HC Deb 19 February 1954 vol 523 cc2293-379

11.5 a.m.

Mr. Kenneth Robinson (St. Pancras, North)

I beg to move, That this House, whilst recognising the advances made in recent years in the treatment and care of mental patients, expresses its concern at the serious overcrowding of mental hospitals and mental deficiency hospitals, at the high proportion of obsolete and unsuitable buildings still in use, and at the acute shortage of nursing and junior medical staff in the menial health service; and calls upon Her Majesty's Government and the hospital authorities to make adequate provision for the modernisation and development of this essential service. The subject which I have the privilege to introduce today to the House is not one which is frequently discussed on the Floor of this House. We do occasionally have Adjournment debates which are addressed to some particular aspect of this problem or to some particular hospital in an hon. Member's constituency, but it seems to me, alter making considerable researches, that the last occasion on which the subject of mental health was discussed here in the general sense was not less than a quarter of a century ago.

The occasion was the Second Reading of the Mental Treatment Bill, which was introduced on 17th February, 1930, by my right hon. Friend the Member for Wakefield (Mr. Arthur Greenwood). There have, of course, been occasions since then when we have touched on it incidentally in connection with the National Health Service debates, but it is a quarter of a century since the House discussed the general problem. In that quarter of a century something like a revolution has taken place in this field of mental health, so perhaps it is time this House should take stock of the position. I think that it is an important subject, and one of very deep interest indeed to me, and I hope that the House will bear with me if I speak for rather longer than is my custom in addressing the House.

I hope that we shall have the widest possible debate, and in the interests of that I tried to word the Motion as widely as I could, with perhaps one exclusion. Had I been fortunate six months ago in the Ballot, I should also have directed the attention of the House to the out-of-date and unsatisfactory state of the law on lunacy and mental deficiency. However, a Royal Commission has now been set up to deal with this aspect of the problem, and so I will not touch on that important topic. All that remains for us here is to wish the Royal Commission well in their very important labours and I hope that, in so far as this debate may perhaps impinge here and there on their terms of reference, they will find, it a helpful contribution.

From the researches I have been able to make and the discussions I have had with a number of people in this field, I believe that what I have to say today will be generally applicable to the whole country. I must make it clear that my own first-hand direct experience of this subject is limited to the North-West Metropolitan Region of whose hospital board I am a member. I want to make it clear at the outset, because I shall have many serious and strong criticisms to make on certain aspects of this problem, that I make them in no party political spirit whatever.

I have no wish to make political capital out of this subject. There are shortcomings, many shortcomings, but they are not the responsibility of any particular Government; they are the responsibility of numerous successive Governments and of the local authorities as well, and are perhaps due even more to public apathy and ignorance. So far as the present Minister is concerned, I have no doubt whatever about his sincerity and concern for the welfare of the mentally sick I certainly hope that we can keep politics out of this debate.

Anyone introducing this subject is under a serious difficulty. It is very hard to strike what I think is the necessary note of urgency without also providing food for sensationalism, and that is the last thing I want to do. I shall try my best to steer a middle course between complacency on the one hand and sensation on the other. Since I am going to make a number of criticisms of this service, I think it is only right that, in the first part of my speech, I should deal with the advances, the numerous advances, which have been made in the last 20 years.

I spoke of a revolution in the mental health service. It has been in a sense a twofold revolution: a revolution in the public attitude towards mental illness and, secondly a revolution, which has gone perhaps even further, in the treatment and care of the mental patient. Mental illness used to be considered a somewhat shameful thing. It was something which was not talked about except, perhaps, among doctors. If this catastrophe befell people, they went in those days not into a mental hospital, but into a lunatic asylum. Those nightmarish institutions were cut off from everyday life by high brick walls and locked gates, and the public was glad that they were so cut off. They were regarded in much the same way as prisons. Indeed, certification carried much the same sort of stigma as prison itself.

Today, people are slowly but inevitably coming to appreciate that mental sickness is not fundamentally different from physical illness or accident and that it is something which can be treated in a mental hospital, in the same way as pneumonia or some other complaint is treated in a general hospital. That is a very important development, and I only wish it were progressing farther and faster.

The mental hospitals today are less cut off from the community than they were even 20 years ago, and that is a good thing. They have now even open days, on which they invite the public in to see what is going on. I am myself attending one of these open days in a mental hospital in the North of London in a week or two's time. We want the public to know and to realise that it is their responsibility. It is the responsibility of us all. We want the people outside to know what the problems are.

Admittedly, certification still carries a stigma, but I think this is diminishing as the years go by. That is partly due to the fact that the vast majority of patients coming into mental hospitals are now admitted as voluntary patients and are comparatively short-stay patients. That is, incidentally, largely the result of the Mental Treatment Act, 1930, which represented a big stride forward in this matter. I think that more than 80 per cent. of the admissions to mental hospitals today are voluntary. Perhaps the hon. Lady the Parliamentary Secretary may be able to confirm this when she intervenes in the debate.

At last we are getting people suffering from mental illness to submit themselves for treatment at an early stage in the disease, with far better chances of a cure, although psychiatrists are always reluctant to use the word "cure," and perhaps wisely so. It is now possible to get a reasonably open discussion, not only in medical circles, about the problems of mental health and mental deficiency, and the patients in our mental hospitals are no longer the community's forgotten men and women.

The second aspect of this revolution, on the medical side, has been even more dramatic. Today there are in use three main forms of treatment for mental patients. The first is electro-convulsion therapy better known, perhaps, as shock therapy or, to those who deal in initials, E.C.T. Secondly, there is insulin coma treatment, and thirdly, less often employed than the other two, leucotomy. a form of brain surgery, which has numerous variants.

Twenty years ago, not one of these forms of treatment was practised in our mental hospitals. Indeed, they were almost totally unknown. Even as recently as that, the usual treatment for even the most disturbed cases was liberal doses of sedative. Twenty years ago, the electro-encephalograph had not been invented. This apparatus, better known as E.E.G., has already done a great deal to detect and locate brain abnormalities and injuries. It is virtually a post-war development and is still in its infancy.

Then there is the attitude of hospital staff towards patients. This, too, has been revolutionised. Quite recently I was looking over a comparatively modern hospital, built, perhaps, 50 years ago, and all the ground floor wards had an adjoining room. These rooms had been converted into various useful purposes, but they were all very similar and were originally built as "boot rooms." The medical superintendent explained to me that 20 years ago the patients in the morning used to be lined up in the ward in two ranks. They were marched into the boot room. They took off their shoes and put on their outdoor boots. They fell in again in two ranks, they were marched out into the grounds for, perhaps, 20 minutes' exercise, and were marched back again. The same procedure again went on: out of their outdoor boots, into their indoor shoes, and back into the ward.

Of course, that sort of thing is dead and buried, and we are profoundly grateful that it is. Most of the patients can now wander about at will in the grounds of the hospital—and lovely grounds most of them are. Whereas the policy used to be one of maximum restriction, the policy now is the maximum liberty compatible with the safety of the patient and of the community.

There have also been enormous developments in the field of occupational therapy. In the old days, almost the only form of occupational therapy was farming. That is not very useful for the man who had spent all his life in a town. But now, a wide variety of subjects is taught, including rug-making, basket work, tailoring, weaving, sewing, shoe-making, boot-repairing, carpentry, bookbinding, and many others. In one hospital with which I am associated, the patients have themselves built for their own use two large huts to be used for occupational therapy purposes. The therapeutic results of this constructional work have been quite amazing. Then there is art therapy, in which patients are encouraged, if they show the inclination to model in clay, to paint, and to express themselves. This is useful not only from an occupational point of view; it is sometimes very helpful to the doctors from a diagnostic standpoint.

Occupation is vital to mental hospital patients, whether therapeutic or not. For many of the chronic patients it is about the only form of treatment there can be. The alternative is something that is terrible to see—the patients sitting down, doing nothing, miserable and morose, and in fact waiting for death, whether consciously or otherwise.

Another thing which has been a godsend is the introduction of television into mental hospitals. It is wonderful to see patients who have never hitherto shown the slightest interest in their surroundings or anything else, positively glued to the television screen. Television has something to offer almost every type of patient. In one hospital I know the introduction of T.V. was resisted on the grounds that most of the patients went to bed before the evening programmes began, to which our reply was that they had better change the bed-time. Because this is a really important amenity and it has some therapeutic value as well. Indeed, if they only see the Children's Hour or an occasional football match in the afternoon, it is well worth while. For my part, I shall not be happy until every mental defective hospital in the country has got a television set in pretty well every ward.

Now I come to a rather extraordinary fact. Despite all the undoubted advantages of these new forms of physical treatment and the other forms of treatment, the chronic population, that is, the long-stay patients, the quite often incurable cases, is not decreasing. At best it seems to be remaining static, though in some hospitals it is, in fact, increasing in numbers.

I want to give a few explanations of this, or, at least, what I think are the explanations. First of all, the published admission figures and the discharge figures to the hospital tend rather to mask this fact. It is common to find in a hospital of about 2,000 beds an admission and discharge rate of about 1,000 a year. In some hospitals it is very much higher, and at first glance that would suggest that well under half of the patients in the hospital were chronic cases. But actually these admissions are mainly acute cases. They do not stay anything like 12 months, but more like one to three months. That means that the acute beds turn over, in the statistical sense, three and four times a year.

A psychiatrist writing recently in the "Lancet" said that in a large mental hospital of 2,000 beds there were perhaps 500 acute and recoverable cases. I do not think that that is an over estimate. The remaining 1,500 will be chronic cases, and it is these figures which are not decreasing but rather the contrary. Before I suggest what I think are the reasons for that, I want to ask the Parliamentary Secretary whether she has any evidence that mental illness in general or that chronic mental disorder in particular are increasing in the population as a whole.

One reason for this increase in the chronic population is our success in other medical fields. The incidence of tuberculosis in mental hospitals in the past has been very much higher than in the population as a whole, and in the past the death rate from tuberculosis has always played its part in keeping down the chronic population. Today, with the development of antibiotics and other forms of treatment, tuberculosis is nothing like the scourge it used to be and the result of this is that patients live longer. A T.B. case which was probably fatal 20 years ago may be cured today in a matter of a few weeks by antibiotics.

Secondly, with the general improvement in medical skill, with the National Health Service, and with higher nutritional standards, people generally are living longer and this fact must apply a fortiori to those who live in hospitals where medical treatment is immediately and continuously available to the patients. So perhaps a trend which seems disturbing at first sight may, in a sense, be a cause for gratification.

Clearly, the fact of the chronic population remaining static and not actually increasing means that there is very serious overcrowding in all our mental hospitals. I believe that the figure for overcrowding for the whole country is about 14 per cent., but perhaps the Parliamentary Secretary will have more precise information when she intervenes.

What does this mean to patients, to nurses and to the public as a whole? To the patients it means that their beds are crowded together in the wards, sometimes no more than nine inches apart. They are far too close for comfort and, in my view, far too close for health and hygiene, or it means that they cannot dress beside their beds and there is not proper locker space available at their beds. Alternatively, it means that the beds are placed in corridors, which should be used for access to the wards, or in the day rooms, which means that the recreational space which should be available to the patients has to be cut down. Just as important, it means that the proper segregation of the patients into categories is difficult, if not impossible.

To the nurses and the doctors it means that their work, which is difficult enough in normal circumstances, has to be carried on in conditions which are well nigh intolerable. To the public outside it means that in some hospitals voluntary admissions have to be limited. Hon. Members will realise that when a patient is certified the hospital must take him or her in, and, therefore, chronic and certified patients overflow into the accommodation which should be available for the voluntary and acute admissions and the waiting lists increase.

The condition of those on the waiting lists deteriorates, a patient does not get to hospital early enough, so that in the end he needs longer treatment when eventually he gets in. Worse still, he may change his mind about going in at all, or change his mind and wait until it is too late. Those are some of the results of overcrowding in our mental institutions.

Serious as this is, the waiting list for the mental deficiency hospitals is far more so. These are an index of tragedy. There is sometimes some confusion with the public at large as to the difference between a mental hospital patient and a mental defective. The simplest explanation is that a mental hospital patient is like an engine that has broken down, while an engine with a vital part missing is like a mental defective. The ascertained waiting list for the country as a whole for mental defectives is 9,000, of which nearly half are children. The actual need for hospital care for mental deficients is probably higher, because there are many who need this care who are not on any waiting list.

I went into the figures for my region, where we have a waiting list of 527, of which two-thirds are children under 16. They are divided into three categories, low, medium and high grades, or, to use the more brutal alternative terminology, idiots, imbeciles and feebleminded. The proportions are roughly 25 per cent., 45 per cent. and 30 per cent., respectively. The high grade defectives and some of the medium grade need care and training, so they should be got into the mental defective hospital as early as possible in their lives in order to be taught if possible to function in the community outside. The great majority can so be taught. But the low grade type and most of the medium can never function in society.

I want the House to reflect on what the existence of one of these low grade defectives means in a family. The child is probably incontinent, perhaps doubly incontinent, and somebody in the family, usually the mother who is perhaps harassed with several other young children, has got to be constantly cleaning up after this child, keeping a constant eye on it to see that it does not injure itself or set fire to the home or do some damage of some kind.

The mother has to spend far too much of the day washing foul laundry, and all this means an intolerable strain on anyone. I know one case in which it was too much for the mother, and the result was that the father, who had a steady job which he had held for years, had to give up his work, come home and himself look after the mentally defective child. This situation causes untold misery and every one of these defectives in a family means that the lives of two, three or half a dozen other people must be affected adversely. Every one of them should be in a mental deficiency hospital where he can be looked after with kindness and understanding and can be insulated from a world with which he can never come to terms. I have spoken frankly about this in order to give the House some idea of the quantitative effect in human suffering that is represented by this waiting list of 9,000 mental defectives.

I come now to the question of buildings. Here and there in the country there are fine modern hospital buildings, both on the mentally deficient and on the general hospital side. Recently I went over what was possibly the most modern mental deficiency hospital in the country. It was delightful, with well-designed buildings, well-spaced, plenty of room, and on a pleasant rural site. The whole thing was admirable. Yet even that place was overcrowded to the extent of between 20 per cent. and 25 per cent. These, however, are few and far between, and the majority of our mental hospitals are ex-workhouses or ex-poor law institutions, mostly dating from the middle of the 19th century. Far too many of these are still in use.

A rather interesting point came to my notice recently. I have not been able to check it, but I have no reason to believe that it is not true. The Board of Control, which gets a lot of abuse in some quarters, made a report in 1860 on the design of mental hospitals. The report said that whilst they should be well built, they should not be built so solidly that they were incapable of being adapted to changes in the form of treatment. That was far-sighted, but unfortunately the recommendation was made in vain. The Victorians could not build other than solidly, and there the buildings stand, grim, almost indestructible, and they constitute the majority of our mental hospital accommodation. They contain vast, unmanageable wards, they are badly designed, the sanitation is often inadequate, and they are practicably impossible to heat properly.

None of these things can be put right without expensive capital expenditure, and that is the dilemma which faces every regional hospital board: how much of their limited resources are they to spend in trying to patch up one of these really hopeless buildings, because there is so little and such a large field over which to spread it. I am not suggesting that nothing can be done, because a good deal has been done in many hospitals to improve the situation. A lot can be done by interior decoration and by the intelligent use of colour but, do what one may with these buildings, the result is inevitably a second or a third best.

Here I want to enter one caveat. I do not want anything I say to deter members of the public from going into mental hospitals as soon as possible to obtain treatment. I also want to make it clear that most hospitals in the last 10, 15 or 20 years have at least developed a small admission unit for voluntary patients which has every modern facility for treatment and is well designed. In the main, it is the chronic, long-stay, the certified patients, who suffer from the grim institutional atmosphere of these Victorian barracks, and it is on their behalf that I am making my main plea. There is only one answer to this problem, and I shall come to that when I sum up.

I want to say a word now about the most acute and immediately problem of all, the shortage or nursing staff. We all know that mental nursing is a difficult job, calling for high qualities of patience. skill and human understanding as well as physical endurance. That it is a worth-while job is a gross understatement, but I know that to those who are temperamentally suited to it, it is deeply satisfying and rewarding work. Nevertheless, the recruitment of student nurses in the mental field is lamentably low and the wastage rate of those who enter is appallingly high. The result is a nation-wide shortage of mental nurses, both male and female.

In my own region, which is only one of 14, we have between 200 and 250 beds closed for lack of staff, 58 vacancies for trained nurses, 580 vacancies for staff nurses, student nurses and nurses' assistants. In a written reply from the Minister last week, the right hon. Gentleman gave me some figures about the relationship between hospital beds and nursing staff. Comparing 1952 with 1948—that is, in four years—the increase in the number of beds in mental hospitals and general hospitals has been the same, roughly 7 per cent. During those four years, however, the full-time mental nurses have increased by rather less than the beds, by 6 per cent., and in the general hospitals the full-time nurses have increased by no less than 24 per cent.

This suggests two things. The first is that the relatively satisfactory situation in the general hospitals has been largely at the expense of the mental hospitals because there is only a limited pool from which to draw all nursing staff. Secondly, it suggests that the mental health service has only just managed to keep its head above water in this respect. It is much more disturbing when one sees how even that modest achievement came about.

It is no exaggeration to say that the mental health service has been kept going from the nursing standpoint in the post-war years by the flow of nursing staff coming from abroad. This vital service has been sustained largely out of the post-war unemployment in Europe and the plight of the displaced persons. Of course we are profoundly thankful to those who came from abroad to help us but not many of them stay, and it is a fact that the majority came primarily to learn the English language and, having learned it, they went home again. A few have stayed to qualify. Fewer still have remained after qualifying. The whole operation was highly uneconomic because we pay their fares, we pay them to learn our language, and then we lose them. In any case this cannot continue, even if we wanted it to do so, because the source is drying up.

I think there is something wrong with an essential national service which cannot be maintained, or even largely maintained, out of our own labour resources. There are three factors in this job, as there are in every job—pay, working conditions and status. There must be something wrong with one or all of these since we cannot staff these places.

I will not say much on pay, because the matter is under arbitration, but I should like to know why the arbitration took about 11 weeks to get started after the breakdown of the Whitley negotiations. Perhaps we can be told why? In my view, the differentials between mental nursing and general nursing at present are quite wrong. On the second point, I have already mentioned overcrowding as one of the things which make working conditions very hard for nurses. Today we have to compete with industry in a state of full employment. We have to compete with people who can offer a five-day week, much more convenient hours, and often much shorter hours.

Secondly the hospitals are frequently isolated and there are poor transport facilities. As to status, there seems to be a feeling in some parts of the nursing profession, particularly, I regret to say, amongst the matrons of teaching hospitals, that somehow mental nursing is an inferior category to general nursing. [An HON. MEMBER: "Nonsense."] It is nonsense and deplorable, but nevertheless it has an effect on recruiting. Even the "Lancet" in a leading article recently called upon the heads of the nursing profession to end what it called: "This silly and out-dated snobbery."

A good deal of mental nursing is done by nursing assistants. Theirs is a dead end job with no status, no recognition and frequently with a wage less than that of the domestics who clean the wards. The only proposal that has come from the Minister so far on this problem, published in a circular some time ago, is that we should try to increase the number of nursing assistants. Even if this were possible, and I doubt it, is it reasonable or fair? Another suggestion has been widely canvassed and is I think far preferable. It is that there should be a new grade of mental nurses—enrolled mental nurses or assistant nurses (M)—who should do two years training in a mental hospital on practical rather than theoretical lines with a comparatively simple examination at the end, a recognized status and a salary scale. This suggestion is put forward by many responsible people including regional psychiatrists and regional nursing officers.

Why cannot mental nursing be included in the general nursing curriculum, possibly as an alternative to tuberculosis nursing? The General Nursing Council, of course, will raise objections. They raised the same objections to the tuberculosis nursing proposal, but the difficulties were overcome and that scheme is now working quite well. Why does not the Minister encourage the cadet nursing scheme? An article in the current "Lancet" describes one such scheme which is highly successful. I know that that costs money but if it brings more recruits that money is well spent. One of the great problems is the bridging of the gap between school-leaving age and the age of 18, which is the earliest age at which training in mental nursing can begin.

The latest recruiting drive on which the Minister has embarked is on a very limited local scale. Hardly anybody has ever heard of it. Cannot we have a national Press and poster campaign? Let us spend some money on publicising recruitment to the mental health service.

As to junior medical staff, in my region there does not seem to be enough younger doctors coming into this field. There are junior posts, especially on the mentally deficiency side, remaining unfilled. I do not know whether this is a general trend, but possibly we can be told what the Minister is doing to encourage young doctors to specialise in psychiatry. I should have thought it offered one of the most exciting prospects in medicine today.

I obtained on Monday some figures about the expenditure on research since the war, which I must confess appalled me. In eight years the Medical Research Council has spent nearly £8 million on research, and of this sum only £87,000 has been spent on research specifically into mental health. With 42 per cent. of all hospital beds in the country, the mental side receives just about 1 per cent. of the resources available for research. That is not good enough. Surely there are great opportunities, and an even greater need, for research into mental illness.

In particular, we must discover new physical treatments for mental disease. If I seem to concentrate on the physical aspect of treatment to the exclusion of other forms, such as psychoanalysis, it is not because I am one of the scoffers at this kind of psychotherapy. It is because the sheer economics of these longer forms of psychotherapy tend to rule them out as a common treatment. The course of analysis lasts anything from two to three years, and the small number of cases that can be handled by one analyst means that the service can only be available to a fraction of those who might benefit from it. I hope that the Minister will call the attention of the Lord President of the Council to this miserable amount of money that is devoted to research and will see that the mental health service gets its fair share in future.

I should like to sum up by quoting two or three sentences from a leading article in the "Lancet": The main body of patients forming the vast population of our mental hospitals are sad, withdrawn, confused or frightened people who excite only compassion, and whose paramount emotional need is for comfort and support…The first need of the sick mind, seeking to come to terms with reality, is an atmosphere of peace and security. This atmosphere is quite unattainable in grim, crowded, out-of-date institutions, still reminiscent of the Poor Law. It cannot be obtained even in good modern buildings if those buildings are badly over-crowded. It cannot be obtained if nursing staff is harassed, inadequate in numbers and largely untrained. Even the doctors have not a fair chance to exercise their skill until there can be a better segregation of patients into categories, the kind of classification only possible when a hospital is less than full, let alone 15 per cent. overcrowded.

The hospital service as a whole has been starved of capital ever since the "appointed day," but out of the total of £40 million capital expenditure in the first five years of the National Health Service less than £6,500,000, or about 16 per cent., went to mental hospitals. I should like to remind the House that the mental health side, with 42 per cent. of the beds in our hospital service, is allocated only 16 per cent. of the available capital. My right hon. Friend the Member for Middlesbrough, East (Mr. Marquand) directed that there should be an expenditure of not less than 20 per cent., which was at least a beginning. It is of course the responsibility of regional hospital boards to allocate their capital monies as between mental and non-mental hospitals. For too long we have had too little on the mental side, for the answer to nearly all this problem is money.

I know that the Minister has set aside £1 million for the coming year, especially for capital development on the mental health side, but he knows, and we all know, that that is a drop in the ocean. We want many, many millions, and we need them urgently. There is one mental hospital under construction, but we want many new hospitals. This is the only solution. We want day hospitals. They are a very promising modern experiment about which my hon. Friend the Member for Lichfield and Tamworth (Mr. Snow) may have something to say if he is called in this debate.

In my view, the mental health service has not had its fair share of this country's resources. Those who carry this burden so magnificently, the doctors and nurses, are doing so in many cases in conditions which should not and need not be tolerated. My last word is for the patients, especially the chronic patients. These people are a small minority with no voice with which to speak, and most of them without even the vote. That is all the more reason why we in this House should see to it that they are getting the best that we can give.

11.50 a.m.

Sir Frederick Messer (Tottenham)

I beg to second the Motion.

I feel sure that in doing so I shall have the sympathy of the House. The speech of my hon. Friend the Member for St. Pancras, North (Mr. K. Robinson) was of a character that, without making any reflection on anyone else, I should describe as exceptional. It showed a close attention to deep research into and sympathetic understanding of the problem. I do not know how anyone speaking in this debate can do so without referring to some of the things which my hon. Friend has said. I had a very uncomfortable feeling as, one by one, thoughts I had in preparing my speech were more adequately dealt with in the speech to which we have just listened. But, if only to reinforce what has been said, we shall be wise to express our views on this great problem.

I was delighted to hear my hon. Friend say that he was not approaching this problem in any party spirit. If there is one thing which bridges this side of the House and the other it is the common ground of humanity which we have found. Just as my hon. Friend has no desire to exploit what may be political capital, neither have I. I know that the Minister is deeply interested in this problem and deeply interested in an aspect of it which, perhaps, has not yet been sufficiently grasped by all those who are working on it. I will refer to that later.

This is a big problem and, I say with all diffidence, an unparalleled problem. Mental disease, mental handicap, is unlike any physical disease or handicap in that it is many-sided. As my hon. Friend said, there is the low grade mentally defective, the medium and the high grade. There is as much difference between the low grade mentally defective and the high grade as there are variations in ordinary intelligence. The low grade may be quite impossibly incurable, permanently insane. All that one can do for those in that position is to make them as comfortable as is possible, allow them to drag out their life, bereft of the consciousness of their surroundings, with minds which are distorted and unable to interpret what would be the normal influences on those minds.

The experiences of my hon. Friend have been much the same as mine because we were on the same regional hospital board. I was the recipient of many pathetic letters which indicated the complete disruption of the home by the presence in it of a child who was mentally defective and which resulted ultimately in the nervous breakdown of the mother, a child who was a danger, not merely physical danger to the other members of the family, but a danger to the extent that the other children, being constantly in the company of that mentally defective, themselves obtained a distorted idea of their relationship. It is not any exaggeration, therefore, to say that this problem, in addition to being a problem of the patient, is a problem of those who may be affected by the patient.

It is not a problem that can be dealt with by the medical profession alone, for it is more than a medical problem—it is a social problem, a problem which has to be handled by the parent, by the local authority and by the hospital authority. It is a problem which is our responsibility, the responsibility of the community. That low grade mentally defective ought not to be left in the ordinary domestic home for one day more than is absolutely essential.

I hope that attention will be given to that type of case, although I realise—and this is one of the contradictions we are facing—that we have to ask whether we should put the incurable case in a bed which might be occupied by somebody for whom something could be done. That is one of the difficulties of this situation. Clearly in the case of a voluntary patient of a type bearing no relationship to the mentally defective—a neurotic case, a nervous breakdown—the machine is still there. What is required is modern treatment for the purpose, first, of dealing if possible with the cause of mental weakness and then restoring that instrument to the strength that is required for it to face ordinary life. That is a real difficulty. Are we to use a bed for a mentally defective for whom nothing can be done and, therefore, shut out somebody for whom something can be done and who will suffer if he does not get that treatment?

I join my hon. Friend in seeking to encourage those who feel that they have in the least degree the need for help and advice to take advantage of the opportunities offered to those who are prepared to become voluntary patients. When the high grade mentally defective is in the home, often it is the case that the parent can do a great deal, if only the parent knows just what to do. I am wondering whether all local health authorities are doing all that is possible in the way of training parents of high grade mental defectives, notwithstanding their limitations.

When we are dealing with a matter of this description we should have an objective, a purpose. In my view, in this type of case the purpose should be to bring within the reach of that unfortunate the maximum degree of normality. Obviously that means that we must take account of the fact that here is a child declared ineducable, a backward child, but that, although it is ineducable—which means that it has not the degree of intelligence and has not the capacity for the ordinary academic education—yet there is within it the capacity to do something.

Those of us who have worked on local authorities have seen what great work has been done at occupational centres. There are not enough of them. Most local authorities are constantly being asked why there are children at home who would be benefiting themselves as well as benefiting their homes if they could get places in an occupational centre. The strange thing is that, whilst that retarded mind appears not to be capable of understanding the abstract, it does understand the reality.

At Potters Bar there is an institution for high-grade mental defectives run by a Roman Catholic organisation. There the mental defectives are taught a simple operation and somehow, automatically, they learn how to do it. I do not know, but it may be that without guidance they would fail to repeat the operation. It is, however, true to say that so improved are these patients that they go out to work and come back to sleep at the institution, until eventually they are allowed out to take their place in the community. That should always be the object and the purpose of treatment for such people.

I am particularly interested in this aspect of the problem because I am certain that if the ordinary members of the public saw the work which is done in that institution they would marvel that it was performed by people other than of high intelligence. The method of doing it is repetitive, automatic and calls for no great mental effort, but the results are very satisfactory. That example could, of course, be repeated up and down the country.

I was pleased to hear my hon. Friend say that now we have got away from the idea that all that people in an institution are capable of doing is farm work. I have seen some of the work done in mental hospitals and, more important than the success of this work, the effect it has upon the patients. We who are not afflicted know how it feels if we are inactive. What must it be like for a mentally defective person who can do something, but is not allowed to do it? Surely the cessation of effort must have a bad effect on those types of mentally-defective people who can enjoy life.

In a mental hospital I have seen a group of girls dancing and with them was their teacher. That hospital had modern ideas, and directly one entered the place one felt a spirit of comfort. Anyone could go in. They might be challenged at the entrance, but the gates were open. Inside, one experienced an atmosphere of sympathetic understanding which radiated from the medical superintendent right down to the hall porter.

I sometimes wonder whether we regard mechanical efficiency as too important. In some cases it is not only what is done that matters, but the way in which it is done. The girl instructing these mentally defective girls to dance was dressed in exactly the same way as they were, and I thought that a fine piece of psychology. It meant that she bad placed herself on their level.

I mention these things because I think great care should be taken in the choice of staff for mental hospitals. My hon. Friend touched upon a very important point when he referred to the lack of accommodation—I would say rather a lack of facilities—for dealing with mental cases. We have the beds. I do not know the extent to which we should reduce the waiting list were all the beds occupied. We have the beds, but they are of no use whatever without the staff.

The problem is how to attract staff and I wish to say a word about recruiting nurses. Although not present when the Parliamentary Secretary to the Ministry of Health spoke, I read what she said in the House a few weeks ago regarding the gap between the school leaving age and the age at which a girl may take up nursing. In my view the General Nursing Council are deterring recruits. We must remember that of those who enter the nursing profession, 40 per cent. leave before becoming trained. Four out of every 10 who start their training do not go through with it. I do not wish now to question why that should be, but I think the General Nursing Council should consider, in addition to the standard it wished to attain, the difficulties arising from the fact that there is no margin of labour from which to draw.

The female working population is fully absorbed. There are jobs waiting for every girl who leaves school. In those two or three years between leaving school and the age at which she can start to train as a nurse a girl may find that freedom, a decent salary, an attractive job and a developing interest in industry are sufficient to prevent her taking up what might have been a vocation.

A girl will not readily leave a job where she is getting a fair salary to go into nursing. I regret that cash considerations come into the matter at all but, that being the case, if we are to attract nurses to mental hospital work, not in rivalry with general hospital work, we must recognise the difference between mental hospital work and general hospital work and, so far as possible, assess how much more it is worth to the person concerned, to the patient and to the community. I do not think that money is the only thing, though it is important, and we have no right to rely upon the nobility of character of people who enter the nursing profession and use that as a reason for underpaying them.

Leaving aside the question of money, however, the life lived by members of the staff at a mental hospital must be compared with that lived by the members of a general hospital staff. Take, for example, the Three Counties Hospital, miles away from the nearest town—Bedford on the one side, or Luton, or whatever town it may be, on the other. It is in the heart of the country. It is difficult to get up to town. What recreation the staff get is that which they organise themselves. These conditions must be taken into account, not merely their residence.

Hon. Members ought to visit some of these institutions. I have not a doubt that, being Members of Parliament, they would come out again. They should go to a hospital not very far from this House. The terrible, heavy iron gates will clang, and as one walks up the stone stairs in which deep indentations have been worn by human feet over a period of 140 years, one feels depressed. As one walks through the miles of corridors one feels depressed at every step. How those suffering from mental illness ever recover there is something which borders on the miraculous.

Is not it true that we reflect our environment? Our outlook is determined, by the impressions made on our minds. When we go into a depressing place we feel depressed. When we go somewhere where the sun is shining and we see brightness all around, our spirits are in harmony. Some of these old places are in need of a coat of paint. Why those who had control always thought that dark brown was a suitable colour for institutes of this description I have never been able to understand.

Why they used to think that warmth and enthusiasm in some of these long wards was sufficient to keep the patients comfortable, I do not know. I know a mental hospital where it was necessary to bring in gas radiators as soon as the regional board saw what was happening. There was no central heating. The Minister cannot be blamed for any of this. Indeed, he inherited a terrific job. No one can foresee the possibility within our lifetime of these places being pulled down. We have to look to a reorganisation so that, as far as possible, we can make the maximum use of what we have got.

In that connection it is as well to remember that of the 500,000 beds under the National Health Service, no fewer than 211,000—I am speaking from memory—are for mental and mentally deficient cases. That is an alarming thought. More than two-fifths of our beds are in use for this purpose, and there is a long waiting list. This is serious. We should ask ourselves whether the best use is being made of what accommodation there is, apart altogether from staff shortages. During the war the country was driven to expedients and, rightly, it was decided that hospitals in the big danger towns should be evacuated.

Is not it time that some of the general hospitals which were evacuated to mental hospitals should come back to the big towns so that the beds which are used now for general cases on the sites of mental hospitals may be used for mental cases? I have two cases in mind. At Hill End Hospital in Hertfordshire there are about 190 cases which could be accommodated elsewhere if St. Bartholomew's brought their patients back to Smithfield. One of my hon. Friends tells me that more could be accommodated.

At Arlesey, that is, the Three Counties Hospital, there are about 20 hutted wards. I think that 12 of them are used by the London Chest Hospital and eight of them are used for other purposes. We have staff there. Is not it possible for us to see whether or not the London Chest Hospital patients could be accommodated in London so that the beds there may be used for mental cases? I admit that the wards were not put up for mental cases. They were emergency wards, but they happen to be on the site of the mental hospital. If staff can be found, would not it be a good thing if we were able to organise our affairs so that mental cases could be accommodated on the site of the mental hospital?

Mr. R. J. Mellish (Bermondsey)

If the regional boards have control over matters of this kind, why have they not dealt with them? I can imagine the Minister saying that this is a matter for the regional boards.

Sir F. Messer

These London hospitals went out to the mental hospital sites. The hutted wards became part of the London Chest Hospital.

The point is that on the mental hospital site there are beds that could be used for mental cases if only the parent hospitals could now have accommodation for their own patients. I do not blame anyone for this state of affairs, but it is a matter that might be discussed. I do not know whether the regional hospital board could deal with it. It might be able to say to the London Chest Hospital, "We have got hospitals where we could deal with your cases if you will let us have the beds that you have already got on this hospital site." Usually when a hospital authority has got something it clings to it as hard as it can. It does not let it go easily. The London Chest Hospital will want to keep the beds for its own purposes; but that is by the way.

There are two other considerations about hospital accommodation. This is a national service. It is not a regional or a local service. Any patient, whether suffering from a mental disease or otherwise, is entitled to a hospital bed where there happens to be a vacancy, whether it is in the town in which he lives or somewhere far away. Are there any vacant beds which could be used for patients in a region which has long waiting lists? One of the difficulties is that of the financial arrangements. When a regional board has got its allocation, it spends it on the hospitals and institutions within its region. If it takes patients from another region, the other region cannot pay. The region in which the institution or hospital is situated must bear the cost. I do not know whether that is a deterrent.

There is also what is called a contractual arrangement whereby the regional board is entitled to use disclaimed private establishments. It enters into a contractual relationship with the private establishment and pays for the patients who go there. But if a London patient needed admission to a private mental hospital in Birmingham, the London region could not make arrangements contractually with the private establishment there but could only send the patient if the Birmingham Region agreed, because the Birmingham Region would have to pay.

I wonder whether that is a matter which is worthy of some consideration. I wonder whether a vacancy in a private establishment in one region could not be used by some other region. I referred to Birmingham merely as an illustration, but it is a fitting illustration because, when a vacancy occurred in a private establishment in Birmingham, the North-West Metropolitan Region wanted to fill it but it was unable to do so without permission from Birmingham.

I repeat that this is a national question, but I am afraid that all regional boards do not regard it as such. I have been approached by other regions who have said "We have patients from your region in our mental hospital. Will you pay for them?" The Ministry has said "No, the region in which the hospital is situated must pay." It is a matter which ought to be considered, for if in mental health one were dependent entirely on the mental hospital accom- modation within one's region it would be a very bad thing for a large number of regions. For instance, one Metropolitan region has almost a monopoly of mental accommodation. There are hospitals such as that at Epsom and hospitals in other parts of London, such as at Springfield and Tooting, and fortunately, we have a very good arrangement. In the main, regional boards work very well together. However, I wonder whether some national investigation into the organisation might not prove to be of Value.

I feel guilty about having spoken for so long when, after what I had heard, I thought I had nothing further to say, but this is a matter which demands serious attention on the part of hon. Members and also education of the public. We ought not to feel, as appears to be the case, that we can merely push the responsibility on to someone else. This is something on which we can all join forces.

We realise that the great revolution which some people claim to be the only solution—the building of new hospitals—is not practicable. But if we get together, pooling our ideas and concentrating our energies, we may be doing something for every section of the mentally affected—for the poor soul who is lying like a log without consciousness of any impression, for the one who could perhaps be given some hope because his condition lends itself to treatment, and for the boy or girl who, having been denied the opportunity of treatment at an early age, might develop into an incurable.

Those are the ones who have the greatest claim, for they have a handicap worse than others. Physical handicap can be met. Even those who are sick are conscious of the possibility of recovery and at least of the comforts with which they can be surrounded. Those who are blind and spend their lives in eternal darkness have consolation which is denied to those who are alive, yet dead.

12.26 p.m.

Dr. Reginald Bennett (Gosport and Fareham)

I feel that I cannot do better than start by saying that I regard the speech of the hon. Member for St. Pancras, North (Mr. K. Robinson) as an absolutely masterly conspectus of the whole of mental medicine and its problems.

As one who has practised for some years now as a psychiatrist, and for many of those years in mental hospitals, and also as one who sits on a regional hospital board, I have seen, face to face, all the problems mentioned by the hon. Member. He is greatly to be thanked by all hon. Members and the country for having, as he said, for the first time in a quarter of a century brought the mental hospital system out of the limbo just as science is bringing the mental hospitals out of being limbos themselves.

The hon. Gentleman mentioned the revolution in mental medicine and that in mental hospitals which has followed it. That revolution consists of just this one thing: previously—I am not referring to any particular epoch, but it is always relative to today—the mental hospitals were limbos and almost tantamount to the ominous words: All hope abandon, ye who enter here. Today the whole outlook has changed from being merely a custodial one to being a dynamic one where treatment is given and hope provided for those who come in that they will indeed go out. That is the most basic factor of all.

In passing, the hon. Member mentioned some of the treatments. It is important that they should be recognised for what they are. He mentioned the electrical convulsion treatment which was brought to life only in 1937 by Cerletti and Bini. Like many other treatments in mental medicine, it was designed at first to combat schizophrenia, that most intractable of all diseases. It does not resemble the Hollywood representations of it, but consists of a dilapidation of the whole personality. There is no neat division into a Jekyll and a Hyde.

That disease was found not to be touched substantially by the treatment, but now it is found that those who, especially, as commonly happens, in the middle period of their lives, become taken over by sudden and, usually, unaccountable depression, can be restored in very quick time to normal life by a course of treatment with this therapy. I do not know how widely it is appreciated how dramatic is the recovery that can often be expected of this treatment within a few days and weeks once it has been administered. That, I feel, is one of the great rays of hope which we have at the present time.

Another one, of course, is in the treatment of schizophrenia by putting the patient into a coma by the use of insulin. It has been demonstrated in that particular type of case that the use of this method for a few minutes a day may soon produce a lightening of the condition during the recovery from the coma and later a general lightening of the schizophrenic process, bringing the patient more nearly to his or her own previous underlying personality.

Both these treatments, although they sound very frightening, as one is called convulsion and the other coma, are not in themselves alarming phenomena, once they are understood. A coma is like a temporary sleep, and a convulsion is like a mild fit, and it is really most important, for the future of our mental hospitals and our mental health service, that it should go out that these forms of treatment are not to be regarded with terror, but that they are of the greatest and readiest help to those who come under their scope.

There is another one, which sounds perhaps the most terrifying of all, and which is called a prefrontal leucotomy, which is an operation in which the brain is cut across on the line of the temple on either side. That sounds a terrible thing, but I believe that it contains the most dramatic of all the improvements we may yet see in mental medicine. In this, as in all other medical fields, we get the enthusiast who uses it wrongly, but I have seen and taken part in many of these operations and have watched the results in many cases.

The patients have to be most carefully selected, and, generally, they are people suffering from one form or another of dreadful mental stresses, causing them great tension and anxiety and giving them an appalling feeling of restlessness and mental agony. That condition can be cured by this operation, but a lot of people have got the idea that this operation turns the sufferer from a violent animal into something of a passive vegetable. That could not be more misleading. I know of one case of a man of high intelligence—and one shudders to cut the brain of a man of high intelligence—who was in a dreadful state and who took the operation. Afterwards, the only fault that was noticed about him as an ordinary citizen when he had returned to full social life was that his bidding at bridge was not as good as it used to be.

This illustrates the new dynamic attitude to mental medicine. These surgeons and their physical treatments have, of course, the accompaniment of psycho-therapeutic methods and the methods of occupational therapy, such as have been so accurately set out by two hon. Members who have spoken, but one thing which I feel really ought to be noted is that occupation is itself treatment; and not only is it treatment, but I will go further and say that interest is also treatment, and that that is the way in which we should regard this matter. The hospital beds are useless without this human accompaniment.

No doubt, most authorities are aware of this, but there is one most startling thing which we find is a challenge to our efforts in this branch of science. It has always been the case, as far as I am aware, that mental deficiency—the "massing part" to which the hon. Gentleman referred—amounted to something deficient in the way of intelligence and capacity which at any period of life would remain relatively the same.

In America, a research worker has demonstrated that, by working on them hard in favourable circumstances and atmosphere, the intelligence quotient of such people could be caused to rise remarkably, so that, with the most assiduous attention, these people could be actually improved. If that is so, and I guarantee that this is work done by valuable researchers and no mere charlatanry, if this is really true, we can see that it presents us with a new opportunity in the medical treatment of mental deficiency.

Another point is perhaps a little baffling. We had here in this House a little while ago my late professor who gave us an address on industrial psychology, and he produced a number of examples which he had found in his work in studying conditions of work in various types of factory and workshop. It was found that, if people were taken from their ordinary surroundings to another type of atmosphere, or were provided with music and things of that sort, output went up. They were then changed to another type of surroundings, with greater strictness of overseeing, or, on the other hand, laissez faire, and again output went up. At the end of the experiment, the people were put back to work in their original surroundings and atmosphere and output went up still further. What I think we can learn from that is that interest taken in these people produces a very favourable impression and effect upon them.

When we talk of interest, we must think of the people in charge, and I should say that, certainly, the whole thing rests on the personality of the physician superintendent. As has been said of military forces, there are no bad privates, but only bad officers, and I myself know of hospitals which occupy deplorable buildings but which achieve a magnificent therapeutic record and a high morale. I think I can say that of a hospital in which I used to work on the borders of my constituency in Hampshire, which, with a most energetic and kindly management committee and a vigorous secretary, turned some buildings which originated during the Crimean War into gay, and, as far as could be, brightly coloured wards, with reasonably comfortable and well-fed patients. This place could have been just another of these ghastly limbos.

I should also refer to Dr. Thomas Beaton, who has performed in Portsmouth one of the most revolutionary services that have come to my knowledge, in that there is none of that unreasoning terror among the local population about visiting out-patient clinics at the local mental hospital, whereas in this other hospital's neighbourhood, people still regard it as some kind of penitentiary. Dr. Beaton has certainly achieved a remarkable success. By contrast, I can think of yet another hospital I saw recently which is situated in modern premises but has half of the turnover of other hospitals of the same size and where treatment is absolutely minimal. The tragedy of it is that this hospital occupies some of the best buildings that we have.

Of course, this whole thing depends on leadership, although leadership cannot avail without the necessary staff; and here we come upon the dreadful problem of nursing, and its recruitment. It is a dreadful problem, largely because mental nursing has been mis-represented so very widely by such things as horrific films like "The Snake Pit," which was a very good film concerning the idea which it set out to represent, but which gave rise to the feeling that all mental hospitals are like the conditions depicted in that film. We may have some defects, but our mental hospitals are really not like that, not only for the sake of the patients but for the sake of getting the staff. I have mentioned all these different kinds of treatment and I would never have bored the House with all of them if I had not had an object in doing so.

In mental hospitals, change is going on all the time. Something is being done, and results are being gained. Nobody who goes into nursing in mental hospitals need go in with the dreadful, hopeless and defeatist idea that they are going into one of those awful custodial establishments. I have the highest regard for the article which I have seen in this week's "Lancet" by Dr. T. M. Cuthbert, physician superintendent at St. Luke's Hospital, Middlesbrough, who spoke at Manchester and delivered a brilliant paper on the cadet scheme he has brought in. He mentions some of the formidable difficulties there are in getting nurses, and above all in resisting the bad ideas issued by local people, by authoritative bodies and by just general old wives' tales.

His scheme closes the gap between the end of school age and the beginning of nursing. He may take enthusiasts, or people who were not previously enthusiastic but have been fired with enthusiasm by getting down to the work. As a result of this scheme, he has raised the ratio in his hospital to one nurse for every 3.7 patients, as against the general level of one nurse to 5.4 patients; that is to say, about half as much again.

What are we really driving at in this debate? We know that the Minister has an awful job in finding money for new buildings. What we seek to establish is that there are ways of using buildings which make some beds twice as useful. I am appalled sometimes at what goes on in the nursing world and at the really terrible disincentives that are applied to girls who wish to become nurses. I was recently shown two letters by the matron of a big London teaching hospital South of the river. They were sent to a doctor who had been trained in the hospital and who had a daughter he wished to enter. I think that matron had decided that the doctor was afflicted by the deepest moral turpitude and that his daughter was a mental defective. They were most insulting documents and I trust that I shall be able to supply them to my right hon. Friend, because the board of governors may be interested to see them. If that is the way we recruit nurses we have to think again, and there are still many wrong ideas about a rigorous discipline which is not directed to preserving order but is discipline for its own sake. Much as many people have done in the direction of rational discipline, we have a long way to go yet, and the entrenched old ideas have to be blown away before we can get on.

What I wish to convey to the House is that I do not believe we are really short of beds in mental hospitals. We have a big future, and there are brilliant new treatments coming out all the time. A bed well staffed is as good as two beds. These scales of things are not iron bound, and rigid; they are flexible. If we give attention to the use of the beds which we have we do not necessarily have to try to rebuild all these Crimean War buildings at once.

12.44 p.m

Mr. W. A. Wilkins (Bristol. South)

I cannot hope to follow the hon. Member for Gosport and Fareham (Dr. Bennett) in the medical and scientific analysis which he has put before the House of the problem which we are now discussing. I am sure that the whole House will be grateful, not only to him but to my hon. Friend the Member for St. Pancras, North (Mr. K. Robinson), who has given us this opportunity. The whole House appreciates the way in which my hon. Friend approached this subject.

I am sorry that the Minister of Health has had to leave us, as I was hoping that he would be here sufficiently long for me to assure him that, so far as I am personally concerned, this is in no way an attack upon his administration or upon himself. We have raised this matter in debate in the House in the hope that it will strengthen his hand when he makes the approaches which we hope he will make to the powers that be for the money required for the improvements which are so greatly needed in the mental health services.

A fortnight ago I was present in the House when the hon. Member for Walton (Mr. K, Thompson) initiated a debate on the question of overcrowded prisons. We listened to statistics showing that we had to keep three prisoners, and in some cases four, in a cell. The House was deeply sympathetic, as it so often is with these human problems, but I cannot help reminding myself that the remedy for overcrowded prisons is very largely in the hands of the criminals themselves. There is no reason why they should find themselves there and why their problem should arise. Today we are dealing with unfortunate members of the community who cannot help themselves and are victims of illness. My hon. Friend the Member for Tottenham (Sir F. Messer) has already said that a sick mind is probably the worst of all afflictions that visit the human race.

There is nothing I regret more than making a comparison between the money spent on general nursing services and the money available to mental hospital services. Before I came into this House in 1946, I was, from 1936 until 1946, very closely connected with the local authority administration of the hospital services in my city—general hospital service, sanatoria, orthopaedic treatment etc. I was never brought into close contact with the work of the mental health committee. The only thing I know about it is that I was a member of the Bristol City Council when we decided to build the Barrow Gurney Hospital to relieve overcrowding at the Fishponds Mental Institution which, even in 1937 was grossly overcrowded. And what a blessing that hospital was to the nation during the recent war.

I remember a report which came before our authority in 1937 relating to the mental defective institution, which stood next door to the comparatively modern Fishponds mental hospital. There were mental defectives, and cases of imbecility and sleepy sickness. The report contained a request to the city council to spend, I think, about £90,000. It catalogued about nine requirements of that institution. I still have that report. I did not destroy it because I was so intensely interested in what it said.

Every paragraph began with words like: "Such and such a thing is entirely inadequate." I remember that it said that the boilers were so completely outdated that no insurance company would insure them, and that the water supply and the heating system were totally inadequate. It went on in that fashion. A very dear friend of mine, a young man who died very shortly afterwards, was sitting by my side. He turned to me and said: "The truth is—it was a French prison, it is a French prison, and it will always be a French prison." That really seems to be the problem with which we are faced throughout the length and breadth of this country so far as mental health is concerned.

I want to deal, essentially, with three points, and I shall be as brief as I possibly can be. As I said, this problem is no responsibility of the Minister so far as the past is concerned. It is a heritage handed down to him from an unenlightened age when we did not appreciate what this problem was and what was needed to be done in order to correct it.

My first point relates to the need for capital expenditure. If my information is correct—and I believe it is—there is not a region in this country which is not in the direst need of capital expenditure on its mental health services. I said at the opening of my remarks that I deeply regretted having to make any sort of comparison between the branches of the Health Service, and especially between the general hospital services, which deal with the immediately acute cases, and that of mental health. But when, as I am advised, the capital expenditure on the mental health services in my region is only about one-sixth of the total capital expenditure over the past five years, I really think that we are called upon to reflect a little on that situation.

Some of my hon. Friends and I have a feeling that there may be room for an inquiry into the way that the present allocations to the regions are dispersed by the regional hospital boards among the various services for which they are responsible. I am satisfied that something really drastic must be done about capital expenditure.

I recently had the opportunity of seeing a report of the Commissioners of the Board of Control following a visit which they made to a very large institution in the south-west of England. Those of us who have any knowledge of the Commissioners of the Board of Control would certainly absolve them from any sort of over-statement of the conditions which might prevail in any given institution. The report which I have here about two visits paid by these Commissioners to an institution has a very familiar ring and is in line with some of the observations I have already made.

The institution in question is not, incidentally, the same institution as that to which I referred a moment ago. The report says:

This is a large and important hospital group with 1,897 patients on the books…There is, of course, overcrowding"— The "of course" seeming to imply that this is the normal state of affairs so far as mental hospitals are concerned—

not only were the buildings ill-designed for the work, but they had been allowed to fall into disrepair…Flooring in many places needed attention; they are badly worn and besides collecting water are uneven enough in places to be a risk to those walking on them. Throughout the building there is a shortage of W.C. and wash-hand basin accommodation. This is probably made worse by overcrowding, but…it is not likely that this overcrowding will be diminished in the future. Then there is an observation to which I think the House should pay some attention, because it is implied in the report that it arises directly as a result of the overcrowded conditions The personal hygiene of patients is a primary essential…Since the last visit of the Board, the health of the patients cannot be said to be satisfactory. The hospital has suffered from quite extensive outbreaks of whooping cough, measles, mumps and chicken-pox. There have been 24 deaths from pneumonia, which were probably due to the measles. As my hon. Friend the Member for Bermondsey (Mr. Mellish) said in our last debate, we must really try to shock the public conscience on this issue. I do not believe that the people of this country would object to expenditure on any sort of project which they were satisfied constituted a national need. If this problem is put fairly to them, they will not say unkind things about the Government, the Minister or anyone else if a real attempt is made to bring about an improvement in the situation. So far as I am concerned, I do not mind in the least whether the credit for the improvement in our mental hospital service goes to the present Minister of Health or to

his successor so long as someone tries to improve it.

Therefore, the first point is that if we cannot get more money—which I really think we ought to be able to get—for this service, then we shall have to look at the present allocations to see whether they are being really wisely distributed among the different services, and whether we can justify an expenditure of 72 per cent. of these allocations on the general hospital services while the mental health service only receives an allocation of 28 per cent., bearing in mind that of the 33,000 beds in the South-West Region over 17,000 are occupied by mental patients. I cannot help feeling that there is some room for investigation and for adjustment.

My second point is the one to which my two hon. Friends and the hon. Member for Gosport and Fareham referred, the question of the staffing of these institutions. I have here a cutting which appeared in my local newspaper only two or three days ago. It is an appeal by the Chairman of the South-West Regional Board, particularly to young women in the area, but also to young men, to respond to the call for 750 student nurses, which represents the shortage of nursing staff in that region.

I have spoken from the pulpit on this subject and have tried to encourage those who feed that they may have a calling for this kind of work, and I hope to do so again very shortly. But I feel that a much wider appeal could be made. My hon. Friend the Member for St. Pancras, North suggested that there should be a poster and Press campaign—"advertising campaign" were the words he used. I believe that if the Press would realise its responsibilities to the people of this country and would bring this matter to the notice of the public without the advertising revenue that would normally accrue to the newspapers, that would be a very great contribution by them to this effort to get the staff for this national service.

This is what worries me. An urgent appeal for 750 more staff has been circulated to all the churches in the locality. If we secure that staff—and there has been a declaration made that we should certainly not turn down any application—then the regional board will be immediately confronted with the problem of where the money is to come from to pay them. I am informed that it would entail using another £225,000 from the existing allocation. I am sure that the House will realise that that just cannot be done. It is no use our making these appeals to our young men and young women to come forward and help in this service unless we are prepared to pay the bill which we shall have to face if they respond to that call.

I want to make a reference to the diet provisions. I had an awful shock a few weeks before Christmas when a friend of mine who serves on a Hospital Board—not the Bristol board but a local board—drew my attention to the fact that the board had received a circular stating that it had to reduce its diet costs by 1s. per patient per day or, if it exceeded the amount suggested, the difference between the amount which it was suggested should be allocated and the amount spent would have to be met out of its general income. That refers to a general hospital.

I cannot help thinking, when one makes a comparison between the daily diet costs of hospitals in the mental deficiency group and those of the main general hospitals, that there is room for some readjustment. I appreciate that people in general hospitals probably require more special diets—indeed, I know they do—and some of these diets may be costly; but I suppose that the average turnover of patients in a general hospital is roughly 14 days or just over. We all know that during some period of that time patients usually do not feel very much like eating any large amount of food.

During the Christmas Recess I went to a mental deficiency colony and I was absolutely staggered—staggered is the only word I can use—at the abnormality of the appetite of certain groups of mental patients. I understand that this is not unusual in certain types of patients. I saw one lad being given a piece of bread about an inch or an inch-and-a-half thick, and my wife said: "Surely you do not give such thick slices of bread to these youngsters?" The man in charge of the boys said, "Offer him a thin slice of bread, Madam, and he will refuse it: he does not want it. He wants this huge piece." These patients have enormous appetites but generally they are fed on what we call the "filler" foods; they do not get the same diets as are provided in general hospitals.

I should like to draw the attention of the Minister to two items out of a number of which I have details here, because I want to show that there may be—I say may be—some grounds for having a look at these costs. In a main general hospital, the diet cost per day for meat and bacon is l0d. per patient or approximately 6s. a week. That does not take into account special diets of poultry. When we remember that for some portion of the time these patients are probably taking no food whatever of a solid character, I think we are entitled to deduce that that represents something like 12s. worth of meat per week. I suggest that there are many housewives in this country today who would like to be able to spend even 6s. per head of their family per week upon meat and bacon.

In the general hospitals, eggs per patient number about four per week; in the mental deficiency hospitals the figure is about one-and-a-half eggs per patient per week. I could enumerate many other items of diet provisions, but I think that what I have said conclusively shows that there is room for reconsideration of the allowances made in this respect. I understand that the average weekly cost for diet per patient is 15s. 5d. in mental deficiency institutions, 17s. 2d. in mental hospitals and in all other types of hospital, £1 14s. 9d. per week.

I want to make one further reference to the South-West Region. This was stated in last night's evening newspaper in my own city of Bristol: £1 million cut is a severe blow… I understand that the correct figure is £900,000: Hospital board faces 'very difficult year.' The newspaper says: The Government's clamping down on Health Service spending has hit hard the South-West Regional Hospital Board who have been allocated nearly £1 million less in this financial year than they asked for. They are in a very difficult position. Several committees have sent deputations demanding more money than they have been allocated. They have had to be told, 'not a penny.' 'If every management committee takes this seriously, when we get to the revised estimate stage we will be able to hold our own,' said a Board spokesman, 'but if we are not able to, every regional board in the country will be in the same position, and Parliament will have to be told'. That reflects the anxiety of this regional hospital board and of its officials during the coming year.

The Minister of Health has returned to the Chamber and I am sure that the Parliamentary Secretary will be able to advise him that I have been in no way unkind to him. I wish him all the luck in the world. I believe that he can feel absolutely confident that he has the wholehearted backing of this House in anything he may do to try to alleviate the problems of mental health. I can say to him now that my hon. Friends on this side of the House take the view that, whatever his opinions may be about some aspects of the Health Service, we have always credited him with a very deep sympathy towards this particular branch of it.

If we can, by what we say here or even by what we say outside, encourage people to come into this service, and if we can in any way assist the Minister to bring about, as rapidly as he possibly can, improvements in this service, we shall be only too ready to co-operate with him.

1.10 p.m.

Mr. Basil Nield (City of Chester)

My right hon. Friend the Minister of Health must, I know, appreciate enormously the remarks of the hon. Member for Bristol, South (Mr. Wilkins) at the conclusion of his impressive and interesting speech. We are all anxious to help in this really difficult human problem. The hon. Member began by thanking his hon. Friend the Member for St. Pancras, North (Mr. K. Robinson) for initiating this discussion. I add my word of gratitude also, because I appreciate the importance of the problem of the needs of our mental hospitals.

Hon. Members, in all parts of the House, have not contented themselves simply with advancing criticisms, but have advanced constructive suggestions, all of which, I am certain, my right hon. Friend will very carefully consider. My particular interest in the problem arises from two reasons. First, there is in my constituency a large and, I think, very efficiently run mental hospital, the Deva Mental Hospital, with nearly 2,000 beds. The House will understand, therefore. that I have often to consider the problems of conditions in such hospitals, and questions of accommodation and conditions of service of the mental nursing profession, a profession for which we must all have an immense admiration and respect, such is the human value of its work.

The second reason for my special interest is that in other capacities I see something of mental instability as a factor in the incidence of crime. Those of us who are concerned with the administration of justice in the criminal courts—and many hon. Members are justices of the peace—frequently find ourselves confronted with the situation in which the offender, perhaps a young person, is certainly not insane, certainly not certifiable, but suffers from a sub-normal mental capacity and is plainly psychologically handicapped. When that situation presents itself, and particularly in the case of young people, the mind of the court turns very often to the question of dealing with the offender by means of a probation order.

I ask the House to recall that by Section 4 of the Criminal Justice Act, 1948, the court is empowered, if it is satisfied that the offender's mental state is such as to require, and to be susceptible to, treatment, to include in the probation order a requirement that he shall submit to treatment for his mental condition. The order may either require the offender to be a resident voluntary patient under the Mental Treatment Act, 1930, a resident patient in anon-mental hospital, or an out-patient at a clinic. What I am anxious to remind hon. Members is that before the court can adopt this course, which may do so much good to the patient, it must be satisfied that adequate arrangements are available to receive the offender, if he is to be a resident, or to provide him with out-patient treatment, if that is the term of the order.

Thus it will be seen that if the usefulness of these provisions—and, I suppose, one of the most grave modern problems is that of the young offender—such as Parliament intended is to be fully implemented, there must be adequate facilities, accommodation and treatment for these young offenders, who may benefit so much and who at the end, as a result of treatment, may become perfectly decent citizens.

The latest statistics which I have been able to discover come from a Ministry of Health report, published in September last year, and relate to 1951. In that year, according to the figures, magistrates made probation orders involving residence in a mental hospital in 319 cases, and the higher courts in another 85 cases. The magistrates made what I call the "out-patient" order in 456 cases, and the higher courts in an additional 57 cases. This means that the provisions of Section 4 of the Criminal Justice Act were made use of in about 1,000 cases. I ask my right hon. Friend whether the accommodation and treatment is regarded as adequate to meet the number of cases with which the courts would wish to deal. We all know of the difficulties, and this is I suggest a not unimportant aspect of the problem.

During the debate there have been earnest appeals from all sides of the House for improved accommodation and for the best possible conditions for the profession of mental nursing. I conclude by adding my voice also, and expressing the firm conviction that the Government will do their very best in this field of human endeavour.

1.18 p.m.

Mr. Victor Yates (Birmingham, Lady-wood)

The hon. and learned Member for the City of Chester (Mr. Nield) has undoubtedly drawn our attention to the serious situation that magistrates have to face when dealing with these difficult cases. The debate has been extremely interesting, because it has been so constructive, and I should hope in no way to change the atmosphere in which the debate has been launched.

I should like to deal with two aspects of the problem as it affects both children and aged persons. I shall make some suggestions in the hope that we can, perhaps, relieve the difficulty of the present situation if the Minister thinks that these suggestions can be accepted. I have not the slightest doubt that the Minister, if he could have a small proportion of the money which at present is being allocated to research in other directions as indicated in a White Paper published yesterday, would be able to introduce some changes and improvements.

I am concerned about the situation as it affects children. During the period of the last Parliament I had numbers of cases brought to my attention of the distress in which parents were obviously placed because their mentally defective children could not be admitted to an institution. So I decided to visit our institution at Coleshill, and I satisfied myself that the authorities were doing everything they possibly could. I am certain that if hon. Members visited some of these places they would find that things were being done as efficiently as possible.

I have great admiration for the officers and nurses, who are heroic. When I saw what was being done in Coleshill about the care of children, I could not help feeling that, if the general public knew precisely the problem that had to be faced, there would be a larger measure of public co-operation.

I understand from the Ministry of Health that in Birmingham today the waiting list for institutional accommodation under the Mental Deficiency Act is 153, and that of this number actually 116 are under 16 years of age. At the same time, there are 50 children who are regarded as being most urgently in need of institutional care. In some cases there are children amongst these numbers who have been on the waiting list for seven years, since 1946, and yet in the last year 1953 only 11 children under the age of 11 could be admitted and 12 between the ages of 12 and 15, making a total of 23. They could not possibly admit any more.

This creates an enormous problem for parents. Their anxiety is terrific, and yet it is difficult to know what can be done. As has already been pointed out, it creates most serious problems in the home, if many years must elapse before the children can be taken away from their parents. I realise that accommodation is, in fact, a fundamental problem. We must also face the fact that mentally defective persons are living longer because of the introduction of anti-biotics and other drugs.

I would ask the Minister to consider this aspect. Is it not possible for a quicker turnover of the higher grade type of mentally defective cases so that some of them can be released sooner and take their place in the community? I agree that this poses a great problem. Two weeks ago my attention was drawn by one of my own constituents to the fact that he had two grown up children in a mentally defective institution in Birmingham. His son was aged 40 and his daughter 38. The daughter has absconded, and has been missing for 10 weeks. I have not the slightest doubt that the authorities, in co-operation with the police, have done everything possible to try to find where this girl is.

This girl absconded with another. I suppose it is true to say that they are anxious to demonstrate that they can live amongst the community. It is extraordinary that an epileptic can be absent from an institution for 10 weeks without being found. That would help to justify the claim put forward for some of these people that they can live outside. Of course, it remains to be seen in what state these girls are when they are discovered.

I do not mention that particular case as a reflection upon the authorities. These places are understaffed and they cannot do any more than they are doing. But would it not be possible for some kind of hostel accommodation to be provided for these higher grade mental defectives? We have to realise that we cannot provide adequate accommodation for them at the present time, and probably it will be a long time before we can do so. We should bear in mind in connection with this problem of the higher grade defectives that in many cases they are sent to these institutions because they have no homes, or have bad homes, or perhaps because they have shown delinquent propensities.

I was a member for about six years of a committee dealing with mentally defective children in schools, and I served for a short period on the Mental Deficiency Act committee. I was always impressed by the fact that many of these children were basically dull, due to a large extent to their environment and background. They needed training which they could not get at home, and obviously if they had no home training could only be secured by placing them in an institution.

I have always felt that it was wrong that persons should be sent as mental defectives because they are basically dull, because their home life is bad, which has contributed towards their social failures. I feel sure it would be a good thing if local authorities could have permission to build a few hostels to accommodate these higher grade defectives. I under- stand that the Ministry of Health does not seem inclined to grant these powers, although they are possessed by the London County Council.

The second aspect is that of the aged people. A few years ago I brought one or two questions to the notice of the then Minister of Health about the large number of aged persons who had been placed in mental hospitals in Birmingham. Although there was a good deal of excitement about this at that time, I have no reason to doubt that there is an increasing tendency to place aged and senile persons in mental hospitals where they occupy beds which might be better serving the need of those requiring mental hospital treatment.

The situation in the Midland region is very serious. So far as the Midland Regional Hospital Board is concerned, at the end of December 608 patients were awaiting admission, and of those 305 were urgent cases. Only two weeks ago I mentioned the overcrowding of Winson Green Prison. Adjoining that prison is the Winson Green Mental Hospital. The authorities are doing their best, but in the admission ward at present they are having to put patients on overlays on the floor and they cannot possibly take in any more.

The large number of aged persons who are being placed in these institutions is one of the greatest tragedies of the post-war era. I know that doctors feel this practice to be undesirable. The expert specialist, the late Dr. Josiah Old field, once wrote a letter to me in which he explained how easy it was for a doctor to certify an aged person because things happen which make that course justifiable.

Can we not do something to prevent this tragedy of so many aged persons being put into mental hospitals? I suggest to the Minister that the domiciliary services might be increased. The Minister would be performing a great public service if he could initiate working parties, through local authorities, for the purpose of giving advice and assistance to aged persons; in other words they should be given treatment which would prevent them from being transferred to mental hospitals. I am sure that many young people who are interested would be willing to bring help to their aged friends by joining such a team. Therefore, could not the Minister try to evolve some such system which would overcome much of the misery of illness and old age?

I have been in all the mental hospitals in Birmingham and I am troubled about the fact that so many aged persons find their way there. I am not casting any reflection upon magistrates because this is a difficult problem, but we should find a half-way house for these people instead of sending them to large institutions. In Birmingham there are some interesting and valuable small homes for aged persons, and if there could be more of these places the result would be a saving in hospital beds. I realise that it is no use saying that we must build more because, although I believe we spend far too much money in destruction and not sufficient on construction, we must be realistic about our budget which both sides of the House accept. So while I feel that we should allocate a greater proportion of our resources to the mental health service, I think we should pay more attention to saving beds in the mental deficiency institutions by providing hostels and by making better provision for accommodation for aged persons, and so enable them to spend the eventide of their lives in comfort and without being placed in large institutions.

I offer those few suggestions to the Minister in the hope that the right hon. Gentleman will give them serious -consideration.

1.38 p.m.

Mr. Henry Channon (Southend, West)

The hon. Member for St. Pancras, North (Mr. K. Robinson) said he hoped that we would have a broad debate. I think we have done so, but he and successive speakers, with the exception of the hon. Member for Ladywood (Mr. Yates) concentrated, no doubt rightly, on mental defectives, conditions in their homes, certified people and voluntary patients. Like the hon. Member for Ladywood, I wish to draw attention to a class of persons who do not fall into this category but who are, nevertheless, a serious and pathetic problem in our community. They suffer from the lack of hospital accommodation and perhaps more from the shortage of nurses.

There is no one in this House who at some time or another has not come across an old person, most frequently female, never criminal, never dangerous, but whose eccentricity grows and who gradually declines almost into a state of helplessness caused either by some unfortunate accident of ill health, poverty, bad luck, disappointment or loneliness. These persons are only insane on certain subjects and they are subject to hallucinations of a mild nature as well as to delusions. For instance, sometimes they get fixed ideas or grievances against certain people

If these people are brought up in and live in happy homes, with many children and kind relations, one does not hear much about them. They are called a "bit peculiar" by the neighbours and they are looked after. If they come from well-do homes there is usually somebody to look after them, sometimes as a part-time attendant. I know many of these people. I do not know whether these harmless but pathetic people are more prevalent in seaside towns than elsewhere. Quite a number of these people are not cared for at all. They are eccentric, helpless and unhappy and there is almost nothing that we can do about it.

There is one woman whom I should like to help but she is convinced that the local authorities and especially the police are persecuting her and one cannot help someone like that until she is certified. Another woman haunted the early years of my Parliamentary career by coming to see me every month. She was perfectly sane and rather charming but she thought that she had known "better days." Many people have that obsession. She was perfectly convinced that she was the widow of a late, unmarried Archbishop of Canterbury. Nothing would convince her that that was not true. She has since died. These people are a problem to local authorities and Members of Parliament, and I hope that it will be possible to have an increasing amount of some form of domiciliary visiting.

Extraordinary events bring these cases into high relief. In the recent cold spells old people were quite unable to cope with things. A case was brought to my notice in my division—my hon. Friend the Member for Billericay (Mr. Braine) is also familiar with it—of two people with whom we did not know what to do. There was no room in the local hospitals, the obvious place to send them for the duration of the cold spell or until they were better. Nothing could be done for them. They had no relations, they had no coal at home, and they had nobody to help them.

They were both certified. That, I think, is a scandal. If it happens in Billericay or Southend it must happen elsewhere. They will be released, because they are in no way dangerous to the community. They are just a little helpless, old, lonely and eccentric. Obviously they will be let out in time, but for the rest of their days they will bear that stigma of temporary incarceration in a lunatic asylum.

I hope that the Minister will provide a scheme to help these people on a larger scale. Some of them are very proud and they are not easy to deal with. That seems to me to be all the more reason for giving them all the help that we can to make their old age as happy as possible.

1.43 p.m.

Mr. Somerville Hastings (Barking)

Whatever we may think of the National Health Service, it has one great advantage, in that it enables medical problems to be looked at as a whole. We have learned that in connection with tuberculosis; I think that the improved results of treatment which have taken place recently have occurred not only because of better means of treatment, but because of the unification of the services which are provided. It is because of that possibility that I have great hopes for the future of the treatment and prevention of many forms of mental disease.

Our outlook on mental affliction has undergone a profound change during the last 30 or 40 years. The separation between mental and physical diseases has become much less marked and people have realised that not only does the mind affect the body but that the body affects the mind as well. Several physicians with whom I have discussed the subject have told me that half the patients in their out-patient and in-patient departments have some psychological condition which is an important factor in the disease from which they are suffering. That being so, surely we may hope that in future the stigma of mental disease, which I am afraid still exists, will be lessened or got rid of entirely. The next point that has been made very clear during the course of this debate is that the diagnosis and treatment of mental disease has become much easier during the last 30 or 40 years. I do not want to reiterate the examples which have been given of electro-encelograph and electric-shock treatments and many others. But I am afraid that these improvements in treatment and diagnosis, and therefore in the interest of the nursing and medical treatment of mental disease, are not really understood by people. Do potential nurses realise that if they go in for mental health nursing they will have an exceedingly interesting life? Do doctors realise that this is not just the back-water that it used to be 30 or 40 years ago, but that there are great possibilities for doing real good in the mental health service today?

But the chief point to which I want to call the attention of the House in connection with our new outlook is that mental disease can be and must be treated much earlier that we ever realised 30 or 40 years ago. When the Mental Treatment Act of 1930 was under discussion in this House and we were debating it on Second Reading, I was fortunate, as I have been today, to be called to speak. If I remember aright, I was also put on the Standing Committee which dealt with the Bill upstairs. Did any of us who spoke on that occasion realise that in a quarter of a century 80 per cent. of the admissions to the ordinary mental hospitals—I am not including mental deficiency institutions—would be temporary or voluntary patients under that Act? I do not think that we did.

We must do more in the future to deal with mental disease at its earliest stages if we are going to do good. We should do much more for mental out-patients. I want to see them at ordinary general hospitals and at health centres, where those are developed. I want patients to be made welcome there and made to feel at home, and I want to see them treated there at times when ordinary people can go without too much interference with the affairs of their daily lives.

I am attached to one hospital where we receive such mental out-patients and where we are adopting practices which were not thought of a few years ago. We are giving electrical shock treatment to out-patients and therefore saving beds; and getting cases early and having them put right.

Much more should be also done in the way of after-care. Day hospitals have already been mentioned in this debate. Patients at day hospitals can sleep at home, but during the day all their activities are supervised and they are kept interested and busy. By means of half-way houses, convalescent homes and in many other ways patients can be followed up after they leave mental hospitals and looked after so that their cure may be made more permanent.

Although our ideas of mental disease have changed very much, unfortunately the machinery by which we put those ideas into practice—the mental hospitals—have not changed. I am not blaming anyone for that, but only stating the fact that those barrack-like buildings—built 100 years or more ago, tucked away in the country so that they can be more easily forgotten—do not make for modern treatment. Within the last month or two I have had occasion to visit two mental hospitals and have seen the annexes provided for early treatment. One was the Three Counties Hospital, which has been mentioned already today. Th building for early treatment was only completed just before the war. There is a happy atmosphere, it is a completely homely building, light and airy, and it is easy to understand that under those conditions patients get well. On the other hand, I have been to many of those old mental hospitals such as have been described today. I was on the committee of management of one of them for a considerable time. My wonder is that any patient who enters one ever gets well and that any nurse who enters them ever stays for more than a day.

That brings me to the question of nursing, which is such a difficulty. I have two suggestions to make to the Minister about this. I do not think we want to insist that every nurse who works in a mental hospital should be doubly qualified. I agree that the nurses who attend in the sick wards and work in the operating theatre must, of course, be doubly qualified, but, if the ordinary mental nurse has a basic training in general nursing and then goes on to psychological study, that seems enough. At any rate, that is my view of the situation.

The second point I want to stress is that if a mental nurse is to keep her sanity and also to retain that milk of human kindness which is so essential in this difficult task, she has to get away from the mental hospital. I know that there are many interests in the mental hospital. I know that much is provided for the amusement of the patients, dances, cinemas, television, wireless and so on. But it should be easy for the mental nurse to live out, away from her job, so that she may develop other interests. I know the difficulty of the situation. Many of these mental hospitals are a long way from towns. Cannot hostels be provided in those towns and transport for the nurses? Cannot the nurses be encouraged to get lodgings in a nearby town and transport be arranged to take them backwards and forwards each day? If we can make not only the salary but the amenities of mental nursing more attractive, we shall not only get more nurses but more nurses of the right type.

I wish to deal with the question of the elderly mental patient. About a quarter of the patients in many mental hospitals—I am not referring to mental deficiency institutions—are over 65. As has already been suggested, a great many get there because, in the circumstances, it is thought to be kindest to certify them. Their home conditions are not suitable for them to live alone; there is no one to look after them and they may have some physical defect which also needs treatment. Somehow or other they get into the mental hospitals, but I am not sure that all of them ought to be there. Some of them are merely confused, and it is a disgrace that they should be certified. When the London County Council was a hospital authority it had a hospital at Tooting Bee where such people were taken without certification and their physical as well as their mental condition was treated with success. Some, of course, came out, but I am afraid there were not many.

The other category is those who are much more difficult to deal with because they are suffering from something more than confusion. They are mentally afflicted. Those, I am afraid, must go to a mental hospital. I think they should be in special annexes or wards where their physical as well as their mental condition can be dealt with easily, because not infrequently old people have some physical condition as well as mental condition which needs treatment.

I appeal to the Minister to see what can be done for these old people without certification. Would it be possible to change the legislation so that people of over 70 could be admitted to mental hospitals and treated as "temporary" patients without being certified? I know that they do not conform to all the requirements of the Mental Treatment Act. They will not be expected to recover and will not be incapable of saying whether they want to come in or not, but could not the law be changed so that people over 70 could entermental hospitals without certification and be treated under the Act as "temporary" patients?

I have another suggestion to make with reference to mentally deficient children. I have been impressed with what can be done for high grade mental defectives if they are taken early and given concerted, continuous treatment in an institution. I do not know the percentage of those who develop into normal citizens, but even if the percentage is relatively small, we shall have done a great thing by engaging in this task. The trouble is that these high grade mental defectives are hidden by the family until they become such a nuisance that the aid of the local authority has to be sought. If only we could get these cases early, if only we could realise where they are and persuade parents to let them go—perhaps for a time—to see how they develop in a proper type of institution, I am sure that a great deal could be done. Whether it would be necessary to change the law so that early mental disease could be made certifiable in children, I am not certain. We must get hold of cases of mental deficiency, or perhaps I should say social insufficiency, as it is now called, at an early stage and give them a test of treatment to see what can be done. We should not give up the struggle until we are sure that they cannot be returned to the community as useful citizens.

These are some suggestions which have occurred to me as I have thought about this problem. I welcome this debate and shall listen with interest to what the Parliamentary Secretary has to say in reply.

2.1 p.m.

Mr. Charles Doughty (Surrey, East)

I regret that I was not in the Chamber when the earlier speeches were made in this very important debate. In Surrey we have a number of mental deficiency hospitals and a number of smaller homes dealing with the same type of patient. It is right that the overcrowding and the conditions in those hospitals should be the subject of debate in this House.

Having visited many of these institutions, I believe that one of the causes of the overcrowding today is the modern treatment which is applied, and the drugs used, which have resulted in a longer expectation of life. To take one example, pneumonia no longer reduces so drastically the number of patients in a hospital, because of modern treatment. There are, therefore, a far larger number of patients left to be looked after.

We have inherited some awkward hospital buildings from a less enlightened age. Not only was that age less enlightened, but the architects and builders of those days had not the same ideas as we have today. They did not consider that if buildings, whatever their nature, are to be heated they must be reasonably close together so that there are not miles of piping, with consequent loss of heat. Also, if it is necessary to carry food to wards upon a third floor a lift is a great asset, though we cannot blame the architects of those days for the absence of lifts, because then they were practically unknown.

Many of these buildings are too good to pull down and replace, particularly in view of the limited resources available. The only thing to do is to make them as congenial as possible, which can be done at a comparatively small cost, sometimes no more than £1,000. In one of these institutions in my constituency it is possible to compare an old ward which has not been changed and another ward which, at a cost of £1,000, has been made to look entirely different. In the old ward there are still brick inside walls. There are holes in the floor. The beds are hard, and quite unsuitable for any kind of patient, and the atmosphere is depressing. At a cost of £1,000 all that could be changed.

When one remembers that patients in these wards will have to spend practically the whole of their lives in the same room, one is justified in saying that expenditure of that kind,, which is not very great, is fully warranted, so that we may make more pleasant the lives of the patients and of those who have constantly to look after them. It is the fact that were we to contemplate doing everything required in every one of our mental hospitals the cost to the National Health Service would be such that it could not be justified in any one year.

There is one matter, however, to which I wish to draw the attention of the Minister, and about which I have written to him in a particular case. There are charitable bodies, and possibly charitable persons as well, who are prepared to give money out of their funds to assist in providing amenities in these hospitals. In the case about which I wrote to the Minister, a well-known charitable fund offered £5,000 to build a recreational hut in the grounds of a mental hospital. But that was not allowed unless the amount was deducted from the next year's grant to that hospital.

Under those conditions, charitable bodies and persons are, therefore, not giving their money to a hospital, but to the whole Service. There can be no more direct way of discouraging persons from taking an active financial interest in the amenities and welfare of a hospital than to say, "If you give this money we shall in fact take it and not let the hospital have it." I hope that matter will be investigated and a change made. I do not blame the Minister, because it may well be that he inherited the system under which that procedure is followed. But it is time a change was made, and I hope that it will be made, and that thereby these charitable institutions—some of which are very rich—may be encouraged to take a greater interest in the mental hospitals of this country.

The staffing of such hospitals depends largely upon two things. First, it depends upon the senior staff in a hospital. Anybody in any profession who is anxious to learn naturally goes where he believes he will get the best instruction, where he will find those who know their job and are best able to teach it. Students will go to a hospital where there are capable and well-known doctors on the staff, and where decent quarters are provided for them.

I am happy to say that in Surrey we have both these qualifications. Also, we do not suffer from the problem, referred to by the hon. Member for Barking (Mr. Hastings), confronting those hospitals in remote and lonely country places. I do not say that we have no problems in Surrey, but we are not faced with that one.

Mental deficiency hospitals are somewhat depressing places, particularly where there are low grade mental defectives. There is always the knowledge that whereas in a general hospital a patient who is extremely ill may recover in a short time, the possibility of a low grade mental defective making a recovery is extremely remote. They may come into the hospital very young and spend 60 or 70 years there without the slightest hope of being able to leave. Indeed, were they to leave it would be to their own disadvantage, because they are incapable of looking after themselves.

It is gratifying to see that in such institutions the low grade mental defectives are being put to work which is of use to themselves. Some are able to go out to work for suitable employers, and very often to live out. Others are capable of doing useful work in the laundries and bakeries and in other places in the hospital, which is far better for them than if they were locked up in wards. The fact that mental defectives are not lumped together but put into grades reveals how much more enlightened is the present-day policy. They are now treated as individuals and given that amount of attention, liberty and restraint which their individual cases require. For that state of affairs we must be grateful to those experienced and capable people who make a life-long study of this work.

When the Minister considers the mental hospitals, I ask him to look at what has been done to those parts of hospitals where it has been possible to spend money. He should see what an excellent return we have had and consider whether a little more money could not be found to bring the other more antiquated parts of the system up to the condition of those parts which have been improved. We should continue to look after the interests of the staff and provide them with good quarters. Then, with the modern knowledge at our disposal, I am certain that mental defectives who require our interest and care will be able to live out their lives in a better way than before.

2.10 p.m.

Mr. A. J. Champion) (Derbyshire, South-East

I feel, with others who have participated in the debate, that I must praise my hon. Friend the Member for St. Pancras, North (Mr. K. Robinson) for the quiet but most impressive speech he made. It seemed to me to be a model of its kind, lacking the extravagancies which are part of the stock in trade of the politicians. It was even the more impressive for that.

I pretend to no specialised knowledge of this subject, but I encounter this problem continuously in my constituency. There is a serious shortage of institutional accommodation for mental defectives under the age of 16. I do not know what is the experience of other hon. Members, but my heart sinks when someone comes to me and I realise, from the first few words, that they have a child for whom they want to secure a place in an institution. It is distressing to realise that if, as a result of some little intervention, one is able to help a child to find a place, one might be causing someone who requires it even more to be excluded because of the general shortage of accommodation.

Recently I had a case brought to my attention of a boy aged 10 who has become increasingly destructive and vicious. He has been on an "urgent" listsince 1950. His mother is a struggling, decent woman, as decent as one could possibly find, and she had to put off an operation for month after month because she felt that she could not leave the child. Eventually her medical condition made it imperative that she should have the operation. The child was taken for a short stay into an institution which, I believe, is called a "short-term stay home."

No sooner was the woman out of hospital than the board, because of its shortage, had to press her to take the child back into her care. That was long before she was really fit to do her ordinary duties, never mind undertaking the care of a child whose state had become such that he was practically unmanageable. That child happens to come from a good, clean home. A little pressure on the board caused them to permit him to stay in the institution for a little longer, but I was assured that it could only be done at the expense of some other child whose harassed parents badly needed a rest.

What is the position? I can judge only of my local knowledge. The position in Derbyshire is that 126 patients are urgently waiting admission; 76 of these are children under the age of 16. During 1952 only 26 were admitted to institutions, and of these seven were under 16 years of age. Over and above these 76 children urgently awaiting admission, a further 70 patients are awaiting admission but their case does not happen to be urgent at the moment. We know that what is today not an urgent case can become an urgent case by tomorrow if something happens to the parents. It can become urgent if something happens which causes the parents not to be in a position to be able to look after the child.

These cases are indeed tragic. The Minister, in answer to a Question of mine, told me that he hopes to provide a further 60 places in the next two years. The difficulty is that after the first 60 patients are taken off the list the number that can be taken thereafter are but a drop in the ocean. I am tremendously impressed not only with the shortage of places and the necessity for increasing the number, but by the work of the occupational centres. If we could get a large extension of these, we should be doing something toward meeting the major problem of those under 16. The medical officer of health for Derbyshire has said about these centres: The children are away from their homes from about 9 a.m. to 4 p.m., thus relieving parents of the supervision during the daytime, and in a number of instances patients are manageable at home who might not be so if they were not attending the centre. We might be able to extend the number of these centres without having first to get the additional nurses, and so on, that we need for the other institutions. Another type of teacher, perhaps with different qualifications, could be used.

The second point Iurge upon the Minister is that he should do as much as possible to increase the number of short-term stay places. They provide a welcome relief for parents who are enabled to have a short period free from worry and anxiety. This helps them to face once again the tremendous problem which is theirs when the child comes home.

The third point is that we really must devote something more from our national resources to the great task of increasing the number of institutions to deal with this great problem of so many parents—that of mentally deficient children.

2.19 p.m.

Mr. Bernard Braine (Billericay)

This has been a fascinating debate. It has been one of the most interesting that I have ever had the pleasure of listening to in this House. We are deeply indebted to the hon. Member for St. Pancras, North (Mr. K. Robinson) for having taken advantage of his good luck in the Ballot to introduce this subject, and for doing it in the way that he did. If what he has done today helps to awaken the nation to a realisation that mental illness is susceptible to medical treatment, that the afflicted can be cured in many cases, and if it helps to induce a new attitude of mind on the part of the general public towards this great social scourge, then he has indeed done a great service.

I approach the subject with much humility, because I am not a psychiatrist and have no medical background at all. I was not even aware that it was possible to use neuro-surgery to relieve those of unsound mind until, having become a Member of Parliament I found myself coming into contact with the problem in my own constituency.

Frankly, where mental illness or mental deficiency is concerned, the public have hitherto preferred not to think about it but to thrust it into the background as though it was something rather shameful, certainly something which they could not understand and which they would prefer not to be bothered with. We must get out of that state of mind, and if the debate can help to change that attitude of mind it will perform a very useful service indeed.

I am very proud to have on the borders of my constituency Runwell Hospital which has led the country for a long time in the application of new surgical techniques and new pharmacological methods of treatment. In short, as so many hon. Members have already said, what were once lunatic asylums, dark forbidding places into which people went with no hope of ever coming out, have today become hospitals, places of light, where sick minds can be treated in the same way as sick bodies are treated in general hospitals, where darkness can be dispelled and hope engendered.

The most striking fact which had emerged from some of the speeches that we have heard is the very large number of voluntary admissions which are made to mental hospitals today. The figure has been put at about 80 per cent. I did not know it was as high as that, but it certainly is very high indeed. That has obviously given rise to all the difficulties about which we have heard today, in relation to accommodation, staffing, out patient facilities and so on.

With regard to staffing, it is obvious that if more people are to be attracted into the field of mental nursing we must pay more attention to the incentives. I know that people say, rightly, that nursing is a vocation and that it is not the pay but the inner satisfaction given by the job which matters. That is true of a large number of people who enter the nursing profession, but it is not true of all of them, which is shown by the high wastage which takes place.

In addition to that, anyone who has visited not only mental hospitals but also mental defective institutions will appreciate that the demands made upon the mental nurse in the way of patience, affection, kindliness and tolerance—the physical demands upon the strength of the individual—are very much greater than the demands made upon those engaged in general nursing.

Recruitment into our mental hospitals is not helped by the lack of differentials. An hon. Member opposite said he thought there was not a sufficiently large differential between those engaged in mental nursing and those in general nursing. I believe that the differentials operating within the mental nursing field itself are insufficient.

Let us take, for example, the charge nurse, who is, I suppose, equivalent to a sister in an ordinary general hospital. He may have 20 years' experience behind him. He has probably devoted his life to mental nursing. He would not have stuck it for 20 years unless he had been a good type of chap. He is certificated and trained. He is probably in charge of a closed ward with 40 or 45 difficult patients. He has always to watch them; he can never let his attention relax for a moment, for he never knows when a patient in a closed ward will become violent or get into difficulties. His maximum gross salary is £10 18s. 8d. per week.

Let us now take the case of a ward orderly working in the same ward. He can be a young man or, as is so often the case because of the shortage of staff, an old man. He may be an Englishman, but more likely than not he will be a displaced person. He starts at £6 16s., whether he is 16 or 60 years of age. He gets various overtime rates, and at the end of the week can take away in his wage packet £9 15s. I am not grumbling about that, for there is a shortage of orderlies, but, when one considers the responsibilities which are borne by the charge nurse, where is the incentive for a young ward orderly to train to become a charge nurse?

To go a little further, let us take the case of a resident third-year student nurse, who is unmarried, and is working an additional shift on one of his rest days. I will not trouble the House with details, but his total payment is £4 10s. 7d. after deduction for board and lodging. But a resident ward orderly receives £8 0s. l0d. per week after deduction for board and lodging. Of course, he starts at £6 12s., plus 4s. for having to deal with mental patients.

Young men often do not think in terms of the long run. In terms of the short run, it pays a young man to take the job of orderly rather than to enrol as a student nurse and spend years preparing to collect a wage of about £10 as a charge nurse. This is a matter which should be looked into.

Sir F. Messer

The hon. Member has not referred to the fact that there are proficiency allowances.

Mr. Braine

That is true, but I said I would not go into the matter in detail. Nevertheless, we ought not to underestimate the very considerable feeling that exists among skilled nursing staffs on this subject. The whole matter needs to be looked into. It has repeatedly been said in the debate that the problem is a matter not so much of accommodation but of attracting into the mental hospital service the right type of young men and women. It is people we want.

There is also another problem which is thrusting itself increasingly upon our generation, that of elderly people who are not only weak in body but also weak in mind. It is a problem which grows as the span of life lengthens. Ideally, such people should be in some sort of institutional care.

It would be wrong if the impression went out from the debate that elderly people have been certified and sent into mental homes wrongly. As I understand it, senile dementia is a state of unsound mind, and people who are certified as suffering from senile dementia are being certified correctly. It would be wrong for anyone to give the impression that the duly authorised officers who perform a magnificent and devoted job of work, the magistrates who are called upon to sign the certificates, and the doctors, are doing something which they ought not to be doing. That would be utterly wrong, but very often the mental weakness of such old people is accentuated by their physical weakness. They are very often quite harmless people, and all they want is care and attention. I think that there really is no need for such people to be certified at all. But we find that the Part III hospitals are choked up with chronic sick, and that they are not willing to take these people. Every hon. Member in this House knows that in every constituency there are long waiting lists of normal old folk who ought to be receiving care in institutions, but who cannot get into them, and one can scarcely blame the Part III hospitals for declining to take people suffering from senile dementia.

The choice before the doctors is either to use the machinery of the Lunacy Acts or to leave the patients where they are, and I think the point put to me by one medical officer of health is very important. A magistrate had written to me asking whether it would not be possible for half-way houses to be set up by means of an extension of Section 47 of the National Assistance Act, 1948, and I thought that was a most interesting suggestion. I, therefore, wrote to one particular medical officer of health. He agreed, and this is what he said At the moment, I am compelled to choose between using the machinery of the Lunacy Acts in dealing with old people or leaving them in circumstances which are rightly reprobated by the public who know the facts. This is a grave responsibility, but one which is accepted because I sometimes feel it is better to leave old people where they are than to bring them within the purview of the Lunacy Acts. That is a pretty serious state of affairs, and it is perturbing magistrates up and down the country. Whatever view we may take of it, there is a dire need for accommodation to which old people suffering from mental deterioration could be sent after treatment in mental hospitals—people who are sufficiently stabilised not to require full hospital facilities and nursing.

I should have thought that the provision of such accommodation might, and indeed, ought, to be the duty of the local authorities under Part III of the National Assistance Act. I know that, perhaps, one is trespassing here on the grounds of the Royal Commission which is to inquire into the matter, but we ourselves ought to start thinking about this aspect of the matter now, because this nation must be shocked into a realisation of the problems of old age, the dreadful loneliness of some of these people, and the mental and physical decay which large numbers of them have to face simply because the facilities for their proper care and attention are not there.

Rightly, the Minister has given attention to the problem of mental deficiency. I have had it borne in upon me more than once that here is the saddest and most tragic of the social problems facing our country. I remember, about two years ago, visiting a particular house, in which a family consisting of mother, father and four children were living, to all intents and purposes, perfectly normal happy lives, like their neighbours. Yet for 11 years they had carried the burden of a mentally defective child—a girl. I was shown the child lying in an iron cot, caged, confined like a wild animal. The parents had never had a holiday in the 11 years; they had never dared to go.

The other children were perfectly normal, healthy and happy.

Consider the strain upon the minds of the parents, which they had borne with Christian-like fortitude all through those 11 years. The child had been on a waiting list for admission to an institution for years, and that sort of thing is happening all over the country. If the Minister can do anything to alleviate that kind of suffering, he will have the blessing of the whole House.

I pay my tribute to the present Minister for the way in which he has concentrated on this particular aspect of the problem, and I wish to say "Thank you," on behalf of us all, for the efforts which he has made so far.

2.37 p.m.

Dr. A. D. D. Broughton (Batley and Morley)

I think it has been made clear in all the speeches to which we have listened that my hon. Friend the Member for St. Pancras, North (Mr. K. Robinson) has raised in this debate a subject of considerable national importance. Undoubtedly, there is a high incidence of mental illness in the country. We have been told about overcrowded mental hospitals, it has been suggested that there is a shortage of beds in these hospitals, and there seems to be no doubt that there is a shortage of staff.

I think it is true to say that the care of the mentally ill has been, and I suggest still is, to some extent, the Cinderella of the health services of this country. It is not really so very long ago that people who suffered from mental illness were described as lunatics, were said to be possessed of the devil, were removed to institutions called lunatic asylums and there given treatment which was literally brutal torture.

It was at The Retreat, a Quaker institution at York, that the humane treatment for the mentally ill was started—a form of treatment which has since been adopted by all mental hospitals throughout the civilised world. That was an enormous step forward in the treatment of mental diseases. Much more recently there have been other advances in the treatment of mental illness, and I think the hon. Member for Gosport and Fareham (Dr. Bennett) described both briefly and clearly the modern treatment of occupational therapy, the use of drugs and the performance of operations.

There is a long line of great names of people who have taken part in the advance of psychiatry, and amongst them I think we should bear in mind the name of Professor Sigmund Freud, that genius who unveiled some of the great mysteries of the mind, although the subject of mental illness is so very complex, and the incidence of the disease so widespread, that I claim we have really done no more than touch the fringe of the subject in our search for causes and cures. Although it is difficult to understand the subject in all its complexity, that is no reason at all for neglecting research into it. We should try to learn more about the causes of mental disorder—that is the most likely means of preventing the onset of the illness—and the devising of other forms of treatment. By preventing and rapidly curing the illness we shall reduce the number of cases. There is an urgent need for research in this field.

My hon. Friend the Member for St. Pancras, North gave us interesting figures about medical research which showed that 1 per cent. of expenditure on medical research is devoted to mental illness. We must immediately ask ourselves whether that is a reasonable figure. If the amount of mental illness in the country were 1 per cent. of the total illness the figure might be reasonable.

Only a few days ago I went as one of a deputation of Yorkshire Members of Parliament to call upon the Minister of Health because we were concerned about this problem under discussion in relation to the Leeds and Sheffield regions. We were very grateful to the right hon. Gentleman for listening so attentively to the case that we put before him and for the promise that he would give very careful consideration to all the points that we raised.

In reply to our representations the right hon. Gentleman informed us that 43 per cent. of the hospital beds were for mental cases and that those beds were all in mental hospitals. I think that the Minister will agree with me that a few cases of mental disorder are to be found in other types of hospital, and therefore it is not unreasonable to say that approximately 50 per cent. of the hospital beds in the country are occupied by mental cases. If that is true, then it is ridiculous that we should be spending only 1 per cent. of our expenditure on medical research into that type of disorder.

I therefore join with my hon. Friend in putting forward a plea to the Minister for the encouragement of more research into mental illness. I would not suggest for a moment that any less money should be spent on research into other types of illness, but I ask the Parliamentary Secretary to give us an assurance that she and her right hon. Friend and her colleagues in the Government will look into this matter more closely to see whether it is possible to devote considerably more money to the purpose of finding out more about the causes and cure of mental disorder.

2.45 p.m.

Mr. J. K. Vaughan-Morgan (Reigate)

I speak with some diffidence in this debate as I am one of the minority who claim no expert knowledge of this subject. I represent what the hon. Member for St. Pancras, North (Mr. K. Robinson) in his brilliant speech referred to as "the ignorant public."

Quite recently I had the experience of visiting a mental hospital which lies just within my constituency. I was appalled, and the gravity of this problem was brought home to me by certain statistics which have not been quoted in this debate. They are that one in 16 of the population of this country is at one time or another a patient in a mental hospital; and that one in 48 of the population dies in a mental hospital.

That this is a grave and urgent problem is fully realised by all of us, after this debate. Although, inevitably, one must strike a pessimistic note, as some hon. Members have done, one cannot help remembering that enormous improvements have been made, and therefore a note also of optimism and hope has crept in at intervals. It would be wrong if anything said today tended to exaggerate the gravity of this problem. What has been said should make us all ashamed of the ignorance that still exists.

I realise the gravity of the problem of accommodation to which hon. Members have drawn attention, but before that is too much stressed let me point to another side of the question. A report was published in 1953 by the expert committee on mental health of the World Health Organisation. It stated: The need to provide more psychiatric hospital beds is at present being over-emphasized in some countries of Western Europe and North America to the detriment of the provision of other services which would reduce the need for admission of patients into psychiatric hospitals or alternatively reduce the length of stay of those patients who must be admitted. This point is amplified further:

There is no doubt that in the past too much attention has been given to the mere provision of further psychiatric beds and too little to the development of a real community mental health service. That as the point to which the hon. Member for Barking (Mr. Hastings) rightly and wisely drew attention. I hope that the stress in this debate will be on prevention and not only on the accommodation question.

I said that I had paid a visit to a mental hospital. I must honestly say that it was a happy and refreshing experience. It was a hospital for the mentally sick and not for the mentally defective. It was run on the open system, that is to say, there was free ingress and free exit from the hospital. All bars, railings and walls were being torn down, and the patients were walking about freely. There was less discipline and restraint on those patients than we see in many general hospitals. I might almost say there was less discipline and less restraint than we find in party politics. At all events, I got the impression of a really happy and free community. I could not help being struck by the normality of the life of those who were being treated. Hardly any staff were in evidence. The patients were busy on various task. It was a happy and useful community.

I understand that, medically speaking, the real test of efficiency is the percentage of voluntary admissions. The figure of 80 per cent. has been referred to as a national average. I understood that it was lower than that, and if my hon. Friend could give us the correct figures I would be grateful. In this hospital, the voluntary admission rate is 90 per cent., and that, surely, is something of which to be very proud.

The reasons for the success of this hospital, other than the character and the qualifications of the medical staff, seem to be twofold. First, the hospital is very closely linked with the life of the local community and with out-patient clinic work in a general hospital. The result is that it is an integral part of the life of that community and is not, as so many mental hospitals apparently are, a place apart.

Much work has also been done at the hospital on clubs for former patients to help them to re-establish themselves in society and thereby to encourage those who themselves need to become voluntary patients. This and many other methods are employed which are all calculated to break down the barrier of ignorance and fear that exists.

The medical superintendent made arrangements for me to meet a dozen or 15 of the patients who were completely free to state their opinions about the hospital and to make suggestions for its improvement. The main ground for complaint was the disparity in the amount allowed for feeding the patients in a mental hospital as compared with that allowed in a general hospital. I think that the figure for a mental hospital is 14s. whereas that for a general hospital is 21s. It has to be borne in mind that the majority of patients in a mental hospital do a day's work on a farm or elsewhere like ordinary active workers. Some explanation of that disparity in the figures would be of interest.

Here are the main questions I wish to put to my hon. Friend. What is being done to raise the standard of the worst hospitals to that of the best? What is being done to raise the percentage of voluntary admissions, which in some cases is very low? In the Report of the Ministry of Health for 1951, it is stated: The Report of the visiting Commissioners of the Board of Control reflect that despite the many restrictions at present operating a satisfactory standard of care and treatment is generally being maintained, but, at the same time, a curious unevenness is noticeable. No reference was made to this point in last year's report.

It was struck by one quotation from the Report of the Royal Commission, on which the 1930 Act was based. It said: The keynote of the past has been detention; the keynote of the future should be prevention and treatment. After what we have heard today, the keynote of the future should be hope.

2.54 p.m.

Mr. Julian Snow (Lichfield and Tamworth)

I want to underline the whole question of day hospitals which has been touched upon by one or two hon. Members in this debate. Perhaps I may be permitted to refer the House to a debate on the Adjournment Motion in which I participated on 17th March, 1950, when this question of day hospitals was brought up, and when I said, in effect, that research was needed into this new type of hospital for treatment of a different character. In reply, my hon. Friend the Member for Neweastle-upon-Tyne, East (Mr. Blenkinsop), who was then Parliamentary Secretary to the Ministry of Health, said he thought, by and large, that this was a matter which ought to be left to hospital boards and local health authorities, although, of course, he was prepared at that time to say that the Ministry would keep an eye on the whole matter.

In the four years since that date, a day hospital has been in operation, and has, in fact, been copied in one or two other places in the country with most interesting and worth-while results. I should be less than fair if I did not mention the encouragement which has been given to the pioneers of this type of hospital by the North-West Regional Hospital Board, of which my hon. Friend the Member for St. Pancras, North (Mr. K. Robinson) is a distinguished member, and by the Central Middlesex Group Hospital Management Committee who, in fact, administer the pioneer day hospital in Hampstead which is known as the Social Psychotherapy Centre.

There is a very good reason why this type of hospital ought to be better known, and I wish to ask the Parliamentary Secretary whether she is satisfied that the principle of this type of hospital has been adequately considered by all regional hospital boards and regional hospital management committees. The pioneers in this country of this type of day hospital, the people who initiated the whole idea—I am referring to the Institute of Social Psychotherapy, of which I am a lay governor—were pretty disappointed at the Report of the Central Health Services Council for the year ended 31st December, 1951, in which it was stated that two day hospitals had been started—one in Canada and one in the United States—to examine which the Board of Control had sent out a representative.

It seems rather a pity that an idea which originated in this country should have been transferred to the United States and Canada and adopted there, and that we should then send out people to examine it. I mention that in passing because I do not think that sufficient credit has been given to the pioneers in this country. Indeed, if some of the things that one hears about medical treatment in the United States are true, I cannot see that we have any reason to have an inferiority complex.

If we consider the merits of this type of hospital in relation to typical in-patient treatment, it would appear that there are various reasons why certain patients should never be subject to in-patient treatment, but should be treated at day hospitals. For instance, consider the shock of admission to an ordinary mental hospital. Take, for instance, the tendency for a patient going into a mental hospital to become hospitalised and to remain a permanent burden on society. Take, for instance, the case where it is highly undesirable to remove a patient from his or her environment. Take, for instance, the difficulties which patients discharged from mental hospitals have in finding employment and adjusting themselves to a life outside, to say nothing of the stigma attaching, most unfortunately, to people who have been in-patients.

Lastly, there is little doubt that the cost of running these in-patients hospitals is considerably more than that of running day hospitals. Then there is the question of the day hospitals relative to outpatient treatment. Here there is ample evidence that out-patient treatment of the normal kind is not in many cases adequate. Large numbers of patients require intensive treatment, which it is impossible to give them because of lack of accommodation within mental hospitals, and yet which cannot be given in outpatient clinics.

On this subject of the comparative cost—to revert to my original point about in-patient treatment—it is interesting to note that the cost of treating a patient at the day hospital in Bristol is about one-third of the cost of that for in-patient treatment.

My hon. Friend the Member for St. Pancras, North, in commenting upon the very small amount of money available for research into mental health—I think he quoted a figure of 87,000 out of a total of £18 million on research—drew attention to this apparent discrepancy which needed some explanation. The main plea which I am making is this: There is a very distinct need for a grant of money for research into the day hospital system, and to see to what extent these day hospitals can draw off the load which is at present imposed upon the mental hospitals.

I should like to draw the Minister's attention to a case of costs and investment in connection with this system which, I think, needs looking into. I hope that the hon. and attractive Minister will not think that I am talking at her, but I do think that she might give this matter very serious consideration. The Social Psychotherapy Centre at Hampstead has been trying for a long time to find proper premises to carry on its work. Nine months ago the question of new accommodation was agreed in principle at regional level, and for nine months discussions have been going on as to where they might find proper accommodation.

It got to the point, I am advised by the Minister of Health, where acceptance in principle of new premises for this important pioneer project was agreed by the Ministry, and the matter was then referred to the Treasury. Everyone knows what happens when that occurs. Here comes the point which I should like to have looked into. When the Treasury got hold of this recommendation for permanent premises, they came back with the answer, "We have premises of our own which may be available; why not use them? Why ask us to buy new premises?"

When that information was received, these premises were inspected and were found, subject to small modifications, to be entirely adequate, fully furnished and within 300 yards of the existing obsolete premises. How is it that this accommodation which, as it were, is on the books of the Treasury, is apparently unknown in the Ministry of Health? That is why I prefaced my remarks by saying that I am not talking at the Minister.

This is a matter where once again we find the small men in the Treasury holding on to information and not giving that information to the Ministries which are concerned. It seems to me that this irresponsible sort of thing is going on—wastage in time, money and effort in research over nine months to find accommodation available which is just round the corner in the hands of another Ministry.

Section 16 (1) of the National Health Service Act gives the Minister power on the subject of research to give money to organisations to carry out necessary research, and mental health is a case in point. I beg the Minister to look at the efforts made, which have so far been frustrated, to secure money for research so far as the day hospitals are concerned, and to see that a fund is put at the disposal of reputable organisations who can do so much to relieve the terrible congestion in the existing orthodox institutions.

3.4 p.m.

Mr. R. J. Mellish (Bermondsey)

Ishall sit down at ten minutes past three to enable my right hon. Friend the Member for Middlesbrough, East (Mr. Marquand) to express the point of view of the Opposition. I wish to say to the Minister that what I have been asked to say on this subject has been at the request of trade unions associated with the mental hospital service. Following the debate on 12th November, I was approached by many of the workers and trade union officials to discuss the general aspects of this matter, and I am grateful to my hon. Friend the Member for St. Pancras, North (Mr. K. Robinson) for giving us this opportunity, by the wide terms of this Motion, of discussing so many aspects of this service.

I have been asked to point out that the average cost in general hospitals, according to the Ministry's own figures, on 21st March, 1953, was £13 3s. 6d. per patient per week, yet the average cost in mental hospitals is only £4 6s. 7d. per patient per week, and in mental deficiency hospitals £4 1s. 7d. per patient per week. It is argued that this discrepancy is absurdly large. Recently in "The Times" the suggestion was made that the mental hospitals and mental deficiency institutions were able to keep down their costs because they produced so much of their own food at cheap rates. It is true that they produce a fair amount of food, but it is nothing like as much as to account for the difference between £13 in the one case and £4 in the other case.

I am assured by experts that the most that could be added to the £4 1s. 7d. per patient per week in a mental deficiency hospital in respect of the food they produce would be about £1 5s.

The Parliamentary Secretary to the Ministry of Health (Miss Patricia Hornsby-Smith): I suggest that the hon. Member is confusing the cost of food per patient with the total cost of upkeep.

Mr. Mellish

I am not confusing it. I am giving the total cost per patient. I gave the £4 1s. 7d. figure as the total cost.

It was argued recently in "The Times" that one of the reasons the cost per patient overall was low was that the proportion in respect of food was small, since they produce it themselves. Even if no food were produced by patients, there would only be an increase in the figure, so these people believe, to £5 5s. per week as the general overall cost, as against £13 3s. per week per patient, in general hospitals. That leads to the conclusion that there is a great shortage of money in the mental hospital service generally, and, as a result, clinical inefficiency.

These people, who work in the hospitals, know what they are talking about. They believe that the hospital management committees in charge of the hospitals, having, with the existing rates, to provide food, heating, clothing and the rest, do not provide the adequate physiotherapy, social therapy and rehabilitation programmes that they would like to do, because of the shortage of money. I hope that the Minister will give an answer on this point and, if it is not true, will be able to say that the money is available for the hospital management committees to do all the social therapy and rehabilitation work that they would like to do.

Another problem is the existing costing system within the Ministry on hospital management committee budgets. The present system, whereby when 31st March arrives the "axe" falls and any money which the management committees may have in hand must be returned to the regional board, causes panic spending. Long-term planning is needed in the mental hospitals, and they ought to be allowed to have special reserves to deal with this problem.

I should like to deal with two other aspects which concern the staff. Following the recent Danckwerts award, the doctors have had increases in remuneration, with which I do not quarrel except to point out that specialists did not come out of it so well. It is argued by people in the trade union world that mental hospitals today suffer from the fact that, because of the added inducement in general practitioner work, the hospitals are not getting the specialists that they would like. Recruitment has fallen to a disastrous level as regards both quantity and quality. Recently an appointments committee for registrars in various specialities offered eight situations. They had only eight applicants, some of them of very poor quality. The specialist services are causing the mental hospitals great worry.

A great deal could be said on the question of nursing and one could argue a case for the pay of those employed in mental work. In the debate on 12th November, when we asked the Parliamentary Secretary about wages for nurses, the hon. Lady said: The Council met in fact this Tuesday. Both sides are desirous of reaching a conclusion, and I believe that that conclusion will be on lines which will be found favourable by hon. Members opposite."—[OFFICIAL REPORT. 12th November, 1953; Vol. 520, c. 1280.]

They met on that Tuesday and registered a failure to agree. The hon. Lady was either badly briefed or else she did not understand her brief.

I would ask the Minister, in view of all the platitudes we heard that night on the urgency of a revised wage structure and the need for a better staff, whether she could tell us why it was that it took from 12th November until last Friday to arrange an arbitration court to listen to the application over which on 12th November there was failure to agree? The arbitration took place only last Friday.

One of the great troubles when we are discussing wages and conditions of mental hospital staffs is that on the Whitley Council we find so many people engaged in general hospital work. I should have thought that they would not have a full understanding of the special needs of the people in mental hospitals. I suggest that it is ridiculous to ask those engaged in general hospital work to agree on any differential between them and the staffs of mental hospitals.

We cannot pay enough for this job, and if the nurses in general nursing are jealous let them transfer to a mental institution. There is plenty of room and work for them to do. The Minister must be firm about this. I do not know what the arbitration is going to produce, though maybe the Minister has some inkling of it. There has been a week to think about it. I hope the future is going to be much brighter for these people, and that there is going to be a really dynamic drive from the Ministry to ensure that the wages and conditions are worthy of the people who are employed in this great humanitarian service.

3.13 p.m.

Mr. H. A. Marquand (Middlesbrough, East)

I want to add my tribute to the many which have been paid to the very admirable speech of my hon. Friend the Member for St. Pancras, North (Mr. K. Robinson) in introducing this debate. He moved a Motion of which we have heard very little but which, in view of all that has been said during the debate, the hon. Lady will find no difficulty in accepting.

The debate itself has been on an extraordinary high level, free from partisan emotion or acrimony, and I shall certainly try to maintain the same atmosphere. It has shown that the House of Commons wants to examine thoroughly and sympathetically, and at the same time with a great deal of knowledge, this whole field in the interests of suffering humanity. The speeches that have been made were not only sympathetic but showed the interest which hon. Members take in the welfare of those of their constituents suffering from this disease who might otherwise be completely forgotten. It also shows that the House of Commons possesses a great deal of authoritative knowledge on the subject. Speeches like that of the hon. Member for Gosport and Fareham (Dr. Bennett) and of my hon. Friend the Member for Tottenham (Sir F. Messer), who is Chairman of the Central Health Services Council, reveal how wide a subject this is, and we have all tried to do what my hon. Friend the Member for Tottenham said needed to be done, to educate the public outside.

What we have also done will, to some degree at any rate, reassure those who work in the mental health service. I hope the right hon. Gentleman the Minister of Health will send a marked copy of Hansard containing this debate to the Chancellor of the Exchequer, as I am sure he intends to do; but might I suggest to him that it might be a good idea to take special care to see that every mental hospital in the land receives two or three copies of Hansard carrying the debate. I dare say some of them get it already, but it would be a good idea to make a special effort to see that they know about this debate. They would then feel that there are many people here who appreciate their problems and difficulties and who admire the skill and courage with which they do their difficult job.

I am speaking today not only because I had a brief responsibility for this matter for nine months as Minister of Health but also because I have had the honour since then of being appointed chairman of the all-party Committee which has been working on the problem of mentally defective and backward children. On that Committee I have found many hon. Members who take a great interest in this subject, although they could not be here this afternoon.

This wide field is roughly divisible into three parts: first, treatment and prevention, secondly, buildings and equipment and, thirdly, recruitment and pay. I should like to say something on each in turn. There is a divided responsibility on the question of treatment and prevention because of the division of the National Health Service into three parts. The regional hospital boards have responsibility for the hospitals and institutions, but the local authorities have responsibility for prevention and after-care. Perhaps not quite as much reference has been made today as might have been done to the work of the local authorities in this field. First, however, I want to say something about hospitals.

The hon. Member for Gosport and Fareham made a remarkable and inspiring speech which we were all glad to hear. Of course there is a dark side to this picture—there are many things about it which must worry us—but there is also a bright side, and this afternoon the hon. Gentleman encouraged us as an expert in a way which none of us could attempt to imitate, by telling us of the progress that is being made in treatment within the hospitals.

I can only speak as a layman; as one who, when responsible, took a keen interest in all this work and visited a large number of hospitals and mental defective institutions. I shall refer to one aspect of treatment on which alayman can legitimately have a view. When visiting mental hospitals I was very much impressed with the difficulty of occupying time. Of course there are hours set aside for specific instruction in workshops and there are specialist instructors in carpentry, basket making, and so on. However, there is all the rest of the day to be got through, and I carried away an impression of many hours in which people seem to have little to do but sit about in a large ward. We cannot expect such, people to be readers to any great extent, so I repeat what has been said already about the advantages of introducing television wherever possible and as fast as possible.

When I visited Warlingham Park, near Croydon, which is one of the best of our hospitals, I was much impressed by the manner in which Dr. Rees, when he became superintendent, at once got the able-bodied patients to pull up the palings around the hospital, thus turning it from something like a prison into a place which everyone can visit. There are no "clanging gates" there. I was also impressed with the wonderful concert given by expert instrumentalists from outside, in which the patients joined, and this was not laid on specially for my visit. These things go on everywhere.

I remember that my first visit to a mental hospital was when I was 14 years of age. I was a member of a probably deplorable amateur dramatic society and went to the hospital to take part in a performance. I doubt whether it could have given the patients very much benefit. These dramatic performances and cricket and other sports have been going on for quite a long time at the best hospitals, but let us have more music and more of what is called art therapy. Need it be always at specified times laid down in a time-table with a particular instructor? It seems to me that the art therapy which, for instance, I saw carried on in the great Veterans' Hospital in Chicago with great success, must be extremely inexpensive and would occupy many of these long hours.

Let us see also whether we cannot have better clothing for the patients, because it is sometimes an awfully depressing sight at these places to see the drab clothes and to hear from those responsible how difficult they find it to provide the kind of clothing which gives one self-confidence and assurance in meeting other people. I suppose that it is particularly desirable that women should have bright and attractive clothes at these hospitals, but men also benefit from feeling that they are not specially dressed as an inferior class or anything of that kind.

But it seems true, as the hon. Member for Gosport and Fareham said, that now in large numbers of our mental hospitals none of that unreasoning terror remains among the local people. That is certainly true of Warlingham Park Hospital which hementioned, of St. Luke's Hospital in Middlesbrough to which I shall refer later, and of many others throughout the country. The more people realise that so much of this mental disease is curable and that mental hospitals are no longer places of which to be afraid, the better the hospitals will become, because visitors will go there frequently.

I should like to say something about the responsibilities of local authorities. The hon. Member for Southend, West (Mr. Channon) referred to the job of the psychiatric social workers. I pay tribute to them for the very valuable work that they are doing. I wish that there were more of them. I appreciate that it is desirable and necessary to have a long course of training with quite exacting examinations, because these people are doing very responsible work in households for psychiatric sufferers. But some relaxation might be made in the way of using voluntary assistants who might not be completely qualified. Perhaps by some dilution in that way we could make a bigger force available to help the people outside.

Prevention here, as everywhere, is better than cure. My hon. Friend the Member for Lichfield and Tamworth (Mr. Snow) was the first person to draw my attention to the existence of psychiatric social clubs. As I knew when I was Minister of Pensions that no less than 30 per cent. of pensioners of the Second World War were psychiatric cases, I arranged—after taking medical advice—for war pensioners to go to these chubs. Payment was made to the clubs for each patient. As Minister of Health I attended a grand meeting of psychiatric social clubs held under the auspices of the London County Council. I hope that when the Parliamentary Secretary replies to the debate she will be able to spare a moment to tell us what has happened to that work and whether it is still going on.

I must briefly mention the subject of buildings and equipment. As has been said, 40 per cent. of all the beds in the National Health Service are devoted to mental health, but, in spite of that, the hospitals are overcrowded. The hon. Member for Gosport and Fareham encouraged me a great deal by what he said and the hope he held out of a more rapid recovery rate and, therefore, a more rapid turnover in the use of beds. I do hope that comes to pass. Even if that is true, some new building is obviously essential.

No Minister of Health is satisfied, or has been satisfied, with the amount of money he has been able to obtain for this purpose. The facts about recent expenditure were given to me by the right hon. Gentleman on 19th November and appeared in the Official Report for that day. They show a capital allocation for all hospital purposes of £9½million in 1950–51, of which 15 per cent. went to mental health; of £9 million in 1951–52 of which 21 per cent. went to mental health projects. I am only stating the facts and not wanting to make any attack or to introduce controversy. In 1952–53 the total allocation fell to £7½9 million and the percentage for mental health was 18 per cent. In 1953–54 it was £8 million and the percentage for mental health was 18 per cent. The actual sum spent on mental health must have been diminishing. I am glad to find that for 1954–55 the right hon. Gentleman expects to make much more available; I congratulate him on that. I thought it only fair that the facts should be brought out and I do not think the right hon. Gentleman will complain.

He has now been able to obtain a larger amount of money. I am glad that he has set aside out of the additional money which is coming to him a substantial sum for mental health. The all-party Committee to which I referred earlier was glad to hear recently from the Minister that he believes substantial advances can now be made in the reduction of that waiting list for the mental deficiency institutions especially—it has been frequently referred to this afternoon—which is so often a cause of great distress in many families although the total numbers are not very large. Eight thousand on the waiting lists for the whole of England and Wales is not a very large number when spread over the whole country.

Rapid reduction of this list ought to be possible, and I think and hope that it will be found possible, as I believe the right hon. Gentleman wants to get on with this matter. But, build as much as we like, provide additional beds to the fullest possible extent, and we still do not solve the problem or conquer the difficulty if we have not the nurses to staff the beds.

That brings me to the question of recruitment. I hope that this debate, in so far as it gets reported in the newspapers and on the radio, will have done something to encourage recruitment. I think that, if properly understood, it will have done so. That there has been some reference to the black side of things will, I hope, not be over-played, because there has also been reference to improvement and the fact that better things are to come, and indeed solid proof of advance. We want to keep our sense of proportion in the matter, although it is essential for critics naturally to bring pressure on the Minister. I am sure he wants that pressure because, if we did not bring it on him, he could not carry the same force in his arguments with the Government when there are all the other things on which the Government have to spend money.

If we can help him in the matter of recruitment we will do so gladly. Hon. Members nowadays have very little opportunity to speak to their constituents because everyone wants to look at television and not come to public meetings any more. That seems to be the case; but if there is any campaign with which hon. Members could link themselves in their own constituencies, I am sure they would be only too glad to assist.

I hope that the British Broadcasting Corporation—which in some mysterious way unknown to us determines its own affairs—will consider the possibility of a television programme. When I was Minister of Health there was a documentary filmabout mental health which was not bad, although it might have been better. But these documentary films are not seen by many people. I suggest that that film and others better, if such have been produced, might be shown on television, which is now the most powerful instrument for influencing public opinion in this country.

Regarding recruitment, I think that a remarkable job has been done by Dr. Cuthbert whose article in the "Lancet" has been referred to. I suggested to him that he could give me a summary of his scheme, but he informed me that it was impossible to summarise it. However, it is dealt with in the "Lancet" article, and I shall not attempt to summarise it because I have not the time.

He has a scheme of what he calls pre-nursing scholarships so that young people aged 15 leaving school can, up to the age of 18—when they are able to enter the nursing profession proper—go into the mental hospitals, not as unskilled labour but as students. He believes this scheme is successful mainly because it is possible to link the interest of people with their local hospital. Dr. Cuthbert disbelieves in big and generalised campaigns. He considers that there should be campaigns in each locality related directly to the local hospital. Through a system of scholarships young people should be encouraged to be trained in the whole subject of mental health without assuming any responsibility for treating patients. They would be on the spot; meet the patients; become acquainted with the hospital atmosphere; see the relatives; go out with the psychiatric social worker, see the after care treatment, and all the rest of it. I believe that to be the best suggestion which has been made. He has obtained great success. It happens to be true that there is little alternative work for "female labour"—to use that horrible expression to describe young ladies—in Middlesbrough,, and that may partly account for the success of the scheme, but I am sure that the hon. Lady will look upon it with interest.

3.34 p.m.

The Parliamentary Secretary to the Ministry of Health (Miss Patricia Hornsby-Smith)

I have to reply to 15 speeches, three of which, at any rate, lasted for a longer time than I have in which to speak. Therefore, if I do not cover all the points whichhave been made, I hope that hon. Members will realise that my failure to do so is not because of any lack of willingness, but from shortage of time.

To the many tributes paid to the hon. Member for St. Pancras, North (Mr. K. Robinson) I wish to add mine. I know that I speak for my right hon. Friend in saying that this has been an outstanding and invaluable debate in the campaign for the mental health service. We are grateful to the hon. Member for St. Pancras, North not only for taking the opportunity to initiate this debate—and for refusing to be persuaded by his hon. Friends to talk about gambling instead—but also for the lead he gave in setting such a high tone to the debate which put it far above party politics.

He and other hon. Members asked whether there is any evidence that mental illness, as such, is increasing. We have no evidence that mental illness, as such, or mental deficiency, as such, is increasing, but the figures must be reconciled with the fact that people are living longer and there is thus a larger number of aged patients who are mentally ill. With the new outlook on mental illness, people are coming voluntarily for treatment. In fact, in the last 15 years the number of people admitted to mental hospitals has doubled.

I was asked by several hon. Members what the percentage of voluntary patients really was. It varies from 45 per cent. to 75 per cent. for males. This is the average of the regional figures. For females, the figures vary from 40 per cent. to 75 per cent. The national figure of voluntary patients in mental hospitals is 68 per cent.

Mr. Hastings

Do the mental hospitals, as defined by the hon. Lady, include mental deficiency institutions or not?

Miss Hornsby-Smith

No. Mental hospitals only. I am dealing with voluntary admissions to mental hospitals. I will not go into all the details, dealt with by so many hon. Members, about our appalling legacy of overcrowding, old buildings, of the war years when we could not build, and of the antiquated, obsolete and out-of-date engineering equipment. I can only say that perhaps the right note was struck by the hon. Member for Tottenham (Sir F. Messer), when he said that this was an enormous problem. He said that it was a long-term problem which will take years to solve. Further, everyone realises that it is not a question of a few million pounds. It is a question of thousands of millions over many years before the problem can really rightly be solved.

I should like to make a few comments about capital. The difference between the figures of the right hon. Member for Middlesbrough, East (Mr. Marquand) and those which I propose to give is that his figures are of the amounts which the regional boards actually spent and I am giving credit to my right hon. Friend for the sums which he has allocated. The allocation for 1951–52 was 20 per cent.; for 1952–53, 21 per cent.; for 1953–54, 21 per cent.; and for 1954–55, with the additional "mental million," as it has come to be known, the percentage of capital allocation going to the mental side will be between 30 per cent. and 35 per cent. That is a very real step forward in solving the problem, as I am sure hon. Members will agree.

On the question of these special schemes, there is a vast scheme at Sheffield under way and one at Liverpool. Under the "mental million" the hon. Member for Bristol, South (Mr. Wilkins) will get 190 beds in his area. They come from the "mental million." The immediate scheme for the next three years will provide 800 additional beds in Sheffield and Liverpool. These are the beginnings of long-term programmes, as hon. Members know. The Balderton programme will be for 1,040 beds and it is a £1,800,000 project which will be completed in about five years. The Liverpool project, which will have an initial few hundred beds, will ultimately extend to 1,060 beds, and it is approximately a £3 million project.

With these brief figures—and I admit that I am cutting out many items of information which I should like to give to hon. Members because I want to cover as much ground as possible—I would say that so far as bed space is concerned the average per thousand of the population is 2.8, and we should like to see a standard of 3.5 per thousand. The overcrowding on an average in England and Wales is 14.7 per cent., although the area in which the hon. Member for St. Pancras, North is so particularly interested has a much better record, and the overcrowding is only 4.1 in the North-West Metropolitan region.

We have, unfortunately, 1,640 un-staffed beds, but despite that fact and despite the long waiting list on the mental deficiency side we can state that on the mental health side, in the five years of the National Health Service, the number of patients in mental hospitals has increased by 5,600, although we still wish to see many more beds provided and we realise that to some extent that increase in patients has been achieved by overcrowding.

Two or three hon. Members raised the question of the elderly patients whom it was desirable, if possible, not to certify and who, in the later years of their lives, became senile but not really certifiable. As hon. Members know, we have previously discussed in this House the new type of home attached not to the local authority, as my hon. Friend the Member for Billericay (Mr. Braine) suggested, but generally as another annexe to the mental hospital and under the mental hospital management committee, where watchful care and attention can be given to these old people.

That programme is under way. We have many projects that we hope it will be possible to commence, and already since 1950 1,300 beds have been brought into operation in this type of home. I have had the privilege of opening three homes, and I know that they are a great advance and also a great comfort not only to the patients but also to their relatives, who are particularly desirous that these people should not be certified during the last few years of their life. This is a development which we very much soup-port, but, like everything else within our programme, it is limited by the amount of money that we have at our disposal.

So far as mental deficiency is concerned, in our last debate I gave the estimated figure for the mental deficiency waiting list, which was 9,290. We have now the actual figure, up to 31st December last, and it is 8,521. Therefore, some advance has been made; it is not as great as we should like to see, but at least the trend has at last started to go down and we are beginning to break down the admittedly appalling waiting list on the mental deficiency side.

The mental deficiency side, with its great waiting list, has a major share of the special allocation which my right hon. Friend has made. For the year 1953–54 there are schemes to provide 1,314 new mental deficiency beds, although the actual building and completion of the beds may take more than one year. In 1954–55 there will be provision for another 1,200 mental deficiency beds, which, again, will be completed in 1954–55 and 1955–56. Also, centrally financed from other funds will be the 800 beds that I mentioned just now, which are part of much larger schemes which will bring into use 3,000 beds within the next six years.

I now turn to the major problem, which is nursing staff. Many hon. Members have said that it is no use our providing the beds if we cannot provide the necessary nursing staff. The total number of nursing staff has risen by 2,800 over five years, and the domestic staff by 3,100. The difficulty lies in the fact that, although we have more trained staff, we are not attracting student nurses. There has been a serious decline, about which we are very concerned, of 1,500 in the number of student nurses. At the moment we have 15,000-odd trained nurses, 4,500 student nurses, 174 assistant nurses and 10,500 nursing assistants, counting each part-timer as a half.

The hon. Member for St. Pancras, North suggested that we should have a State-enrolled assistant nurses grade, which would give more emphasis to training and to having that type of nurse in the mental hospitals. The suggestion was supported by the hon. Member for Tottenham. Hon. Members must not mislead themselves into believing that this would provide a solution, even over a reasonable term of years. In the first place, there is no guarantee that the establishment of a roll of what would be a new type of mental assistant nurse, for which we should require legislation, would lead to any substantial influx of candidates of the right kind.

The experience in the general hospitals, which is no mean guide, suggests that the growth of a grade of trained enrolled assistant nurses is a very slow process indeed, so slow that 10 years after the date of the Act authorising us to establish this grade the general hospitals are still relying in the main for their subordinate nursing staff on assistant nurses who were already employed in the hospitals and obtained their enrolment because of their experience and without having to undertake the formal training. They are also relying upon an increasing number of nursing auxiliary staff who are not, and cannot be, enrolled.

I have no desire to cast gloom upon the matter, but we have to be realistic about it. If it is difficult to get State-enrolled assistant nurses to go into the general side it will be even more difficult in the case of the mental side, and we shall be building our hopes too high if we think that the mere passing of legislation and establishing of the grade will give us the number of State-enrolled assistant nurses that many hon. Members desire us to have.

Regarding recruitment, I agree with those hon. Members who have said that the best recruiting campaigns are those centred round the local hospital. I do not think a national campaign is the best or most effective way, although it can help in a subsidiary fashion. The best way is to centre it round the hospital with the active help of the matron, and I do beg of those organisations which are running recruiting campaigns to have an open day and open their mental hospitals to as many people as possible, and not to limit the invitations to the already converted, such as the members of the hospital management committee and the regional board.

They should send out their invitations to the leaders of the churches, members of the W.V.S. and similar organisations and to local leaders in public life in the locality, so that they can tell others whom they contact of the new and different outlook in mental hospitals and of the opportunities which there are for careers in nursing in both mental hospitals and mentally defective institutions.

On the question of pay, I would first of all deal with the point made by the hon. Member for Bermondsey (Mr. Mellish). I neither withheld information from the House in the debate to which he referred, nor was I misinformed by my Department. The disagreement of the staff side was not sent to the Ministry until after the debate had taken place. With regard to the complaint that the question had been unduly delayed, that debate took place on the 12th November last. The outcome of the Whitley proceedings was not formally recorded at the time of the debate and the Staff side's final decision was not known till after the meeting and the debate.

The Staff side wrote to the Ministry of Labour asking for arbitration on 18th November, and the Ministry of Labour replied on the 27th. The terms of reference were finally agreed by the two parties on the 7th January—and this was the longest delay because the two sides were then agreeing on the terms of reference. The Ministry of Labour then wrote stating that the dispute had been referred to the Industrial Court on 14th January. The Industrial Court held its inquiry on 12th February.

Mr. Mellish

I am much obliged to the hon. Lady. The fact is that the Ministry did know that there was a failure to agree on the Tuesday, and we had the debate on the Wednesday.

Miss Hornsby-Smith

I think the behaviour of my Department was perfectly right and proper, because, while they may have known what the result of the meeting was going to be, it was quite right that they should not authorise me to make a statement in the House until such time as the Staff side had officially recorded their failure to agree with the Ministry.

I think it should be known that there is already a £20 higher rate of pay for the trained mental nurse, and the student nurse gets £30 above the rate for a student nurse in a general hospital, as well as receiving a bonus of £20 on passing her preliminary examination and one of £30 on passing the final examination. Further, the nursing staff in mental hospitals, after 20 years' service, are qualified for superannuation benefit in which each year after 20 years' service counts as two years for superannuation purposes.

Several hon. Members raised the question of the cadet scheme. This is a matter into which we are looking very closely, but it raises difficulties. The cadet scheme will be virtually a continuance of education, and we have to consider whether it is an educational cost or whether it is a medical one. We cannot accept the cadets for proper mental training or allow them to do any work in the hospital wards. It is an expensive way of getting potential labour which, for those two years, is contributing very little indeed towards the health service as such.

Further, there is a very strong school of thought that feels that, particularly for those going into mental nursing, the two years between 16 and 18 years of adolescence and development, are ones in which potential recruits to the mental health service should be gaining experience outside in the world in some other field, to increase their fitness for the strain of the work and responsibility when they do come into mental nursing. Hon. Members shake their heads but I am merely putting forward points of view that are very widely held by those responsible for deciding the curriculum of training in the nursing services.

I can assure hon. Gentlemen that we are looking at all aspects of this problem because we are as anxious as they are to solve the nursing staff shortage. It must be acknowledged that mental nursing causes a greater strain than general nursing, and I do not think it unreasonable for there to be some caution about bringing 16 or 17-year-olds into association with mental hospitals except under very strict supervision and with every assurance that they will not be used in the wards until they have reached 18 years of age.

The question of local authority community care has been raised by other hon. Gentlemen. There are schemes under which defectives can live in their own homes and go to occupational training centres. There are 236 of these training centres in 36 counties and 65 county boroughs. As the result of a circular issued by my right hon. Friend in January, 1952, there has been a development in the powers taken by local authorities to board out or accept into a hostel for a short period defective children for whom at the moment we cannot find permanent places in hospitals, and so give some relief to the mothers and possibly give them an opportunity to go away. I am pleased to say that the scheme is working well and has been put into operation by 65 local authorities. I hope that more local authorities will follow that lead.

The matter of high grade defective hostels will come within the purview of the Royal Commission. There is a difficulty about overlapping, as to where a hostel ends and a mental deficiency institution begins. I have no doubt that such difficult problems will be looked at by the Royal Commission.

The hon. Member for Lichfield and Tamworth (Mr. Snow) raised the question of day hospitals. I can assure him that they have the encouragement and good wishes of my right hon. Friend, as many people who cannot be persuaded to enter the ordinary mental hospital as voluntary patients can be cared for in this way. Tributes were paid toy the hon. Gentleman to the units that have been set up, at the Maudsley Hospital, at Bristol, Oxford and St. John's Wood, in which the hon. Gentleman is particularly interested. These units are limited to the extent that they are only applicable to cities where people live near the centre, perhaps on a bus route and can go daily and be taken care of. They are not so applicable to country districts where there are difficulties about transport.

The right hon. Member for Middlesbrough, East (Mr. Marquand) raised the question of psychiatric clubs. I assure him that the work is going on and is in fact being expanded. I think he knows about the centres of the Institute of Social Psychiatry, which the London County Council has supported and find particularly helpful in their area. Similar clubs are being run by other bodies. They do tremendously fine work in helping outpatients, ex-patients and those just leaving hospital to rehabilitate themselves, and to give them confidence and company so that they can readjust themselves again after having had some mental ailment.

The experiment is continuing and developing, and clubs are spreading to many other towns. Middlesex and Essex are the counties which have particularly contributed, and also the Southend local health authority. They are running clubs started by the Institute. Indeed, Middlesex and the London County Council are now planning to run clubs of their own.

Mr. Marquand

Are there any of these clubs in the North of England?

Miss Hornsby-Smith

Without notice I could not say, but I shall be very happy to ascertain that information for the right hon. Gentleman.

I support very heartily all that the right hon. Gentleman said about the increase in therapy, occupational therapy and art therapy, and the doing away with the old drab clothing. I am quite sure that the effect on women patients, of not all having to wear the same identicaldress and of having attractively coloured clothes is tremendous. Above all, the increasing use of hairdressing services in mental hospitals is having a tremendous, effect on the whole social aspect and behaviour of the patient. I know that hon. Members will not say that that is merely a feminine influence, but will agree with me in believing that it is good therapeutic treatment for patients.

Many hon. Members have referred to the question of diet. I think it is very easy to make unrealistic comparisons between general hospitals and mental hospitals. General hospitals have to deal with sick people, and the number of the staff, the specialists, the equipment and the clinics is far greater than in mental deficiency institutions where the patients, generally speaking, are physically fit, and can, in many cases, look after themselves. The staff is considerably less in such institutions because a certain amount of the ancillary work can be done by the patients as an aid to their treatment.

I think it is quite unrealistic and gives a false idea about mental hospitals to suggest that because a teaching hospital costs £20 a week per patient and a mental hospital costs only £5 a week, the one is being robbed of £15 worth of services. The two types of hospitals are not truly and honestly comparable.

So far as food is concerned, it must be remembered that in mental hospitals generally the catering is done on a very large scale, often on the basis of 1,000 patients and more. In the kitchen, there are, generally speaking, three diets—normal, gastric and diabetic. The patients do not change every week or so. There are far fewer individual diets and far fewer catering officers and dietitians in mental hospitals compared with general hospitals, for the simple reason that in general hospitals the diet of a patient may have to be changed as often as three times in a week. Therefore, the cost of providing food and diets to general hospital patients is much higher than for mental defectives, who in most cases have a perfectly normal diet. We must also remember that mental homes grow a large amount of their own vegetables and have their own farms.

In conclusion, I wish to say on behalf of my right hon. Friend that we are very happy to accept the Motion. We welcome it, and I know I am speaking for my right hon. Friend when I say that this has been an extremely happy debate. I am sure it will make a great contribution to the support which we must have from public opinion in the country in solving problems of mental health. It has been a privilege for me to reply on behalf of the Government.

Question put, and agreed to.

Resolved, That this House, whilst recognising the advances made in recent years in the treatment and care of mental patients, expresses its concern at the serious overcrowding of mental hospitals and mental deficiency hospitals, at the high proportion of obsolete and unsuitable buildings still in use, and at the acute shortage of nursing and junior medical staff in the mental health service; and calls upon Her Majesty's Government and the hospital authorities to make adequate provision for the modernisation and development of this essential service.

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