§ Motion made, and Question proposed. That this House do now adjourn.—[Mr. Godber.]
§ 10.36 p.m.
§ Mr. Kenneth Robinson (St. Pancras, North)
I have often raised in this House matters affecting the mental health services, and I think the major part of my remarks have in the past been directed to the shortcomings of the mental hospital service. But I think we all agree that ideally the future development of the mental health services lies not so much in having more and more beds as in emptying the mental hospitals and in preventing people from having to be admitted into the hospitals. In my view, there is only one way in which we shall achieve that, and that lies in developing more and better outpatient facilities and also in developing far more extensive community and domiciliary services.
So far as the latter are concerned, Section 28 of the National Health Service Act lays the responsibility squarely on the shoulders of the local health authorities, and their instruments in carrying out these duties are the mental welfare officer and the psychiatric social workers, and it is about the training of these two categories of workers that I want to speak tonight.
It is rather odd that although both of these people perform highly responsible duties, one category is highly trained and the other category is not trained at all. In July, 1948, just after the National Health Service Act was passed, there was appointed the Mackintosh Committee to consider the question of social workers in the mental health services. The Committee reported towards the end of 1951 and recommended not only that there should be a substantial increase in the number of psychiatric social workers but that the needs of the mental health service demanded a large number of trained mental welfare officers.
I do not know exactly how many mental welfare officers there are in the country employed by local authorities. My guess is that the number is between 500 and 1,000, but perhaps the hon. Lady 168 the Parliamentary Secretary to the Ministry of Health could give me an accurate figure when she replies.
What are the functions of these mental welfare officers? They are responsible for supervising mental cases in the community, the prevention and after-care of mental patients, and possibly their most important function is that which they carry out in their capacity as duly authorised officers. The duly authorised officer carries out duties under the Mental Deficiency Acts connected with the ascertainment of mental defectives and under the Lunacy Acts in connection with the certification of the insane.
It is the duly authorised officer who very often initiates the whole procedure of certification, and he may indeed be the first contact between the members of the public and the mental health service. In this capacity he has great authority, and he can, and in fact frequently does, override the opinions of general practitioners regarding patients suffering from mental disorder.
Only a few days ago a general practitioner told me about a patient of his with acute suicidal tendencies whom he tried to get to hospital immediately as an emergency case. The duly authorised officer disagreed with him and decided not to visit the patient for the next twelve or eighteen hours. I am not saying who was right or who was wrong. I am merely quoting that instance as an illustration of the degree of authority which the duly authorised officer has.
One would imagine that these mental welfare officers would be obliged to undergo a rigorous and extensive course of training and to obtain some kind of national qualification. But upon investigation one finds that nothing of the kind happens. In a Written Reply to a Question of mine, the Minister of Health replied:There is no national scheme of training specifically for these officers, but a number of local authorities arrange courses for them.I should like to know, incidentally, what sort of courses are arranged and by how many local authorities. The Minister continued:The position is now being studied by a working party set up last year to consider the training and field of work of all social workers in the local authority health and welfare services."—[OFFICIAL REPORT, 29th March, 1956; Vol. 550, c. 248.]169 But the position had already been studied five years ago by the Mackintosh Committee, which made the strong recommendation that appropriate training should be authorised, and almost immediately after the Report an ad hoc committee was formed comprising representatives from the universities, from the Royal Medico-Psychological Association, from the National Association for Mental Health and from the Society of Mental Welfare Officers, which was the professional association representing the whole body of these mental welfare officers. They agreed to proposals about training and submitted to the Minister a scheme in July, 1952.
About eighteen months elapsed and then a letter was received from the Minister saying that this question could not be considered until the Working Party on Health Visitors under Sir Wilson Jameson had reported to him. Faced with this somewhat negative attitude the Committee adjourned sine die.
I want to make it clear that this would not be a matter of a training scheme being forced on the mental welfare officers by their employing authority or by some outside body. The mental welfare officers themselves are extremely keen on it. They appreciate that their increasing responsibility demands a high standard of competence, national training and qualification, especially for new entrants into the service.
It is true that the old relieving officers before the days of the National Health Service Act had a whole fund of experience behind them, not perhaps a substitute for training, but perhaps the next best thing. More and more of these men are retiring or approaching retirement age and are being succeeded in this highly responsible work by local authority officers with no training and little or no experience.
Some months after the Minister's letter, to which I have referred, the various bodies once again got together and worked out an actual syllabus for a year's course. They invited the National Association of Mental Health to organise a scheme, and it gladly agreed to do so. A further approach was made to the Minister, with the same negative result, and now, when the Jameson Working 170 Party is almost ready to report, the bodies concerned are asked to await the findings of yet another committee, the Young-husband Committee on Social Workers, which means a delay of anything up to two years.
Throughout this unhappy story the Minister has given, not only no encouragement, but positive discouragement to these proposals. I hope that the Parliamentary Secretary will be able to say why. I can think of only one possible reason, and that is the old reason of finance, because local authority expenditure would no doubt qualify for grant, although I cannot imagine that the sum involved would be very large. That is all I have to say for the moment about the mental welfare officers.
The psychiatric social workers present a different problem. Here there is an established training of a very high quality. The trouble is that there are not enough training facilities and not nearly a large enough output of psychiatric social workers.
Psychiatric social workers are employed not only by local health authorities on community mental health work but also by hospital authorities for work based on the mental hospitals and the psychiatric wards in general hospitals. Above all, they are employed in the child guidance service by the local education authorities. We have recently had the Report of the Committee on Maladjusted Children. It estimates that for a satisfactory child guidance service alone we need four times as many P.S.W.s as there are in the service at the moment. That is a figure of 420 instead of 109. The Mackintosh Committee estimated 500 for this one duty alone.
The hospital authorities need far more P.S.W.s than they can possibly get. There are unfilled vacancies in almost every mental hospital. I do not know whether the Parliamentary Secretary can say how many unfilled vacancies for psychiatric social workers are known to the Ministry. So far as local health authorities are concerned, the situation is even worse. I have a list of trained P.S.W.s employed by local health authorities in the mental health service, and the total is under 40 for the whole of Great Britain.
Why is there this acute shortage of P. S. W. s? First, it is a difficult job. There 171 is a stiff training, and there is quite definitely a limited number of people who are suited for this work. Secondly, apart from the intrinsic interest of the job, which is very high, there is not sufficient incentive for the right people to enter the field. Indeed, there is a disincentive to social workers to take the mental health qualification.
In order to be admitted to the mental health course, the requirements are a degree, diploma or certificate in social science plus experience of social work. That means three or four years' university training and two or even many more years' experience in social work. The salary range for a qualified P.S.W. is £495–£750 per annum, and a very few senior grades go up to £850. For each year of age under the age of 27 £15 is taken off, which indicates that 27 is thought to be the sort of age at which qualified workers start their career.
I should like to quote from a letter from a social worker who has just completed the mental health course and will shortly be taking a job as a P.S.W. He writes:Having a wife and two children, my training grant is £526 per annum. When I commence work as a P.S.W. I shall secure two increments above the starting point in recognition of many years' social work …which will mean…a total of £530. I gain just £4 from moving from a student situation to one of some responsibility in a clinic or mental hospital! This in the middle of one's thirties when one is considered mature and therefore better equipped for work with people. If I had preferred to remain a lesser qualified person in my job with the county council children's department, my salary in September, 1956, would have been about £620!In other words, for taking this additional qualification this worker will have dropped about £100 a year in salary.
The Parliamentary Secretary will say that these are all matters for the Whitley Council and not for her right hon. Friend. That is the answer that we always get. I do not want to get into an argument about Whitley Councils tonight. For one thing, there is not time. Cannot the Minister see that the Whitley Council in question is made aware of the extremely important rôle that the P.S.W. plays in the mental health service?
Compared with a children's officer or a probation officer, both of whom obtain salaries of more than £1,000 a year, the 172 P.S.W.'s opportunities are pretty meagre. A salary of £750, or £850 as the absolute maximum for a university graduate, is not a very great incentive. If they are limited to university graduates, the P.S.W.s would come under a different Whitley Council grading and probably qualify for a higher salary, but then, of course, one would be limiting the field still further. I am assured that it is not necessary to have a university degree, which may, however, be of very great advantage in itself.
At any rate, something must be done. There are only three main training centres at the moment, London, Manchester and Edinburgh. There is a course at Liverpool, but I do not think that there are many students there. The hon. Lady might say that those are sufficient for the numbers coming forward, but the numbers are hopelessly inadequate as I have tried to show, and the Minister must do something to stimulate recruitment.
Equally, I hope that that hon. Lady will be more positive and forthcoming about the training of mental welfare officers. It is little short of scandalous that this vital function continues to be performed by untrained and perhaps even inexperienced officers. Everything is ready and only awaits the blessing of the Minister of Health. Perhaps the hon. Lady will indicate why her right hon. Friend and his predecessor have been so dilatory in this matter. In conclusion, I want to emphasise that we can never hope adequately to develop a community mental health service without many more properly trained mental welfare officers and psychiatric social workers. It is the plain duty of the Minister to see that they are provided.
§ 10.52 p.m.
§ The Parliamentary Secretary to the Ministry of Health (Miss Patricia Hornsby-Smith)
I know the particular interest in health of the hon. Member for St. Pancras, North (Mr. K. Robinson), and I appreciate the reasons which have given rise to his introducing this subject this evening. There can be no doubt—and there is no quarrel between us on this matter—about the value and importance of mental welfare officers in the services provided by the local health authorities. There are considerably more than the number which the hon. Member mentioned. He said the number was between 173 500 and 1,000, but in fact there are about 1,100 in the local health authority services, and they take a major part in supervising the welfare of mental defectives in the community, of whom there are more than 80,000; they provide help, service and advice to the mentally ill, or to those recovering from mental illness, and in some circumstances arrange for admission of mentally ill persons to hospitals.
Many of them, of course, had considerable experience in the days when the local authorities ran their own mental hospitals, and I should not like the suggestion to go out that these people are not doing their job satisfactorily. It might possibly be inferred from what the hon. Member said that because their work has been based in many cases on long years of experience and because they have not taken the examinations that apply to the psychiatric social workers, they are not qualified in their job. Their record of work shows not only the responsibility which they carry, but the manner in which they carry it out. Many of them have had long experience of their work, and their advice and wisdom is available to newcomers in the field.
Many local authorities are in fact providing training courses, some of them being university courses, some of them specified training courses within their own organisation which include secondment to a mental hospital. I am afraid that I cannot give the exact number of local authorities involved, but to mention but a few with specific training arrangements, Somerset, Birmingham, Manchester, Nottingham and Newcastle have schemes. I do, however, realise that we want more of them and I appreciate that the professional associations representing welfare officers feel very strongly that there should be a properly recognised form of training.
They feel, too, that there has been an unjustifiable delay in acting on the recommendations of the Mackintosh Committee. That I accept. But that Committee, as the hon. Member said, recommended in 1951 that there should be university trained psychiatric social workers and a two-year period of in-service training for mental health workers. I am sure that the hon. Member will appreciate that this Committee was set up in 1948 before the new pattern which was to evolve in the mental health service 174 developed, and before the immense amount of new thought and new investigation which has taken place in mental health work in the last seven years. There have been tremendous advances in the upgrading of mental health and its position in the Health Service, and this has called for a much wider review of the welfare services in all other aspects.
Because of its terms of reference the original Committee necessarily considered mental health workers in isolation, but it has become more apparent—and indeed it became so by the time the Committee reported—that the field of work of various social workers in the Health Service needed definition to avoid overlapping of services. We no longer regard mental health work in a vacuum. I know that the hon. Member is as much an advocate as I am of the view that we should not place such workers in a vacuum away from the general medical services.
We are all familiar with the complaints made about not one but half a dozen workers visiting one family which is encountering difficulties of one sort or another, thereby adding to rather than helping the family's troubles. Some reports are exaggerated but there is admittedly some truth in them. That was one of the reasons which led a previous Minister of Health, in conjunction with the Minister of Education and the Secretary of State for Scotland, to set up a Working Party to inquire into the proper field of work and training of health visitors.
Health visitors and school nurses constitute the most numerous group of local authority officers visiting the home. Among their functions, as defined in the National Health Service Act, are the giving of advice as to the care of young children and persons suffering from illness, which essentially will include the giving of advice in homes on problems of mental illness. The Report of that Working Party is expected next month, and it will clearly be essential to consider what is said about the health visitor in relation to mental defectiveness and mental illness before any decisions are taken about the training of mental welfare officers.
To complete the survey of domiciliary workers under the health and welfare services, a further Working Party was set up to inquire into the field of work and 175 training of social workers at all levels in the local health and welfare services. The hon. Gentleman rather suggested that that was a method of delay. I think that he does my right hon. Friends an injustice.
There has been a great development and a breaking down of what was once a real barrier between the mental and the ordinary physical health service, and an increased determination to treat cases before they become hospital cases, which is so much the hon. Member's desire too. It may well be that from these careful reviews there will emerge quite a different concept of social welfare workers and the kind of mental training suitable for them.
This Working Party is now considering the place of the mental welfare officer in the team of domiciliary workers employed by local authorities. It will, of course, be receiving evidence from all interested organisations and will, I know, proceed expeditiously.
There is one other Report which we certainly cannot ignore in any new plans for development in mental health work, namely, the recommendations which will emerge from the Royal Commission on the Law Relating to Mental Illness and Mental Deficiency. That important Commission considering the future of mental health, has taken evidence on the functions of local authorities in relation to mental illness and mental deficiency, and obviously it will have some recommendations to make.
That is an important field. I do not deny for one moment that there is anxiety on the part of welfare officers, but I am sure that this very detailed and full investigation is part of the attempts to raise the status of mental health work and to evolve the best possible plan for a long-term future policy. I sympathise with welfare officers who have waited so long and, if I may say so, so patiently, but I believe that they are rather inclined to consider that the work they do, because it is concerned wholly with mental illness or mental deficiency, is so specialised that their function and training can be considered quite separately.
Frankly, I think that that is a short-sighted view. One of the most successful battles fought out during the past few years has been to break down the sense of isolation and prejudice against mental illness and the barrier between it and 176 physical illness. Whilst, therefore, it is essential that those whose function it is to help and advise on mental health should be properly fitted to do so, I do not accept that social work for the mentally ill can never be combined with work for those who are in difficulties in other ways. In fact, in some cases it may well be an advantage in obtaining the co-operation of a family if the trained worker comes to them as a welfare visitor and not exclusively as a mental welfare worker.
Though we are breaking down prejudice, I do not think that we should ignore a certain amount which still exists. We do not want to label the mentally ill and the mentally defective as people different and apart from those who may be needing much the same sort of help for other reasons.
So far as the hospital psychiatric social worker is concerned, too, there is an advantage in his having a wider sphere of activity, since he provides the link between the patient and his home and friends, and the medical and nursing staff of the hospital or clinic. At the clinic stage he furnishes reports to the doctor on the home circumstances and environment of the patient, and while the patient is in hospital he maintains contact with his family, and follows up afterwards with advice and guidance when the patient goes home. This is a most valuable job.
These psychiatric social workers take a two-year social science course at a university, followed by a year's practical experience in the field, and then a university mental health course. The Minister assists with grants for the university mental health course. Since 1949–50 the grant has been £8,000 allocated as to £6,000 to the London School of Economics, £1,000 to Manchester University and £1,000 to Liverpool University. The average yearly intake of students for those courses is about 50.
I do not deny that there is a shortage of social workers in the psychiatric field, but estimates as to the numbers required vary from 870 to 1,500. According to the Association of Psychiatric Social Workers, the number of qualified workers employed is 447, but that does not take into account many local authority workers who have not taken the recent more 177 specialised training, but whose long experience in the job qualifies them for it. Similarly, the hospitals' returns show that they have 311 whole-time workers, of whom only 182 are included in the Association's estimate. The discrepancy arises because the hospitals have officers of long standing and experience but who have not acquired academic qualifications as psychiatric workers. So the position is not quite so black as perhaps the Association paints it.
We do not believe that greater numbers of students would automatically be forthcoming either if more courses were provided or if the scale of Government contribution were increased. What is certain is that mental welfare officers and psychiatric workers need have no fear of the future as more and more attention is being paid to this work.
The whole purpose of these committees is to evolve, for the new approach to 178 mental health and for the new commitments in the mental health field, the best possible method of welfare training.
This method may vary from the present one. I do not know about that; but it is important that we should first consider the recommendations of the Royal Commission, and the recommendations of the other committees on the right form of training for local authority welfare officers' work. I assure the hon. Member that there is no deliberate delay on our part. I am sure he agrees that this is a vitally important topic which must be considered in relation to the long-term needs of the mental health service in which, I know, he has such a sincere interest.
§ Question put and agreed to.
§ Adjourned accordingly at five minutes past Eleven o'clock.