HC Deb 10 July 1956 vol 556 cc361-70

Motion made, and Question proposed, That this House do now adjourn.—[Mr. Godber]

11.18 p.m.

Dr. Donald Johnson (Carlisle)

I rise to raise the question of the admission of involuntary patients to mental hospitals. I must apologise to the Parliamentary Secretary if once again in a short space of time I have kept her late in the House. As she knows, occasions to debate the health services, or any aspect of them, seem to be few and far between. The exact occasion of this debate arises from the Answer to my Question last Monday concerning the admission of certified patients to mental hospitals, which revealed what seemed an alarmingly high figure of some 20,000 people annually being put into mental hospitals against their will, only some 15 per cent. of that number having been under outside observation in hospital beds.

In other words, some 17,000 people are swept up, if I may use that word, in this way, mainly on summary reception orders, and detained in mental hospitals for an indefinite period up to a year. This is done on the opinion of two or three people who, though of official and professional status and empowered to sign certificates, are as liable to error as the remainder of mankind. This seems to be an extraordinarily large number of people in such a liberty-loving country as ours, to be detained on no other criterion. Such certificates are really the only criterion which warrant these detentions.

In reply to my supplementary question last week, my right hon. Friend stated that the figure was not as large as all that, and that, in fact, a further 20 per cent. of patients, representing about 4,000 people, were annually placed in observation wards of mental hospitals.

Before proceeding further, I wish to ask a further question on this point. If my hon. Friend cannot give me the answer tonight, or if she has not the figures with her, perhaps she could let me know at some future date what percentage of the number of those placed in observation wards of mental hospitals were already certified under summary reception orders before they went to hospital, or whether they were admitted merely under three-day emergency orders, and, if so, what percentage of them were discharged from observation wards at the termination of such urgency orders.

The reason I ask this is that it is my impression, rightly or wrongly, that once a person is in a mental hospital his or her transference from one ward to another is, on occasion, something of a formality and is by no means the same as if the patient were moved from a general to a mental hospital.

To return to my main point, the matter of these 20,000 people annually entering mental hospitals is a vast human problem, and one with which I hope to deal later. My first intention is to convince my hon. Friend and also my right hon. Friend the Minister that, apart from anything else, the way in which people are placed in mental hospitals is really not particularly good business from their point of view.

The real question at the moment is how we can solve the problem of our overcrowded mental hospitals. According to the figures given by my hon. Friend's Ministry at the end of 1954. 140,487 patients were occupying bed space authorised for only 121,555 patients, which represented an overcrowding of 15.6 per cent. There are, of course, two ways of solving the problem. One is by building more hospitals but that, as we know, in the present economic situation is practicable only to a limited degree, and the other and far more practicable and economical way is by exercising far more discrimination than at present over admissions.

This can be done in the way I have suggested, by the establishment of observation wards in general hospitals in which patients can be viewed in surroundings as detached as possible from mental illness and where they can be seen by general physicians who are not quite so preoccupied with their own speciality as are psychiatrists. Such surroundings would provide a respite during which the patient could, perhaps, surmount an acute crisis and resume his or her place in the community without having acquired the stigma of having been an inmate of a mental hospital which, whatever may be said, is quite inseparable from such treatment.

What I have said is confirmed by the experience in the observation wards in the L.C.C. area. According to the figures supplied by the L.C.C. in their evidence to the Royal Commission, there were 4,746 patients admitted into the observation wards in the L.C.C. area during 1953. Out of these, 1,274, or almost exactly a quarter, were discharged at the end of the 17-day observation period, while a further quarter were moved as voluntary patients rather than involuntary patients.

To keep to the point, concerning the quarter who were discharged, it is clear to anyone who has even the most superficial acquaintance of the ways of mental hospitals and the time factor which operates within their walls that these people were discharged very much quicker than they would have been once they were entangled in the mental hospital machine. It is equally clear that if a quarter of the admissions to mental hospitals in the country can be cut down, even if only with short-stay cases, it will go some way to solving this problem of overcrowding. Indeed, it seems to me that this policy offers a dazzling prospect to my right hon. Friend in that at a comparatively small cost he can solve the problem of overcrowding in mental hospitals.

I will, however, turn from this splendid vision to the more sombre human angle. It is probably one of the most distressing experiences that anyone can undergo to be forcibly put into a mental hospital, and we must dispense with euphemisms for a moment and call a spade a spade, because force is the ultimate sanction of putting these unfortunate people into mental hospitals.

As I have said, it is a most unfortunate experience to be put into a mental hospital, to be conducted there by a local authority official and perhaps also a policeman if there has been any show of recalcitrance. Such an experience as this is hardly conducive to the improvement of mental health which, after all, is supposed to be the object of the exercise, even in the best of circumstances. It behoves a civilised community to soften the blow and to ensure that, where detention is necessary, not only is justice done but also that it is seen to be done, and this is far from being the case at present.

The law of lunacy is antiquated, muddled and obscure. The Lunacy Act, 1890, has been amended and re-amended in such a way that practically nobody understands it at present, even the cleverest and most able people being at sea with it. The hon. Lady the Parliamentary Secretary may perhaps deny this, but I hope she will pardon me if I say that she is herself one of the most outstanding instances of this. We all admire her competence and grasp of her Department's work, yet when she comes to talk of the law of lunacy she seems to me to be at sea with the rest of us.

On 19th November, 1952, when she spoke in the debate on geriatrics, in reply to the accusation of over-zealous certification of elderly people, she said that patients can only be certified first on medical examination and then on the order being signed by two justices. I hope she will excuse me correcting her when I point out that, according to the 1953 figures, there were some 20,000 people put into hospital by summary reception order and only 350 by petition. A summary reception order requires the signature of only one justice—any justice who is available.

I think we can say that the Section 16 procedure, under which most people are sent into mental hospitals, itself is a direct inheritance from the Victorian Poor Law arrangements which were incorporated into the Act of 1890, and it is characterised by the same lack of humanity. This can only be softened properly with alteration of the law—and, of course, it is not proper in a debate such as this that I should make a suggestion in that connection—in such a way as I have suggested, namely, by the establishment of proper observation wards such as those which are working very successfully in the L.C.C. area and which could be made to work in other places equally well, so that there would be proper medical observation, proper diagnosis, before this dire and rather terrible step is taken.

11.30 p.m.

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

The hon. Member for Carlisle (Dr. D. Johnson) has, I know, a very great interest in this topic, but I think that he has done less than justice to the great work that has been done towards removing the stigma from our mental hospitals. In fact, the whole tenor of the debate has unfortunately been to put back the stigma which we have worked tremendously hard to get removed.

The very substantial increase in the number of voluntary patients going into hospital over the last years, from 51 per cent. only of voluntary patients in 1946 to 75 per cent. in 1955, shows that there is indeed a new outlook on our mental hospitals and that great efforts have been made to remove any sense of stigma when people desire to get treatment and care in our mental hospitals.

I should first like to correct a misconception which has grown up as a result of reference to Section 20 accommodation as "observation wards." Section 20 of the Lunacy Act, 1890, as amended, says: If a duly authorised officer of the local health authority or any constable is satisfied that it is necessary for the public safety or the welfare of a person alleged to be of unsound mind with regard to whom it is his duty to take any proceedings under this Act that the said person should, before any such proceedings are taken, be placed under care and control, the officer or constable may remove the said person to any hospital or part of a hospital vested in the Minister (whether a mental hospital or not) which is designated by the Minister for the purposes of this Section, and the person in charge of the said hospital or part shall receive and detain the said person therein, but no person shall be detained under this Section for more than three days. There is no mention of "observation". A person is admitted to Section 20 accommodation when it is necessary for the public safety or for his welfare to put him under care and control while the justice, who in such cases has to be notified, puts into operation the steps required by the Act to enable him to inquire into the mental condition of the patient. The purpose is not to provide a period during which the mental condition of the person shall be observed.

The suggestion that unless a person is dealt with initially under Section 20 he is deprived unfairly of his liberty by being sent to a mental hospital as a certified patient, is really not correct. Whether a person is certified in a Section 20 hospital, or in his home or anywhere else, the procedure is precisely the same. The case is notified to a justice; the justice calls in a medical practitioner to examine the patient. On the basis of the medical opinion the justice makes up his mind. He may make an order or decline to do so. Even when the making of an order would be justified he may be content to allow the patient to go to the care of a relative or friend, if he is satisfied that proper care will be taken of him.

The use of Section 20 does, of course, mean that a patient has been in medical charge for a period before an order is made, but a certificate for the purposes of the order is based on facts indicating insanity observed by the certifier at the time of his examination. The certifier may add facts communicated to him by others, such as nurses and relatives, about the patient's behaviour, but a certificate which included only such facts is not valid for the purposes of an order, and the Act expressly says so.

It will, therefore, be seen that "observation" of a patient in a Section 20 case is really irrelevant to the making of an order. I would emphasise that the decision whether an order shall be made rests entirely with the justice and with no one else.

I should also like to point out that practically every patient who is certified outside a Section 20 hospital has been under medical observation and treatment for varying periods previously, either by a general practitioner or through attendance at out-patient clinics.

The primary purpose of Section 20 is to provide hospitals to which persons who need to be placed under control as well as given treatment without delay can be removed without formality beyond the action of the duly authorised officer. In other words, it is for cases of emergency where prompt removal of a patient has got to be made.

Before the National Health Service Act, patients dealt with under Section 20 could only be sent to Public Assistance institutions. In those days the Section was specifically intended for use in urgent cases. It was, in fact, side-noted: Removal of person of unsound mind to a public assistance institution in urgent cases. I realise that professional opinion about the use of Section 20 has been very divided for a considerable number of years, but I think I can give my hon. Friend some of the figures for which he asked. There were at the end of 1954, 71 mental hospitals, 43 mixed hospitals and 26 general hospitals designated to which persons could be sent compulsorily under Section 20. Since 1949 the number of mental hospitals used for the purpose has increased from 67 to 71, and the admissions increased from 2,072 in 1949 to 7,141 in 1954. For other hospitals, the number of units had fallen from 118 to 69, but the number of admissions increased from 16,468 to 17,329.

The number of Section 20 cases admitted to all these hospitals in 1954 was 24,470, of which 7,141 were admitted to mental hospitals, 7,638 to mixed hospitals and 9,691 to general hospitals. There is no clear evidence that the types of patient sent to the three kinds of hospital differed very much. For the most part, each had its own collecting area, and there seemed to be little overlapping.

In the mental hospitals 82.2 per cent. of the Section 20 patients remained in hospital, but only 24.8 per cent. of the admissions were, in fact, certified. The corresponding figures for the other hospitals are 59.9 per cent. sent to mental hospitals and 35.1 per cent. of the total admissions were certified. Thus, more than half the patients sent from general hospital Section 20 wards to mental hospitals were sent as certified patients, whereas of those admitted in the first place to Section 20 wards in mental hospitals only one quarter continued under legal detention. It therefore seems that the proportion of voluntary patients is higher resulting from admissions into the mental hospitals than from admissions into the other hospitals.

Mr. J. E. S. Simon (Middlesbrough, West)

Can my hon. Friend say why that should be so?

Miss Hornsby-Smith

That is a matter of medical controversy, and I would rather not give an opinion on it at this stage.

Of the total Section 20 admissions, 12.7 per cent. were discharged from the mental hospital wards within the detention period, whereas the discharge rate from those of the mixed and general hospitals was 33.1 per cent. The differing results indicated by these percentages support the view—the point that I made just now—that many patients admitted direct to mental hospitals are willing to stay on as voluntary patients.

My hon. Friend suggested that the use of Section 20 accommodation in other than mental hospitals reduces the number of admissions to mental hospitals, particularly of certified patients. That is not really borne out by the facts. As I have already mentioned, more than half the patients sent from Section 20 accommodation in general hospitals to mental hospitals in 1954 were certified whereas of those admitted in the first place to Section 20 accommodation in mental hospitals, only one quarter remained as certified patients.

I feel that this is largely the result of the new outlook which we have striven so hard to get in our mental hospitals and of the upgrading and the improved conditions in many of the hospitals which have resulted in removing the stigma formerly attaching to them and has made people look upon entry into a mental hospital as entry into a specialist hospital for the treatment required for mental illness comparable to their going into a general hospital for physical illness. It is important that nothing should be done to encourage the public to revert to the days when a stigma attached to mental hospitals. The facts that 75 per cent. of the patients go in as voluntary patients, that the rate of turnover is increasing every year, that many patients are discharged within two months, are trends in the right direction which hon. Members on both sides of the House will most heartily support.

As to my hon. Friend's suggestion that we could save beds, a bed, whether in a general hospital or a mental hospital, will cost money, and it will not be easier vastly to extend observation wards than to continue with the deliberate priority hospitals, where 3,000 beds have in the past few years been included in the regional hospital boards' programmes. A like number has in the past few years been included in the regional hospitals boards' programmes.

In any event, the Royal Commission on the Law Relating to Mental Illness, now sitting, can be expected to deal in its Report with all the procedures for compulsory admission, including procedures necessary in emergency circumstances. The House will appreciate that I obviously cannot anticipate what this important Commission, at present taking its evidence and preparing its Report, will say. Certainly my right hon. Friend will give that most important document the fullest possible consideration when it is received. It would be premature to anticipate any suggestions which it may make.

I should like to assure my hon. Friend the Member for Carlisle that there is no lack of sympathy with these patients. Our desire is to see that they get early treatment wherever possible. There has been considerable extension of domiciliary work by local authorities and people can have psychiatric advice and treatment at home; there have also been extensions in annexes for the old in order that they need not be certified if they become a little confused and no longer capable of staying in normal Part III accommodation.

The whole trend has been to help people to avoid becoming certified. I do not think that the patients' best interests would be served by reducing in mental hospitals the importance of voluntary treatment or by moving away from the new approach whereby people look upon mental hospitals as somewhere where they can go for treatment and where only in absolute necessity will they be certified.

Adjourned accordingly at seventeen minutes to Twelve o'clock.