, the new grant was a grant in respect of the public health services almost entirely—I will not mention the exceptions—and the mental institutions were definitely included as part of the public health services. Under the block grant, in future State money will be paid in respect of mental institutions just as much as it will be paid in respect of maternal and child welfare centres. Far be it from me to try and explain a Bill which I did not help to pass, but under the block grant, it was said—I find myself in a very difficult position in these matters—an amount of new money was put in over and above the existing grants paid in respect of individual services in order to permit of this development, one aspect of which we are trying to press forward to-day.
§ Mr. LEIF JONES
In Clause 6, the duty is laid upon every local authority to provide and maintain suitable accommodation for temporary patients. Will not that mean that every local authority will have to make provision for a new class of patient, and will not that involve a very considerable expense to local authorities?
§ Mr. STEPHEN
Before the right hon. Gentleman replies, and as I first interrupted him, I should like to say that I was quite aware that there was already an obligation on the local authority, but, if this Measure is going to be successful and there is going to be this development of treatment without certification, it is surely going to involve an additional expense. My point is that, if the Bill is 966 successful in its purpose, there will be additional expense, and is there not going to be some additional provision made by the National Exchequer in order to relieve the local authorities to some extent?
§ Mr. GREENWOOD
I deprecate this method of interruption. I have already tried to explain from actual statistics of institutions the position with regard to people who were certified and recovered. We ask in this Bill that these people shall no longer be certified and that they shall be treated definitely as possibly curable cases. It is a duty on local authorities to deal with certified lunatics, a statutory duty from which they cannot escape. They cannot deal with them to-day until they certify, and we are asking for machinery which will enable them to deal with these persons without certification. If it should be that the local authorities feel that this is a service which demands further financial assistance, I am quite sure that their constituted organisations will come and press very hard long before the day on which they begin to spend the money. Objection has been taken to making this a new duty, but as I have already pointed out it is not so much a new duty as the application of an old duty in a different way. Even if it were not made a statutory duty, I ought to point out to the, House that, as these mental institutions and the work under these Acts are part of the public health work of the local authorities, if they do not carry out their duties they may, under the Local Government Act, suffer a diminution in their State assistance and that would, if it were applied—and I think that some of these things often ought to be applied—make a power practically into a duty.
Now that we have transferred the boards of guardians and now that there is to be a new development of health services, many local authorities will welcome this new change and this new avenue for the development of a branch of the public health service. If we modify the law as regards local authorities, it is clear that we ought to modify the law with regard to the central authority. The Board of Control has a long history, which goes back, I think, to the forties of the last century. It is now being subjected to criticism. It is no business of mine to deal with that point, 967 except in so far as this Bill is concerned. The whole intention of the reorganisation set forth in Clauses 11, 12, 13, 14 and 15 is to re-establish the Board of Control on a new basis, with a closer contact with the local authorities and with a procedure and a method of administration assimilated to that which is followed now in the Ministry of Health. We are proposing to reduce the size of the Board and the number of Commissioners and to give power for the appointment of Assistant Commissioners and Inspectors, in order to get some effective central provision and administration and a more effective contact with the local authorities. We not merely reduce the number of Commissioners, but we give new authority to the chairman of the Commission, subject, as is laid down in Clause 12, to the directions of the Minister of Health.
The whole desire behind this proposed alteration in the Board of Control is to adapt that central machinery to the rapidly developing work within the sphere of the Board of Control, lunacy, mental deficiency and now the powers and activities under this Bill. It is assumed, indeed it has been stated, that the Board of Control is a star chamber, which is not within the jurisdiction of this House. Nothing could be more untrue. It is important for hon. Members to realise, because their attitude to the Bill will be largely governed by their view of this part of it, that while for administrative reasons it is desirable that there should be a board of some kind, that board is as much within the control of Parliament as the Ministry of Health, the Board of Trade, the Board of Education, or any other State Department. When questions are asked about the Board of Control, and they can be asked, they are answered by the Minister of Health; when their Estimates come before the House, those Estimates are defended by the Minister of Health; when their legislation is before the House, unfortunately, it is introduced by the Minister of Health. There could not be any more complete control than that which is now exercised. It is in character, in kind, and in scope the same sort of control as Parliament exercises over other Departments. Having said that, I must say a few words about Clauses 14 and 15.
968 Clause 14 has caused a little alarm in certain quarters. It is a Clause which transfers certain powers from the Minister to the Board of Control. Those powers are set out in the Second Schedule to the Bill. They are detailed powers affecting relatively small matters of administration, but they do quite naturally and inevitably lead to over lapping and duplication of administration. The Royal Commission, quite rightly, felt that the whole of the power should be exercised by one common body, and suggested that the detailed powers enumerated should be handed directly to the Board of Control. That has been done in Clause 14. Should any difficulty arise about the exercise of powers under Clause 14, my responsibility will not be really changed. There will be as much Parliamentary control as there is at the present time. Clause 15 has also created apprehension in the minds of a few people. There, again, it is desired to have power to make rules for restricted purposes, and it is a power that already exists under the Lunacy Acts. It is clear that there must be residing somewhere the power to make rules of a detailed administrative kind. In another place the Government accepted Amendments, because of fears that had been expressed, to bring such rules immediately under the notice of Parliament. By Clause 15 (2), as amended in another place, it is provided that:any rules which modify or adapt any enactment … shall cease to have effect upon the expiration of a period of three months from the date on which they came into operation, unless at some time before the expiration of that period they have, been approved by a Resolution passed by each House of Parliament.All the other rules made under the Act must be laid before Parliament as soon as they are made, and, if an Address is presented by either House within 21 days, the rule is to be annulled. That will give to Parliament a final say in the matter of the detailed administration of the rules, which, I think hon. Members will agree, is essential should be made.
The remaining Clauses of the Bill deal with one or two matters of importance. Clause 16 refers to the protection of medical practitioners who give certificates under the Lunacy Acts. The position of the medical practitioner to-day is one of considerable uncertainty, in- 969 deed many of them think that it is one of very real peril. The Royal Commission recognised that. To-day, if the medical practitioner is made defendant in a case for wrongful certification the onus of proof rests upon him to show that he has acted in good faith and with reasonable care. I think it is clear that we cannot completely remove responsibility from the medical man. After all, he has made a decision and, therefore, whilst we must keep upon him a certain measure of responsibility it is important on the other hand that he should have reasonable protection against cases which might be brought and which might mean his financial or professional ruin, even if the cases did not go against him. The Clause in the Bill follows very closely the proposal made in the Royal Commission's Report, which was drafted in detail by the very eminent legal members of the Commission.
A further important point in the later Clauses of the Bill is the Poor Law aspect of the problem. The Royal Commission desired a complete overhaul of the whole system of lunacy administration. That has not been possible, but it has been decided to dissociate people suffering from mental disorder from the Poor Law. We have in the Bill removed the pauper stigma by a declaration in Clause 18 that:A person shall not be deemed to be in receipt of poor relief or be deprived of any right or privilege or be subjected to any disability by reason only that he or a member of his family is' being maintained under the provisions of the principal Act or of this Act in any place as a rate-aided patient.5.0 p.m.
That provision, coupled with the abolition of the boards of guardians, will mark a very great step forward in lunacy administration. At the present time, under the Lunacy Acts if you are fortunate enough to be well-off you will not be visited by, shall I say, the relieving officer or a policeman, but, if you are poor and it is a case of emergency and something has to be done with you, you will be visited by the relieving officer or a policeman, as likely as not, and be taken to the workhouse. I think the House will agree that, if we are to get rid of the pauper stigma, that matter must be dealt with, and we have, therefore, in Clause 17 provided the same kind of procedure for the poor person in case 970 of sudden insanity or sudden mental disorder as applies to the well-to-do who may have a member of their family taken to a private hospital.
The provisions which I have outlined cover the main proposals of the Bill and carry into effect, with one exception to which I have already drawn attention, the recommendations of the Royal Commission except on two big points. I have already referred to the recommendation made by the Royal Commission with regard to the assimilation of procedure. It would be well if that could be done, but I am not sure that it could have been done very simply. It would have made the Bill highly controversial and I wanted to get the maximum with the minimum of controversy. It would, of course, have overloaded the present Measure. It would perhaps have been advisable to follow the Report in regard to the problem of licensed houses, but this is a burning question, full of deep-seated differences of opinion, a problem which clearly ought to be dealt with but one upon which the Royal Commission itself was divided. These matters, therefore, have been deliberately excluded from the Bill in order that we may get what I hope will be a relatively non-controversial Measure, designed to meet an urgent need, designed to revolutionise the mind of the people in their attitude towards mental disease, designed to provide better facilities for the early treatment of the disease and designed to reorganise our administrative machinery so as to make the constructive proposals more readily operative and more successful.
The House will not find in this Bill any sources for blinding differences of opinions. I am hoping that it will give a Second Reading to the Bill without the trouble of a Division, so that we may proceed to Standing Committee where every effort will be made to accept Amendments which will really improve the Bill so long as they do not interfere with the principles on which the Bill is based. In this matter, I can appeal to the common humanity and good sense of all sections of the House and ask them to support me in a Measure which I believe will open a new and important chapter in the history of public health in this country.
§ Sir KINGSLEY WOOD
I welcome the main provisions of this Bill, because I think they represent a saner view of insanity. The Minister of Health has asked for the co-operation of all sections of the House in regard to these proposals, and I do not think he will ask in vain. He has asked us to treat this Bill on a nonparty basis and, provided that hon. Members on this side have a reasonable opportunity of discussing the provisions of the Measure on Second Reading and in Committee, we hope to co-operate with him in securing the insertion of Amendments which we think may be necessary in order to make an advance on this subject, as I believe the Bill itself is an advance.
When we discuss a Bill of this character, the question naturally arises whether the number of lunatics in this country is increasing or not. I speak subject to what may be said by members of the medical profession in this House who speak with more authority, but at any rate it can be said that mental illness is not being reduced and that the recovery rate is not particularly good. There is undoubtedly an increasing number of persons who are suffering from temporary mental troubles due to the increasing speed and strain of life; people who are not an active source of danger either to themselves or to others but who are suffering from ill-balances, and others, a second category, with a definite mental disorder but in other respects a clear insight, yet unable to trust themselves and who require care and oversight free from the possibility of further mental stress.
What is our present method and national policy in relation to these people who are suffering from such an unhappy and distressing disease? Although in many respects the old conceptions and the old unhappy methods concerning mental lunacy are disappearing, they die hard. In many respects, we are still manufacturing lunatics in this country, and the old idea of the helplessness and hopelessness of mental disease still prevails in many quarters. We know the old question:Canst thou not minister to a mind diseased:Pluck from the memory a rooted sorrow;Raze out the written troubles of the brain.972 A good many people are still answering this question in the negative. There is still, unhappily, a stigma applying to lunacy, harking back, I suppose, to the time when madmen were to be kept in chains and underground cellars. The idea with a large number of people today is still that mental disease involves some personal slur. The right hon. Gentleman, in his able speech this afternoon, quite rightly referred to the fear and dread of certification which exists in all classes of the community. A very striking communication which illustrates that point of view is, I believe, in the possession of the Ministry of Health. A man wrote a letter which I thought was very expressive of the need for some of the provisions of this Bill. He said:My own wife had a breakdown six weeks after the birth of our little daughter, and we had to get her away at once to a private mental home. She was absolutely fit again in three weeks, yet to get her under proper care she had to be certified by two doctors and a J.P. She did not know it, and I pray she never will, for the knowledge that she had once been certified as a lunatic would be enough to send her permanently insane.There are two grave defects, out of a number, in our present system. The first is that the present law places many obstacles in the way of early diagnosis and early treatment and, the second, that under present circumstances and under the present law there is very little hope of recovery for many poor people. It is perfectly true that the well-to-do man can obtain rest and treatment in some private home and by that means can in most cases, quickly restore his mental balance. The poorer man or woman, and the term includes not only the working men but the middle classes as well, must reach a final stage in the disease by which they are afflicted and be certified before the mental hospital or asylum can receive them. I welcome the provisions in the Bill which, for the first time, give the power to receive voluntary boarders. I do not know whether that is an apt title, but the intention and meaning deserve commendation. There are already a number of voluntary boarders in a number of private homes up and down the country who desire to co-operate in their treatment with the mental man and nurses in the institutions to which they voluntarily go. This provision in 973 the Bill is certainly one which a very large number of hon. Members will desire to support.
It has been put to me, and I daresay will also be expressed by some hon. Members, whether it would not be better, so far as people are concerned who offer themselves in this way for voluntary treatment, to remove them altogether from the jurisdiction of the Board of Control and by that means to dissociate this kind of illness altogether from lunacy and lunacy administration. That is a matter which we might well discuss in Committee on the Bill. It is only fair, in regard to people who are under age and who are placed temporarily in some home or institution of this character by their parents, to point out that the Board of Control can exercise some jurisdiction and can send members of the Board to visit such institutions.
§ Mr. McSHANE
May I say that such a suggestion is impossible, because in the Preamble of the Bill it states that it is an Act to amend the Lunacy Act as relating to the constitution and organisation of the work of the Board of Control. The Board of Control is fundamental.
§ Sir K. WOOD
With all respect to the hon. Member, I do not think that there will be any difficulty in altering the Bill in Committee.
§ Sir K. WOOD
I daresay those observations will be made when the Parliamentary Secretary to the Ministry of Health replies to the Debate. That is a matter which can be considered in Committee. I do not think that the title of the Bill will prevent us from limiting the powers of the Board of Control. We shall hear about that from the Minister later. It does give some protection for the Board of Control to be in charge in this particular way with this class of case—in the cases of what one might call infants, people who are under 16 years of age and who have been sent to these institutions by their parents. I read the report of the discussions in another place, and I found that a good deal of importance was attached by eminent lawyers to the fact that as, simply on the re 974 quest of parents, it was possible to place minors for a certain period in homes of this character, the power of the Board of Control to send commissioners was some measure of protection. How far that can be said to be a substantial statement we can consider when we discuss the Bill in Committee.
I wish to say a word or two on a more important provision which may raise a certain amount of controversy. That is the provision which permits temporary treatment in the case of the involuntary patient when there is reason to believe that there is hope of recovery. My hon. Friend who was Solicitor-General in the last Government will deal more particularly with that part of the Bill, and I shall not go into great detail about it. It will be seen that Clause 5 says—Subject to the provisions of this Section, a person who is suffering from mental disorder and is for the time being incapable of volition, but who is likely to benefit by temporary treatment.I think there is a measure of just criticism that the phrase "being incapable of volition" does raise many considerable difficulties. That, again, is a matter which calls for careful consideration in Committee. It is a very difficult thing to define. We must certainly see whether every protection is being afforded to the subject in this respect. I know that some of my hon. Friends have felt considerable anxiety regarding this part of the Measure. One does not want to state anything that in any way interferes with what is suggested, but it is true that for the first time in the law of this country no order is to be signed by what is called the judicial authority, and no reception order is to be made in respect of the detention of an individual. That detention may last for a considerable period. We have to consider, in the first place, whether such an alteration in the law is necessary and desirable, and, secondly, whether there are proper and adequate safeguards from the point of view of the liberty of the subject. There can be no question that if, subject to proper safeguards, we can make an alteration in the law which will permit people to get away from certification, it should be done.
It has been said to me, by deputations and otherwise, that when I state that there is a stigma in relation to certifica- 975 tion, I am not correctly stating the position, and that what I ought to say is that the stigma applies to incarceration in a public mental institution. But that is not my own particular experience. Anyone who has had to do, as I have had in days gone by, with the legal profession, knows the tremendous fight that most people and their families desire to put up against what is called "certified as a lunatic." There is no doubt of the very real apprehension in the minds of large numbers of people in this country, and that apprehension can be realised only by those who have had experience of a number of cases. Once a person has been certified as a lunatic in this country it is very difficult indeed for people to forget it, and although the patient may have recovered, the fact follows him for the rest of his life. If it can be done, I want to see the need of certification in these cases removed. Again speaking from my own personal experience, I doubt very much whether, from the point of view of the liberty of the subject, the intervention of justices of the peace is any particular protection. It is true that, under the present law, justices of the peace are supposed to consider these matters, and to make inquiry before they come to any conclusion. One need only read the report of Lord Macmillan's Commission to realise how in many parts of the country this part of the law is being carried out at the present time. In very many areas there are not justices specially selected for this purpose, as they ought to be, but the whole body of justices are given this particular power. There is the case of lunatics being certified by a justice of the peace travelling in a taxi, or after a very summary consideration of the facts.
§ Sir K. WOOD
That is another matter. Apart from that side of the question, even from the point of view of justices of the peace who do take their duties very seriously, it is a most difficult position in which to place any justice of the peace, when he is confronted by certificates signed by competent medical men, to ask him to differ from the medical conclusion. I shall not put it any higher, but I think it is possible to 976 exaggerate the safeguards which justices of the peace are in the present administration of the law. Then I ask myself the question, what are the safeguards which are included in this Bill and in the law generally to give the security which we all desire in cases of this kind? The first thing that can be said is this: That the ideas which used to surround the administration of lunacy, probably provoked by novels and works of romance—that there were many cases of people being wrongfully and improperly retained in asylums—are without foundation. Certainly if we have regard to the tribunals which have been set up by this House, the last two tribunals, we are bound to accept the general conclusion to which Lord Macmillan's Commission certainly came, and that is that the cases of wrongful detention must be of the rarest occurrence.
That statement was endorsed by every member of the Commission I suppose there could be no more careful check, and no one more anxious to have regard to the liberty of the subject than the Chairman of that Commission, Lord Macmillan, whom we are all glad to see appointed to the highest judicial body in the land. Associated with him are Earl Russell, who conducted this Bill so ably in another place, Sir Humphry Rolleston, Sir Ernest Hiley, the right hon. Gentleman the present Attorney-General, and my colleague the Member for East Woolwich (Mr. Snell), who certainly would have special regard to matters of this kind. They certainly came to the conclusion that wrongful detention must be of the rarest occurrence. Another conclusion which has a bearing on this matter was that ill-usage is not deliberately or systematically practised in mental institutions'. I place a good deal of confidence in the Board of Control and its operations. I am not one of those who for a moment desire to make any general indictment against the Board of Control. I have had sufficient association with them during the last five years to appreciate the work that they have done and are doing. I was glad to see that Lord Macmillan's Commission, again unanimously, came to the conclusion that they were doing their work very well indeed.
In considering this novel proposal in Clause 5, the fact that members of the Board of Control can visit these patients 977 at any time is a considerable safeguard. The fact that before the provisions of the Clause can be put into operation the application has to be signed by two medical men, one of whom must: be approved by the Board of Control and therefore must occupy what one might call an independent position, is good too. I also attach a good deal of importance to the fact that in all these institutions up and down the country, where these unhappy sufferers may be, there are in charge of them, as superintendents, men who, taking all their many duties into account, perform their very difficult work well; and they are men who, if at any time there was any question of any person being wrongfully detained, would be the first to intervene. As regards the superintendents, I hope that as a result of this Measure and of further administrative alterations they will be given more time to attend to their proper duties and will be relieved of many duties which are not appropriate to their position. Having regard to the many safeguards which exist, apart from those I have mentioned, I am inclined to feel, though I do not speak for everyone on this side of the House, that this proposal is worthy of consideration and that it will mean a tremendous change for the better as regards securing treatment for a large number of cases which are unhappily at the present time unable to get it.
That brings me to a further observation. One of the great difficulties in connection with lunacy administration to-day is the responsibility attaching to members of the medical profession. It is only right to say that the burden of responsibility on the medical profession is considerably increased by this Bill. I have a good deal of sympathy with the plea which many medical men have made that, if possible, some further protection ought to be afforded to them in cases of this kind. The difficulty of the situation is such that large numbers of doctors to-day hesitate considerably about giving certificates. That is not a good thing in the interests of the administration, nor is it a good thing in the interests of the patients themselves. The suggestion is made that there is an endeavour in Clause 16 of the Bill to give some protection to the medical profession in this respect, but I would very much like to see that protection extended. I am doubtful whether the protection afforded 978 under Clause 16 takes us very much further in the matter. Speaking very roughly, and perhaps not very accurately, all it comes to is this. I hope the right hon. Gentleman the Member for Carnarvon Boroughs (Mr. Lloyd George) will follow this particular point, because it concerns those who used to be called members of the lower branch of the legal profession.
§ Sir K. WOOD
Yes. I suppose they were called members of the lower branch because they were paid lower fees. It is suggested under this provision that before any proceedings are taken against a medical man in respect of certification or anything of that kind, the medical man should have the right of asking that the matter be referred to a Judge in chambers who, before the action is allowed to proceed, is to be satisfied that there is a prima facie case. That provision does not seem to add very much to the protection of the medical man. I suppose that any member of the Junior Bar, with little or no experience, could put in a statement of claim showing a prima facie, case on which it would be very difficult indeed for a Judge to take the responsibility of saying, "I am not satisfied that an action should go forward."
I should like, if possible, to have this Clause strengthened. I do not know if it would be possible to have a medical assessor sitting with the Judge in dealing with a matter of this kind or not, but I should be interested to hear what the Attorney-General has to say as to the value of this Clause. The necessity of doing something is very great. I remember answering questions on a great many occasions in this House about what was known as the Harnett case, a case which was brought 12 years after the certificate had been given by a particular medical man, and it was most difficult, indeed, for him to rebut the charges made against him after the lapse of such a considerable period. I think it very desirable that there should be some further alteration of the law so as to give reasonable protection in cases of the kind.
I do not propose at this stage to say anything particularly about the Board of 979 Control because I think we can discuss it more usefully when dealing with the Financial Resolution. But I believe I express the desires and opinions of a good many of my hon. Friends on this side in saying that this question of the extension of the powers of the Board of Control and the transfer of powers from the Ministry of Health to the Board of Control ought to have careful examination. I am not altogether satisfied that the arrangement suggested in the Bill about dividing the Board of Control into two parts and giving a different status to the Commissioners is altogether a good one. At any rate, I will reserve what I have to say on that matter until we are discussing the Financial Resolution.
I wish to say something on the responsibilities and duties which will be placed on local authorities by the Bill. The views of the London County Council, in this case, as always, are entitled to consideration from this House, and they have asked me to put forward certain contentions regarding the claim which they think the local authorities have in respect of additional financial assistance. The right hon. Gentleman the Minister said—and he argued it very well indeed— that the Local Government Act of 1929 had brought further financial assistance to the local authorities of the country. I read about the Minister of Health going, I think it was, to the Poor Law Conference a few months ago, and giving a very excellent account of the new Local Government. Act and all that it was doing for the Poor Law guardians of the country. At the end of his speech there was some sort of a minor riot. They said, "Surely this is not the right hon. Gentleman who used to talk about the Poor Law guardians and how shamefully they were treated by the Tory Government," and they examined the right hon. Gentleman very closely. [HON. MEMBERS: "No !"] I believe that some persons actually shouted out about the extra ordinary position of the right hon. Gentleman—
§ Sir K. WOOD
I understand that there was a reference to the position of the right hon. Gentleman as he was in Opposition 980 and to his present position as Minister. To-day he quite rightly says that the Local Government Act brings further financial assistance to the local authorities of the country. I gather that the right hon. Gentleman made that statement because of a desire to resist any suggestion that the local authorities should receive any further financial aid in respect of this Measure. He was quite right from the point of view of his colleague the Chancellor of the Exchequer who is very nervous on this question at present and is likely to be more nervous still as April approaches. The right hon. Gentleman seemed very anxious that there should be no question of his giving any encouragement to the idea that local authorities should receive any further financial aid from the Exchequer in connection with this proposal. He rightly pointed out that a further £5,000,000 had been provided for the local authorities by a beneficent Conservative administration.
It is only right to say, in support of the contention of the London County Council and other authorities, that Clause 6. Sub-section (1), imposes the duty on every local authority to provide and maintain suitable accommodation for the reception of temporary patients in accordance with the provisions of Clause 5, while Sub-section (2) empowers a local authority to receive and lodge any person as a voluntary boarder and to maintain and treat him in any institution under their control on such terms and conditions as to payment or otherwise as may be agreed. Sub-section (3) also empowers local authorities to make arrangements for the treatment of persons as out-patients, to make provision for the after-care of persons who have undergone treatment, and to undertake research in relation to mental disorder and the treatment thereof. In the Financial Memorandum which was attached to the Bill in another place specific reference is made to the expenses of local authorities in relation to new powers or duties conferred or imposed by the Bill. The London County Council also desires to call the attention of the House to Section 135 of the Local Government Act—that Act which has now been so enthusiastically taken up by the right hon. Gentleman and the Parliamentary Secretary. Section 135 says:It is hereby declared that it is the intention of this Act that, in the event of 981 material additional expenditure being imposed on any class of local authorities by reason of the institution of a new public-health or other service after the commencement of this Act, provision shall be made for increased contributions out of the moneys provided by Parliament.The Loudon County Council state that they are advised that the Mental Treatment Bill, if it becomes law, will create a new public health service and it is only fair to say from their point of view that in the Report of Lord Macmillan's Committee reference is made to the question of new expenditure. On page 173 of the Report is the following passage:If our recommendations are adopted local authorities will be entrusted with powers and duties involving new expenditure. As we have endeavoured to show this new expenditure will not be wholly unremuncrative. But although we are reluctant at the present time to recommend any addition to the burdens of the Exchequer, we consider that in providing a lunacy service on the lines proposed in our report, it is essential that local authorities should be assisted by an Exchequer grant. The present 4s. grant payable from the Exchequer Contribution Account of the county and county borough councils is now wholly inadequate …. The Exchequer grant for lunacy administration should, in our view, be available on conditions designed to ensure active supervision by the Board of Control. We conceive that a lunacy grant may ultimately be included in consolidated grants for health services. We do not know whether the block grant system will adequately ensure the detailed control which we consider essential in the initial development of the new lunacy service. It may be that a special ad hoc grant will, in the first instance, be the more appropriate vehicle.It is only fair to the local authorities that that statement should be made on their behalf, and I have no doubt that the Parliamentary Secretary, when she comes to reply, will state what is the view of the Government on that important matter. It is true, as the right hon. Gentleman says, that there are still a good many urgent matters to be dealt with. The Bill deals with the most urgent and least controversial recommendations of the Commission, but the question of licensed houses, which is not dealt with in this Bill, is one which raises acute controversy. There is a very important matter which will have to be faced sooner or later in connection with lunacy administration, and that is the complete assimilation of the methods of certification.
The Bill, subject to the criticisms and observations which I have made, is to be 982 commended; it is on right lines and makes provision for the preventive treatment of mental derangement, which is so necessary; it will result, if properly put into practice, in fewer people becoming insane; and it recognises that mental illnees, like other illnesses, If taken in time, can in many cases be cured. The Bill is also particularly to be commended because it gives every mentally afflicted man or woman, of whatever station in life, a chance of recovery in a properly equipped mental hospital. I commend the Bill for those particular reasons, and we, on this side, will be happy to help in endeavouring to assist its passage into law. During the Committee stage we hope to make various alterations and suggestions, if possible, for further improvement. Other Members may desire to speak on the Bill, and many of them may speak with more practical experience than I can, but I hope that without undue delay we shall afford the Bill a Second Reading.
§ Dr. MORRIS-JONES
I hope the House will grant me that indulgence which is always accorded to a Member having the privilege, as I have, of addressing it for the first time. I have taken a great deal of interest in this subject, and 20 years as a medical practitioner have convinced me more and more that there is a very-urgent need of such a Measure The fact that for over half that time I have also acted as a magistrate in the County of Denbigh will enable me I hope to look at this problem not altogether through the spectacles of a medical man. The Hill deals, not so much with insanity, as with the prevention of insanity. We know that both the public and the medical profession have in recent years very considerably changed in their attitude towards mental disease. Mental disease has become more allied to physical disease, and, after all, the line of demarcation between the two is very thin. Time was when unfortunate lunatics were put in chains in this country, and even to-day there are echoes of the time when they were regarded more as criminals in dungeons than as mental patients, although for generations past treatment in mental hospitals has been, I think, satisfactory.
At the present time, the State, for all purposes, treats insane persons in two classes—the private and the pauper 983 classes. From a legislative point of view, the State recognises the overwhelming majority of those unfortunate people as paupers, and, if the Bill did nothing but alter that state of affairs, it would be justified. The Lunacy Act of 1890 is, from a legal and administrative point of view, a completely logical and well-drafted Measure, but its very perfection in that respect has been a calamity to persons sick in mind. These cases ought to be treated early, but that is a minor consideration in the Act of 1890, with the result that mental patients to a great extent have suffered on that account.
This Bill tries to remedy that defect in many ways, and it divides the mentally afflicted people into three classes. There are, first, the voluntary or willing, and secondly, the involuntary, or rather the people incapable of volition, who are described in Clause 5. Those are people who are too ill to object or consent: they are people who are incapable of giving a reasoned assent or dissent. The third class of mentally afflicted people are the definitely certifiable people, with whom the Bill hardly deals at all, except by allusion to them and the extent to which the other classes that I have mentioned may merge into this particular class.
I welcome Clauses 1 to 4, dealing with voluntary boarders. I should prefer the term "voluntary patients," and I hope the right hon. Gentleman may see his, way to alter that word "boarder." We all know what a boarder means, but a "voluntary boarder" arouses a little curiosity, and that is the very thing we do not want to do with these people. It is a small change, but it would be a great improvement on the Bill. What is this class? It is the class of persons who may have had an influenza attack, or who may feel out of sorts, who may have headaches and so forth, people who go to the doctor and begin to feel that they are going off their heads, to use a common expression. At the present time in this country there are only two institutions that can deal with this class of persons, if they are poor. If they are rich, there are, of course, plenty of private establishments where they can go. If they are poor, they are the very class you want to cater for. If they can go quietly, without any stigma or curiosity, and secure treatment at an 984 early stage, they will probably never become certifiably insane persons at all. I very heartily welcome this Clause dealing with voluntary treatment.
Clause 5, which is causing more controversy than any other Clause in the Bill, deals with those incapable of volition. It deals with a large class of mental ailments. I have mentioned influenza. I am very reluctant to mention the word neurasthenia, which is very much abused and is sometimes the refuge of the ne'er-do-well. It is also a useful defence in many a Court of Law in this country; but neurasthenia can be a very serious ailment, with very afflicting and alarming symptoms that definitely border on insanity itself, and these are cases which, if they are treated as temporary patients under this Clause, may receive, and, I am sure, will receive, considerable benefit.
I should like to make allusion to one particular class of patients referred to by the right hon. Gentleman the Minister of Health, and also, I think, by the right hon. Member the late Parliamentary Secretary to the Ministry—that type of case known as puerperal mania. That time of rejoicing in a household is in these cases followed in a very short time by a very dark cloud. I have seen cases of this kind in a provincial hospital, with 50 beds, where the mother of a child develops in a few days' time symptoms of acute mania, symptoms where there has been danger, not only to herself and her child, but to everyone around her. At the present time, it is impossible to treat patients of that sort, unless you send them to a mental hospital or a lunatic asylum, and regard them as definitely insane individuals, but I am sure that that is not as it should be, and I think there should be a change in regard to that class of case. The very child whose birth has given rise to such terrible consequences to the mother may all its life be reminded of a stigma of that character, which is a purely temporary matter, and which, in the ordinary way, can be treated without certification and need not entail any stigma which is the consequence of certification. I welcome this Clause very much indeed. It is the very crux of the Bill, and I am pleased to find that in the other place, after very considerable discussion of its main provisions, it has 985 escaped unharmed, and the few Amendments that were incorporated in the Clause have very considerably improved it.
I should like to say a word or two in regard to the position of magistrates. This Clause abolishes, for the first time in this country, the judiciary, as it were, in dealing with mental patients. My own view is that the intervention of a magistrate in this sort of case is unnecessary and may even be harmful. I think that we can in this respect follow Scotland, which in this matter as well as many other things gives us a very good lead. I will give a quotation, and, although it is from a medical man, the House will agree that, on account of his eminence, it is quite an unbiased opinion. I refer to a statement made by Dr. George M. Robertson, president of the Royal College of Physicians of Edinburgh, professor of Psychological Medicine at the University of Edinburgh, and physician superintendent of the Royal Hospital, Morningside. He states, in regard to the Act of 1857. which has served in Scotland for 70 years, that:It definitely recognises the paramount position of the medical profession in the treatment of mental diseases, for under its provisions no layman or magistrate is called upon to interview the patient before he is placed in a mental hospital, and no layman or visiting committee is held to he responsible for his removal when recovered. Medical men discharge these and all similar duties, and to this system must be ascribed the success of the Scottish system. It has gained the confidence of the people, and in place of misgiving and suspicion there is pride in our mental hospitals and their management. No case of improper detention has ever been recorded in our Law Courts.That is very significant in regard to the question of the powers of the magistrates. This Clause is a charter for the poor, and will help them to early treatment, which is the great essential, and to full protection, as far as I can see. Clauses 6 to 10 deal with the powers and duties of the local authorities. I know that local authorities are rather alarmed in regard to these Clauses, but I think that some of them are unduly and unnecessarily alarmed. The powers that are sought in this Bill are powers of co-ordination mostly, and, if the right hon. Gentleman can in one or two respects reassure the local authorities on some of the matters contained in these Clauses, it- might help. 986 They deal with three questions, which will be of considerable help—the question of out-patients' treatment, for the first time in mental cases; the question of after-treatment when patients have been discharged from hospital; and the question of research. I would like to say a word on that. The medical profession do not know anything like as much about mental diseases as they do about a large number of other ailments of a physical character. It is a very intricate, complicated and difficult type of disease, and the more opportunities we can have for research the better. I am glad that in this Bill there are provisions for local authorities to spend money on research in regard to mental treatment.
Clauses 12 to 15 deal with the constitution of the Board of Control. That board was constituted in 1845. It is about time there was some change in its constitution. At the present time, the members are scattered all over the country visiting various hospitals. The problem is so great and intricate, that a certain number of them ought to remain at headquarters in London in order to be able to supervise, guide, and generally co-ordinate the work of their junior officers. Clause 15 deals with the power to make rules, and I am glad to hear the assurance from the right hon. Gentleman that the Board of Control is not going to be a sort of supererogatory body over the House of Commons. I had occasion to ask some questions about one or two semi-medical bodies, and I was informed that there is no Minister in the House who can be asked a question regarding them, and it is reassuring to he told by the Minister of Health that he will be responsible to the House for the Board of Control on all occasions.
I am rather reluctant to talk about Clause 16. Medical men at the present time are seriously perturbed and alarmed about certification; in fact, a large number of them positively refuse to certify. I can assure the House that there is no piece of work, no single individual work that is clone by a medical man in the whole of his life, which he undertakes with more responsibility than that of certifying one of his fellow creatures for a mental hospital. I should like to see a little more protection than even this Clause gives. I should like to see the right hon. Gentleman adopt the Amend- 987 ment which was moved in the other place. We do not ask protection for the rascal or for the unscrupulous; we just ask protection where a medical man has conscientiously and to the best of his knowledge and belief exercised his judgment, so that he shall not be mulcted in heavy damages, heavy expense, considerable anxiety, and, possibly, the ruin of his professional vocation.
While these are a few of the suggestions that I want to make, and which I hope to incorporate in the Bill in conjunction with my hon. Friends on these benches who are specially interested, I welcome the Bill. It does not fully deal with the lunacy code as one would like it to do; it leaves out, for example, the very vexed question of licensed houses. There is the same number of beds in licensed houses to-day as there were in 1890. I understand that the Royal Commission was a little divided or undecided in regard to it, but the question will have to be faced. Either licensed houses are performing useful functions to the community, in which case they ought to have facilities for increasing their beds, or they are detrimental to the community, in which case they ought to be restricted or abolished.
The Bill is a successful attempt to carry out the unanimous recommendations of the Royal Commission, of which the hon. and learned Gentleman the Attorney-General and the hon. Member for East Woolwich (Mr. Snell) were members. It changes the whole attitude of the legislature from the horrible word "detention," associated as it is with all the stigma of lunacy and the clanking of chains. It changes the whole attitude from the word "detention" to the words "prevention" and "treatment." It. makes certification of an insane person, not a preliminary, but the very last resort. It gives the poor something of the chance of the wealthy for the first time in regard to lunacy. It changes the word "pauper" into "rate-aided patient"; and it substitutes for the words "lunatic asylum" the words "rate-aided mental hospital." I congratulate the right hon. Gentleman on bringing forward this Bill, and I can assure him, from my own experience, that he will bring a new era of hope to those of our fellow-creatures who are, or who 988 may be, inflicted with mental disorder, the most terrible calamity that can befall a household, not even, excepting death itself. It is because I believe in the whole aim of this Bill, subject to the necessary safeguards for protection to the individual, which every citizen has a right to expect, and it is because I believe that the whole conception and aim of the Bill is to ameliorate, prevent, and cure mental affliction, that I heartily welcome it.
§ Dr. ETHEL BENTHAM
I heartily welcome the introduction of this Bill, which is a step in the beginning of a reform which has been overdue for very many years. I was glad to hear the hon. Member for Denbigh (Dr. Morris-Jones) express so well some of the views that I hold. The difficulty of the problem is that it is a question of getting the confidence of the. public in whatever kind of machinery is set up. The difficulty of dealing with this subject is enormous; I cannot think of any more difficult thing, because there are so many points of view from which it can be regarded. People naturally believe that lunacy or insanity or whatever you call it, is hereditary, and will prejudice not only themselves if they should recover, but their families and descendants; and they are necessarily and naturally very loath even to call in anybody, or to take any steps to deal with it; and they go on hoping that if they can anyhow keep their dear ones at home, it will be for the better in the long run. They also view with a great deal of distrust the methods by which treatment is given. There are a good many reasons for that distrust. One is that for well-to-do people, most of the institutions in which they can be treated are run for private profit. That makes them absolutely distrustful.
Another reasons is that seven-eighths of the people who are certified have to go through the Poor Law, and there is a horror of the way in which they are treated, although I do not believe that they are badly treated intentionally, but the circumstances surrounding their reception are such that it is no wonder people de almost anything to avoid disclosing insanity. I have seen a reception ward which had about 18 patients. In one corner I saw a case of puerperal mania; in another bed a raging drunkard who had been brought 989 in in the middle of the night; then two people who spent their time whining in a corner; and somebody who took the opportunity to throw things at the nurse every time she turned her back. The reception ward is a scandal and has been for a very long time. The third thing which makes people so nervous of disclosing insanity in the family is the mysterious and awful Board of Control. I may say that I have been 13 years a general practitioner and have acted as a justice under these Acts ever since women magistrates were first appointed, and so I have had considerable knowledge. When, in the interests of a patient, I have had to go to the Board of Control, I have found it human when you could get at it. But it is a mysterious board. People do not know of its name or how to get at it.
Those are the three things which make the treatment of insanity extremely difficult. If we could once get it into the minds of people that there was no reason for them to hide insanity or aberration of the intellect as though it were leprosy, and if it were once understood that the majority of the people trying to treat it, whether magistrates, doctors or the Board of Control, were trying to do their best, but that the circumstances in which they are acting make it very difficult, indeed, for that, best to be done, and if, in addition, we could bring about a more trustful attitude on the part of the public, I believe many of the difficulties would solve themselves. While we are trying to secure the liberty of the subject and are enormously concerned that no person who is not insane shall be kept in an asylum, we must also realise that the patient is an extremely helpless person.
The patient needs to be protected, first of all against himself, and in many instances against his relatives; in my experience, the relatives are the people from whom he most often needs to be protected. I knew a case, a good many years ago now, of a man who had been discharged from a lunatic asylum. On the second morning after his discharge a lady calling on his wife went into his house. It was in one of those northern towns where the doors are always on the latch, and she walked in just in time to prevent him cutting his throat. She had the presence of mind to say, "Not there, man, not there; come over to the sink. 990 Think what a mess you will make !" That saved him. Only two days before that man had been discharged from an asylum, supposed to be cured. I could give many other instances, but I only-want to stress the fact that insanity is such a mysterious thing that it is very hard to make sure that a patient is really cured, and the general public cannot very well judge. They visit a patient and find him apparently in the enjoyment of every faculty, and think it is quite safe for him to be released. In many cases the people who look the best are possibly those least able to be trusted by themselves.
Then there is the question of relatives. My mind goes back to the very sad case of a woman, who was a patient of mine in the North, and came to me when she was pregnant. She said that she had three times been in the asylum for puerperal mania and she begged me to see that she was not released on the next occasion, because of her husband. Regarding the question of certification by justices, I think the chief use of the despised justice is that he provides a second opinion. If it is laid down that in every case, pauper or otherwise, two medical opinions have to be obtained, then the certificate of the justice is not very much wanted; but where there is only a single opinion, then the justice does fulfil a useful part, I remember a case in which a gentleman came to ask me if I would act as certifying justice in the case of his father. I said that I would, because it was part of my duty as a justice, and asked where I could see the patient. "Oh, you cannot see him" was the reply. "We think that will be too exciting." I refused to certify under such circumstances, and from private inquiries which I made afterwards I should say there was probably some financial reason for wanting certification.
Then there was the case of a pauper patient, an old man who was found wandering in the streets of London and was taken to the reception ward by the police. After he had been there two days the time arrived for the bi-weekly visitation of the justices who certify. During the time he had been there he had not spoken, and the medical certificate referred to him as being silent, morose and unable to give any account of himself and evidently needing treatment. Something, 991 I do not know what, suggested to me that I should speak to him in French, and then he gave a very good account of himself. The fact that these mistakes can be made in quite good faith does show that where to-day you have only one medical opinion you certainly ought to provide an opinion from some other person, though I think the non-medical justice is at such a disadvantage in face of medical certificates and medical opinion that it is really better to have the opinion of two medical men. Where there are two medical certificates the certifying justice might very well be dispensed with.
As I have said, the Board of Control is a mysterious body which heretofore we have always distrusted very much because it could not be got at, but where you have the fact that a patient is in an institution run for private profit and in view of the fact that he has to be protected not only against himself but against his relatives, it is very necessary to have some superintending and controlling body. We may call it the Board of Control or anything else—that docs not matter—but there must be someone to protect the patient. I think the re-christening of the Board of Control would be a quite useful thing, but it is to be understood that some steps must be taken to give an appeal to the Board of Control and to bring about a greater public trust in the Board. The Board itself must come more to the front, its name and its place of abode must be known, and it must be possible for the relatives of the patients to get into direct contact with it.
Then, I think, we shall have done a good deal to lessen public distrust and to make the public feel that mental disease is no more a thing to be hidden or ashamed of than scarlet fever or diphtheria, and that it does not impair the prospects of the relations of the patient for the rest of their lives. Get this out into a common sense, open discussion and I think you will take most of the terrors away from it. I would make only one other suggestion about the Board of Control; I think the number of three members is too limited. I feel it will be necessary to have two doctors, one a man and one a woman on the Board of Control, and I would like to see the 992 membership enlarged to five. With that amendment and the bringing of it into the open I believe a great many of our difficulties will be lessened, and that we shall be able to go on to the other steps that will naturally follow when once we have accomplished this first step.
§ Sir D. NEWTON
In his lengthy exposition of this Bill the Minister told us that he was dealing with only a few of the recommendations contained in the Report of the Royal Commission. May I express regret that he was unable to deal with the Report as a whole? The Report was published 4½ years ago and cost the country £2,300 to prepare, and the Commission itself was set up more than 6½ years ago. When the country goes to the expense of setting up an important Commission, I think it is desirable to take due note of the recommendations they make, and deal with them as soon as possible. With the general object of the Bill there will be agreement. All engaged in social work, all who are brought into contact with the feeble-minded are alive to the needs of further legislation and conscious of the value of legislation to deal with those suffering from incipient mental disease. From the point of view of local authorities, county councils and county boroughs, we welcome this Bill although we do not by any means welcome all the provisions contained in the Measure. I would like to refer to Clause 6. Under that Clause the provisions are mandatory, and it is made the duty of public authoritiesto provide and maintain suitable accommodation for the reception of Temporary patients.Those are rather strong words when you are directing a local authority to do something, and when you are not making any contribution towards the expenses of that local authority. I should have thought it would have been better if the provisions had been to the effect that the local authorities should be requested to investigate the needs of their areas, and take such steps as they considered necessary to provide and obtain suitable accommodation.
§ The PARLIAMENTARY SECRETARY to the MINISTRY of HEALTH (Miss Lawrence)
We have already given power to local authorities to deal with these non-volition people, and it is the duty 993 of the local authority to deal with those eases.
§ Sir D. NEWTON
I am much obliged for that explanation; nevertheless, I think some more financial contribution ought to be made. I would like to say a word or two with regard to the Board of Control. The powers of the Ministry of Health are being transferred wholly to the Board of Control, but I challenge the wisdom of that course. The local authorities are responsible bodies. Their powers and duties have been largely increased, and the safeguard is that they are publicly-elected bodies, and thus subject to public control. They should have been consulted in the matter and been given, perhaps, wider powers.
With regard to block grants, these have only recently been fixed, and it seems strange that a new financial obligation is now about to be imposed upon local authorities. When fixing the grants, the Ministry of Health must have known that this Bill was about to be introduced, and they must have known that it would probably be passed and placed on the Statute Book. It seems to me that the powers of the Board of Control are too far-reaching. The duty of the Board of Control is to protect the liberty of the subject, and to say whether in the public interest a man should be detained. It should be within the power of the Board of Control to say when a man should be released, and it should also be the duty of the Board to carry on an intensive system of research. It should not be the duty of the Board of Control to interfere with local government, and possibly to override the wishes of the elected local government representatives. This Measure appears to give the Board of Control far too much power over local authorities, because they have, for example, to obtain the approval of the Board when they desire to enlarge a building, and the Board have to approve of the plan of the local authority. I think the submission of details of that kind to a Board which is not an elected body is a false step, and the past history of the Board of Control does not encourage us to give them new powers when we consider their dilatory methods in the past. I think I am right in saying that in the case of Colchester there has been great delay. Four years ago endeavour was made to put through a scheme and as a 994 result of the action, or inaction, of the Board of Control the services which were badly needed have been restricted, and it has been impossible to deal with certain urgent cases, and there are over 30 such at the present time. It seems to me that under the terms of this Bill when perhaps a county borough is cut out of a county council area, any subsequent negotiations and arrangements between that county borough and the county council should not be subject to the intervention and approval of the Board of Control. Surely it should be competent for the local authority administering an area if it is cut into two sections for both bodies to get into touch with each other without being obliged to consult an outside body. For these reasons I hope the provisions relating to the Board of Control will be considerably amended in Committee. I was glad to hear the Minister of Health state that he would be responsible for answering questions on the Floor of this House, and for the work of the Board of Control, and that he will be responsible for it. There is an old French proverb which runs: "There are more fools than clever people in the world, and among the clever people there is more folly than wisdom." Let us therefore welcome this Measure as a contribution to deal with the difficult problem of mental affliction.
§ Dr. HASTINGS
I think that all who are interested in the early treatment of mental disease will welcome this Bill. There may be two opinions as to the exact status of the Board of Control, but I think such matters might very well be dealt with during the Committee stage of this Bill. The hon. Member for Cambridge (Sir D. Newton) had something to say about the Board of Control. He mentioned a good many of its functions, and I should like to add to the list he gave a supervisory function in connection with the treatment of cases suffering from mental disease. It seems to me that that function is a very important one when we are dealing with the Board of Control. It may be necessary to alter the exact status of that Board, but I feel very strongly that some supervisory authority will always be necessary in dealing with mental disease.
There are two considerations in connection with mental disease which require attention. The first is the question of 995 what is best for the patient, what treatment ought to be given and what can be done to increase the patient's comfort. Another important point is the protection of the public, the protection of the patient from himself and the protection of the good name of the patient's family. It seems to me that to achieve this latter object some form of detention is necessary. I am associated with a hospital in which we treat early cases of mental disease, and our difficulty is that we have no power of detention at all. Therefore, our selection of cases is strictly limited, and we cannot forcibly detain patients even when it is in their own interest, and when we feel that they ought to be detained.
I would like to stress more particularly to-day the possibility of the treatment and cure of mental disease. Not long ago mental disease was thought to be an act of God, but now we are learning more and more that something can be done to alleviate this disease, and sometimes to cure it. I have seen cases of severe insanity treated and cured by ordinary medical treatment or by a relatively simple operation on the nose. I am associated with a hospital where we take in early cases of mental disease. Many of these patients suffer from some other medical or surgical ailments that can be recognised when these patients are closely examined by physicians and surgeons accustomed to deal with these other affections and when those other conditions are treated the patients very often rapidly recover. One great point in favour of this Bill is that it allows public money to be spent on the treatment of early cases of mental disease which is now impossible.
The hon. Member for Denbigh (Dr. Morris-Jones), in a most excellent speech, pointed out that you can divide those suffering from mental disease into three categories. Firstly the patient who feels that he himself is going a little wrong and desires treatment. Secondly, cases which are incapable of volition, that is to say the type of patient who will not say "Yes" or "No" when you ask if he wishes to be retained. The third type of case is one which is not dealt with in this Bill, but which, I think, it is important to say a word or two about—I refer to the patient who does not know that he is insane, but thinks everybody else is. 996 These are the people whom it is desirable to consider at the present time. Sometimes these people recover as has been shown by the Minister of Health, but when they cease their anti-social behaviour their ego does not change. They did not believe they were insane before, and when they recover they do not believe that they have been insane. These are the people who write pamphlets and distribute them to Members of Parliament and try to catch Members of Parliament in the Outer Lobby. It is these people who try to impress the public with the evils of asylum treatment and with the sins of the Board of Control. I think we have to recognise that a great many early cases of mental disease are curable, but it is necessary to have some power of detention in such cases, and, unless that power is obtained, not very-much can be done.
I was very interested to hear the Minister of Health, in his opening speech, say that the stigma of certification is a real thing. There is no question that that is the case, and I would like to remind the Minister that the stigma of association with the certified is also a real thing. I would like to see further provisions in this Bill for the withdrawal of the voluntary boarders, and those who are not capable of volition, as far as possible from association with the certified and for bringing them into closer association with the treatment of ordinary medical and surgical diseases. I believe that, if a Clause could be inserted in the Bill encouraging the local authorities or even compelling them, to do this, it would be a very great help indeed. I must not detain the House longer, because I know that there are other Members who wish to speak, but I would like to say that, although there may be ways in which the Bill can be improved during the Committee stage, it makes a very-great advance in providing for the treatment of early mental disease.
§ Captain GUNSTON
I also would like to join in congratulating the Minister and the Parliamentary Secretary on introducing this Measure, I am one of those who believe that there is good in all people and in all parties. I admit that, having looked for the germ of goodness in the present Government, I have found it to be, like the germ of influenza, very hard to find, but perhaps at last we have found it. The best 997 Measures that are passed in this House are really those which are of a non-party and non-controversial nature, and I have been very much struck, in reading this Bill, by the fact that the putting into force of many of its excellent provisions rests very much on our magnificent Act for the reform of the Poor Law which was passed last year. Like my hon. Friend the Member for Cambridge (Sir D. Newton), I wish that the Bill were more far-reaching. It is quite true that that Royal Commission reported several years ago, but a good many non-party Bills have been passed during the interval, and I think that the present Government are very wise in now including in such a Bill the provisions which the Royal Commission suggested were most necessary.
There is one thing for which we ought to be very grateful, and that is the name of the Bill, "The Mental Treatment Bill," because it describes so exactly what we are trying to do. I would like, not being a doctor but a layman, to point out, because I think there is rather a misconception on the subject in the country, the difference between a mental deficient and a person mentally afflicted. This Bill does not deal with the mental deficient. Someone who has to do with this terrible disease remarked to me the other day that a mental deficient was rather like an engine from which a cog was missing which could never be replaced, while, on the other hand, a mentally afflicted person is like an engine in which a cog or gear has got out of place, which, with proper treatment can be put back, bringing the person concerned into as good a condition as that in which he was before.
I must say that, when I read the Report of the Royal Commission, I was rather shocked to find that there is no doubt—it has been pointed out in the House many times to-night—that there is one law for the rich and another law for the poor, and I am sure that everyone will congratulate the Government on bringing in at last a Measure which as going to enable the poor to get very early treatment, and in many cases to be cured. The Minister gave us some very interesting reasons for the advantages of early treatment, and I think he said that in one hospital a quarter or more of the patients who recovered were people who had had early 998 treatment. He went on to say that they only got this treatment at the present moment by having to go through the unpleasant process of being certified. I do not know if every Member in the House has read the Report of the Royal Commission. Very often reports of Royal Commissions are rather dull reading, but, if anybody has not read this one, I would humbly suggest that they should do so, because it is almost like reading an absorbing novel. It is one of the most magnificent reports that has ever been written, as we might have expected when we remember that it was written by Lord Macmillan. Anyone who has heard Lord Macmillan before a Private Bill Committee will know that he is unequalled in his command of lucid language.
There is one difficulty in regard to these distressing complaints that we are all united in wishing to overcome, and it is very well emphasised in the Report, which says:The keynote of the past has been detention. The keynote of the future should be prevention and treatment. But it is just here that the crucial difficulty of the whole matter resides. Owing to the special nature of the symptoms of mental illness, treatment must in many cases involve compulsion and restraint. This is the element which differentiates the treatment of insanity from the treatment of other illnesses. The patient suffering from an ordinary ailment is generally an intelligent co-operator in his own treatment and cure; he is able to appreciate what is being done for him, and no coercive restriction of his liberty is needed. In many cases of insanity this is not so.I think that the hon. Member for Reading (Dr. Hastings) emphasised that point. The Report goes on:The illness has affected the patient's intelligence and his ability to appreciate his position. His will has ceased for the time being to be rational. In such cases, where there can be no voluntary submission to treatment, the treatment must needs be compulsory.Here we come to the age-long difficulty of finding the right treatment of the subject without violating the ancient law of the liberty of the subject. If the Parliamentary Secretary will allow me to say so, I think she can congratulate herself on her success in overcoming this difficulty. I am emboldened to say that by the fact that very few lawyers have tome here this afternoon to talk about the liberty of the subject, and I think their absence shows that they must be 999 satisfied. We know that as a general rule one has only to mention the liberty of the subject and lawyers flock to the House, a sort of habeas corpus look comes into their faces, and they promptly imagine that they have been briefed in a case of St. George v. Dragon.
The problem of compulsion has to be faced, and we must admit that we are bound in this matter, especially in regard to non-volitional cases, to restrict to a certain extent the liberty of the subject. Every member of society must sacrifice some of his liberty to-day. We are controlled at every step in all walks of life. We know, for instance, that if a man is suffering from an infectious disease he has to suffer some restriction of his liberty. The mentally afflicted, unfortunately, may have to be detained, but our idea must be compulsory detention with only one object, namely, the effective treatment and, if possible, the cure of the patient. I agree that we want to see every safeguard that is necessary put into the Bill, but do not let us overload the Bill with so many safeguards that we cannot get the cure that we all want for these poor people.
The Minister quoted the Royal Commission on the danger of stigma, and I think that every hon. Member who has spoken has pointed out that the stigma of certification is what so many people fear; but I do not know if it has been pointed out this afternoon—I do not think it has—that the stigma not only attaches to the person certified, but extends to his children as well. I should like to call the attention of the House to the evidence given before the Royal Commission by Dr. Devine, who said:It is a very serious slur; it is irrational that it should be so, but it is. If a patient is certified, not only is that patient subjected to a very insidious and unpleasant social censorship hereafter, but the children are as well. I see it repeatedly. Take the case of a woman who is certified for puerperal insanity. I can think of a case at the moment in which the children have been brought up with everyone around them watching every mortal movement they make, and finding evidence of abnormality, creating neurosis. These children are brought up with a sort of biological inferiority, which is the worst thing anybody can have. I have no hesitation in 6aying that many people become confirmed neurotics from the fact that their relations have been certified ….. I have seen it repeatedly.1000 I congratulate the Government on having taken a step towards removing the stigma from people so afflicted, and from their children. The hon. Member for Reading pointed out, I think very rightly, with regard to voluntary boarders, that it is desirable to keep voluntary boarders and all these cases from association with people who are mentally afflicted. I think we can all agree with that, but it would take time, and I think it would be better that a person should get treatment as a voluntary boarder than that he should get none at all; and, while the new institutions for which provision is made in the Local Government Act, 1929, are being set up, I think we should not put any Amendment into this Bill which will prevent those people from getting treatment in the meantime.
I must say that I agree with my right hon. Friend the Member for West Woolwich (Sir K. Wood), that it may be necessary in Clause 1 to provide more safeguards in regard to children under 16. We hear a great deal about malevolent relations. I believe that that danger is exaggerated, but it does seem to me that, if it were possible to have a malevolent relation, it would be in regard to a child under 16, and I think that in Committee we ought to see that a further safeguard is put in in that regard. There is a point that I should like to raise with regard to Clause 5. I am not sure that the definition of the term "non-volitional" will be really satisfactory. I am not a lawyer or a doctor, but it strikes me that that definition is either too wide or too narrow, and I hope we shall have the advice of all the legal experts in the House in trying to get a better definition of the term, "non-volitional," because I think that that term is causing a good deal of anxiety in the country at the present moment.
My hon. Friend the Member for Cambridge, speaking of local authorities, said that it was going rather far to compel them to set up institutions and undertake the care of these patients. He thought that it would be too onerous for them. I understood however, that the local authorities already had that obligation under the Local Government Act of last year. Section 104 of that Act says that the Minister may reduce the grant payable if he is not satisfied that 1001 a local authority is carrying out its work satisfactorily in regard to various services, and particularly in regard to public health; while Section 134 of the Act defines public health services as follows:' Public health services' includes services relating to maternity and child welfare, lunacy and mental deficiency …I think, therefore, that local authorities already have that obligation, but at the same time there is no doubt that the present Measure, while extending the services with regard to lunacy, provides for what may he called new services—services for the after-care of the patient, and so on; and, if that be so, I should imagine that the case of the London County Council, which was mentioned by my right hon. Friend the Member for West Woolwich would be covered by Section 135 of the Act, which says:It is hereby declared that it is the intention of this Act that, in the event of material additional expenditure being imposed on any class of local authorities by reason of the institution of a new public health or other service after the commencement of this Act, provision should be made for increased contributions out of moneys provided by Parliament.It seems to me that the London County Council and, perhaps, the Gloucestershire County Council, if they want to, will be entitled to get more money from the Exchequer in relation to this new service.
I would also like to praise the facilities for the treatment of after-care patients. That is one of the most important provisions in this Bill and the Royal Commission were very emphatic on this subject. They said that a patient often recovers, but it is very difficult to get him good after-care treatment. He may, of course, have a good home to go to, but, if he is a pauper, he probably has not. There is an association, the After-care Association, which deals with these people and has done very good work for many years. They are limited by funds and do most of their work round London. Some of the provinces are neglected not through any fault of the Association, but because they are limited by funds. Under this Rill the local authorities will be able to contribute to voluntary associations like the After-care Association. In the long run, that will do more to help a permanent cure than anything that has been done for years. While we shall be 1002 eager to put in Amendments which will strengthen this Bill in the direction the House desires, that is, to get as much treatment as is possible while at the same time having regard to the liberty of the subject, we heartily congratulate the Government on having introduced this Bill. As a matter of fact, before I had finished reading it, I was at one time almost doubtful about the paternity of the Measure.
§ Mr. LOGAN
It gives me great pleasure, as one who has had some experience of the Poor Law administration of the country, to support this Bill. The important problem which we are discussing to-day is one of the most difficult problems that has confronted the Poor Law administrations of the country, especially with regard to the mental cases which we are now discussing. This is really a classic occasion. We are to-day providing for cases which before were certifiable and had, of necessity, to go in as certifiable cases because there was then no other way of dealing with them. The result was that people really did become insane because of that classification. As most people with any knowledge of institutions know, like brings about like. I have seen sent to an institution for a period patients who got into a mental condition they would never have reached if they had been kept at home and which they reached because of their detention in a lunatic asylum. It has been said here to-day—and it is a fact—that many who are insane think that the visiting justices are insane, and I have seen a patient point to the patient next door and say that he was "dotty." It is very hard to draw the line between those who are insane and those who are not. The remark of the last hon. Member that there was good in all parties led me to believe that there was a sound mind in a sound body on the other side of the House. [Interruption.] I am not dealing with this side; we are all sound here.
We are now approaching a great era in dealing with all these matters. The passing of the old boards of guardians and the coming in of the public assistance committees is bringing in a new trend of thought and a new system into the management of the affairs of this nation. It is necessary that, in this matter with which we are now dealing, the Minister should take into considera- 1003 tion the question of segregation. It is utterly impossible to deal with mental cases, whether certifiable cases or cases for temporary treatment, unless you segregate them. Without segregation the classification will be useless. Those who are certified must, of course, get treatment like other cases, but I take it that the system we are now going to bring into operation is to deal with those cases of a temporary character that any mental men would certify as of a temporary character, or cases that need testing to see whether they really are mental cases needing treatment for many years. I am convinced from my observation that unless you segregate you are going to make insane those you are now dealing with. Anyone who has gone into the observation wards or the receiving rooms of our institutions knows that, when we bring a person in there and keep them for one, two or three days, cases that otherwise would have gone home have become insane owing to the cases they meet with inside. That cannot be disputed, and any Minister bringing in a Bill like this must be confronted with the difficulty of classification in our institutions. The same thing happens in the case of smallpox, where a doctor certifies a case as smallpox and it is then isolated and the smallpox does not develop but is contracted because the man is put in with smallpox patients. On the other hand, cases have been sent in by a medical practitioner certified as smallpox which those who received them could see were not smallpox and, as they were detained as isolated cases, the smallpox did not develop. It is the same in these mental cases.
I am convinced that this Bill will open a new era in thousands of homes where cases of temporary aberration occur, but it raises the difficulty and the purpose of classification. I want to see—and both sides of the House are willing—a business proposition carried out on proper lines of demarcation, so that the physically unfit shall be kept separate from the mental cases, and so that those mental cases of only a temporary character shall be segregated. The question of stigma is an important matter. The very fact of having a father, a mother, a sister, or a brother classified as mental is, even among our schoolchildren, a strong taboo. I have seen 1004 cases in congested areas where families, owing to the mad system of classification have been ruined because; of a case of temporary insanity and where children, even though they have been able to win a scholarship, have not been able to go on, simply because they have been marked out as "luney," like the afflicted father or mother. Those are things which are a great burden in our industrial life, and for that reason I do not want a hotch-potch kind of a Bill, but a Bill incorporating those ideas of reform which can be borne out by anyone with any knowledge of institutional treatment.
There are two things I wish to point out, after 10 years' experience of administration on one of the biggest boards in the country. I am convinced that classification and segregation are absolutely essential. I am prepared to admit that outdoor treatment is essential, and I am not concerned with the Board of Control or with financial obligations, because they have to be met one way or another. I am convinced that there is another series of patients that must be brought to the notice of the Minister. Under the Lunacy Law at present, if one's father goes inside an institution on account of old age, there is no classification for cases of senile decay. These cases of old age are treated as though they were lunatics. I would like to see in this Bill some provision made so that there may be some classification of these senile cases in addition to provision for some classification of cases of a temporary character which are not chronic. We want to deal with these cases so that we can bring back to the children the parent who, under a sane system of administration, can be brought back to them again as a good citizen in the life of the nation.
§ Mr. RICHARD RUSSELL
I would like to add to the congratulations from all parts of the House to the Minister for the good parts of this Bill. There is no doubt that the original purpose of the Bill, the treatment of voluntary cases, is a very beneficent purpose indeed, and everybody in the House will give to it all the sympathy, all the co-operation and all the help that can possibly be expected. The only point I want to make to-night is that, joined with that portion of this Bill, there is another portion which has raised, and which will continue to 1005 raise, considerable controversy. The Minister spoke of having co-operation and getting through this Bill with a united consensus of opinion in the House, and I hope that is going to happen on the present occasion. I cannot, however, allow that to go without making the suggestion that, when we get into Committee on the Bill, the whole question of the relationship between the local authorities and the Board of Control will come under very serious consideration and will need some amount of remodelling. There is no doubt that, perhaps, the greatest work done in this country in our national life during the past 50 years has been done by local authorities. There has been a tendency during recent years to depreciate again and again in this House the work of local authorities.
Take the present subject. The local authorities have built up these great institutions, doing magnificent work. The very touch of the local authorities upon these cases is an element of helpfulness, and, whether the local authorities are right or wrong in their attitude towards the Bill, there is no doubt that they are very much alarmed at the powers that are being given to the Board of Control in regard to them. There is no doubt, also, that considerably increased expenditure is going to be put on them. If this Bill is to be a success, a number of those who to-day go in as certified patients will in the future go in at an earlier stage. In addition to that, there will be a large number of other cases which do not come under treatment earlier but which we want to get under treatment, and this will lead to considerable expenditure on the part of local authorities. We see no provision here for that. The position, therefore, is more control of local authorities and more cost to local authorities, but no further assistance to them, so far as we can see, in the carrying out of this work. That is a position that needs to be faced when we get into Committee. We ought not to depreciate our local government. As much co-operation as you like, but a little less of this spirit of control. There is a danger that the very name "public control" is likely to lead us somewhat astray. After all, it is not a Board of Control of local authorities but a Board of Control set up to deal with patients. I hope when we get in Committee this point will be seriously faced by the Minister, and faced in a sym- 1006 pathetic spirit, so that we shall be able to remove the apprehensions that exist among local authorities ecerywhere.
§ Dr. FORGAN
I gladly join in the chorus of praise of the Bill, though I shall have to qualify it to some extent by calling attention to one or two defects. I should like to say of what great benefit institutional treatment for voluntary boarders and the possibility of after-care treatment can be. The Bill does not apply to Scotland, for the very good reason that we have our separate Board of Control, and the Noble Lord, who was a member of the Royal Commission, said the practice in Scotland showed an enormous advance upon that in England. In Scotland, those suffering from mental disorder are treated in a very flexible way, with enormously good results from the point of view of the health of the patient. The percentage of the population certified as insane is almost 20 lower than in England, and it seems to me that the different method of treatment may to some extent be responsible for that. I had brought to my notice some time ago the case of a young man who had been unemployed for a considerable time, and fear of future unemployment became such an obsession that finally he had to be admitted to a Poor Law institution where, after same months of treatment, not as a certified lunatic but as a voluntary boarder, he was restored to normal mental health and discharged, and then he had to face again the very trouble that had driven him into the mental institution, the fear of continued unemployment. It was only necessary to draw the attention of the local authority to the fact that he was up against the thing that had practically made him insane before, for the parish council to provide him with work. By means, first of all, of treatment as a voluntary boarder and afterwards by after-care he was saved from what certainly would have been permanent insanity. I commend to the notice of the House the practice in Scotland, which apparently is considerably in advance of that in the South.
As regards the defects of the Bill, temporary patients are, in the opinion of those who have framed the Measure, likely to be treated in the existing Poor Law institutions, and there are very many members of the public who will think that there is very little difference 1007 between a declaration signed by two doctors and certification, if the patient is then removed to an asylum. That emphasises the paramount importance of setting up other institutions for the treatment of early cases. But the most important defect is the very serious additional financial burdens which will be placed upon local authorities. Temporary patients are an entirely new class of patient. Fresh accommodation will be required for them, and fresh expense will be incurred by the authorities, and, if our method of allowing non-volitional cases to remain for six months without certification is going to be effective at all, it will mean for some years an increase in the number of persons who will receive treatment; and new accommodation will be required if the authorities are to put into effect the permissive powers which this Bill gives them.
The Royal Commission declared that the Exchequer contributions to local authorities for work of this sort in the past were wholly inadequate, and they themselves were of opinion that an ad hoc grant was necessary if local authorities were to undertake the new duties. Local authorities are now faced with additional work, with their resources for further rating depleted by the De-rating Act of the last Government. I am afraid, if this Sub-section is to remain permissive, the great majority of the local authorities will be unable financially to undertake any of this work at all. The Bill, as it stands now, is not going to provide early treatment except for those who are able to pay for it. For nearly a century the history of lunacy reform has been a history of good intentions. In 1881, the Commissioners reported that for 40 years their efforts had been directed towards obtaining early treatment. That was 49 years ago, so that for almost 90 years the Commissioners have been attempting to obtain early treatment. The fact that early treatment is the keynote of this Bill is sufficient condemnation of the effects that have been made in the past. I hope the Bill will have a unanimous Second Beading and that at a later stage it will be so amended as to make it really capable of bringing about the praiseworthy reforms for which it has been designed.
§ Sir JOHN WITHERS
I rise to say a few words on the Bill as on (c) who has had a good deal of experience of Lunacy Law. On the whole, it is extremely good, and I congratulate the Minister on introducing such a good Measure. Clauses 1 to 4 are excellent, but I am afraid I must say something about Clause 5. I have an old fashioned dislike to doing away with the certificate of the magistrate. That was fought for for a long time, and it has been on the whole a great safeguard. Under this Bill, people can be put away in an asylum or a home for a whole year without any legal certificate, and my own feeling is that that is a mistake. I do not see the reason for it. I think the idea that certification of itself is a stigma is a misconception. The actual fact that the magistrate has signed something which the public do not know anything whatever about cannot possibly hurt anyone. It is the fact that they are put into an asylum which attracts public attention and causes scandal and worry and trouble. Moreover, from the point of view of the persons themselves, certification is a protection. In the first place, it protects the patient; in the second, it protects the doctors, and, in the third. it protects the family.
The expression "incapable of volition" will have to be explained. I particularly think it is unfortunate that this Clause should apply to people incapable of volition. I can quite understand people being put away who have power to express themselves whether they want to go in or whether they do not want to go, but that people should be put away without a certificate who are not able to express their opinion really seems to me to be wrong. Those are the people who ought particularly to be protected. The powers given to the Board of Control are very large indeed, and I was very interested to hear the criticism from the benches opposite that it ought to be brought into the open. I quite agree with that, and I think it is very essential that the members should be known and that the constitution and powers of the Board should be very much discussed. This is a very good instance of delegated powers which an analogous Committee-is considering. No doubt it will come into the purview of that Committee later on. It occurs to me that there ought to be some mode of appeal from the Board 1009 of Control. They have very large, autocratic powers, and some machinery ought to be set up if we are going to have this sort of administrative law, which is so very common on the Continent. We ought to have some mode of appeal, which has been so fully discussed in a great many textbooks on the subject. Subject to these observations, I give the Bill my support.
§ Mr. J. JONES
For 26 years, I have been connected with a mental institution in the East End of London, where they have all the problems to face that we have been discussing in this Debate. Probably some hon. Members imagine that that is a proper committee for me to be on. I want the House to realise that in this Bill no consideration whatever is given to those who are the most helpless victims of the present system. Once sentenced to death so far as the ordinary mental institution is concerned, there is no hope of reprieve. One is under the control of the Board of Control—an unapproachable body. You can write letters, you can send appeals, but you get the old stereotyped reply every time.
§ It being Half-past Seven of the Clock, and Private Business having been set down by direction of the Chairman of Ways and Means under Standing Order No. 8, further Proceeding was postponed without Question put.