§ 3.33 p.m.
§ The Minister of Health (Mr. Derek Walker-Smith)
I beg to move, That the Bill be now read a Second time.
This is a long Bill, with its 146 Clauses and eight Schedules. It is also, inevitably, a technical Bill, but no more complex than the inherent complexities of its subject matter require. It repeals 15 Acts in whole and 37 Acts in part. In their place we propose to put a new pattern—comprehensive, simpler to understand and apply, and in line with contemporary thinking and medical and social advance.
In its leader on the publication of the Bill, The Times called the existing laws on mental health a jungle. They are certainly complex, difficult, and in many respects out of date. Consequently, in replacing the mosaic—to use a politer term—of the law and procedure produced by our fathers and forefathers with a single contemporary design, we are making a clean sweep. But this holocaust of the laws made by our predecessors does not carry any condemnation of their actions. They, particularly in the nineteenth and early twentieth century, laboured for progress in their day as we do in ours, and laboured against a historical background dominated, or at any rate largely influenced, by ignorance and fear.
The classical and mediaeval attitude to mental disorder was based, if not on condemnation, at any rate on a fatalistic acquiescence. It was summed up in the phrase, "Quos deus vult perdere prius dementat"—"Whom the Gods wish to destroy, they first make mad".
The legislation which we now repeal marks, of course, a great advance on this negative concept. I shall have to refer, as we go along, to some of these laws; but to most of us, I suppose, the past is more real in its literature than in its laws. In this context, the House will recall two famous characters of Victorian fiction, representing the two extremes of mental disorder. Mr. Rochester's wife, a Victorian manic depressive, as I suppose we should now say, whose demented screams and homicidal fits brought terror to Jane Eyre, marks one extreme. 705 The simple Mr. Dick, in David Copper-field, with his amiable obsession about King Charles' head, marks the other.
The first illustrates something of the terror and shame aroused by insanity in the nineteenth century, and the other shows the acceptance, nevertheless, at that time, of the harmless mental case within the community. But these two cases had one common factor. Neither had any prospects of any adequate treatment.
It is really the advance in methods of research and treatment that divides us so decisively from the past. The mentally sick, of course, received some care in the past, even in the middle ages. For example, Bethlem Royal Hospital, the traditional Bedlam of popular idiom, was founded in 1247. At a later date, in the nineteenth century, there was some improved treatment, but scientific research and medical treatment are, by and large, a modern plant of an intensely vigorous and rapid growth.
Research in many fields has a bearing on psychiatry. From psychology and from the work of pioneers like Freud there has come a better understanding of how the mind works and why people behave as they do. The bacteriologist has removed the old scourge of general paralysis of the insane. Electro-physiology and cerebral surgery are making more comprehensible the functions of the brain. Metabolic studies, genetics, biochemistry and many others all play their part.
In the hospital, the use of physical treatments such as insulin, E.C.T., leucotomy and drugs have made many hitherto withdrawn patients accessible to rehabilitation through treatments such as group therapy, organised occupation, and the "open door" principle. In the community, out-patient work carried on at general hospitals has helped to encourage early treatment.
Complementary with this advance, and in no small degree due to it, there has been a parallel and most welcome advance in the public attitude to mental disorder. People nowadays are much more ready to face the problems that beset us, and appreciate the potentialities that await us. They probably do not, in general, know that, of all patients admitted in 1956, three out of five were discharged within three months and three out of four within six months. But they are beginning to 706 realise what is implicit in these figures—that mental disorder, and particularly mental illness, is by no means necessarily or normally a life condition. In fact, the change in public attitude has been as rapid as it is welcome. More and more people are coming to understand that compassion and understanding, not indifference and fear, are our best guides in these strange and troubled regions.
The position today is this. Our code of law and procedure, mainly fashioned for an earlier day, is out of phase with our advance in medical skill and public understanding. Our task, therefore, as Government and Parliament, is to provide a new contemporary code in keeping with this advance and able to assist and accelerate the further advance for which we hope. This Bill provides that code. In evolving our new code we have had the inestimable benefit of the detailed study and careful consideration of the Royal Commission on the Law Relating to Mental Illness and Mental Deficiency. Appointed in 1954, when my right hon. Friend the present Minister of Labour was Minister of Health, the Commission laboured devotedly for three years and produced its authoritative Report in May, 1957. This was followed in two months by the debate in the House and eighteen months later by this Bill.
I should like to pay a warm and sincere tribute to the members of the Royal Commission which, I know, will be echoed and endorsed by the House and, indeed, by the country as a whole. My only grief is that the distinguished Chairman did not live to see the introduction of the Bill and its passage, we hope, to the Statute Book. Like all who had the privilege of any acquaintance with the late Lord Percy of Newcastle, I had the greatest respect and admiration for the high quality of his mind, the fertility of his ideas and his humane and progressive outlook.
I am sure that the House would also like to pay tribute in this context to the memory of another member of the Royal Commission who has died very recently. I refer to Sir Cecil Oakes. We mourn their loss and salute their memory.
There are two other members of the Royal Commission, happily still with us, whom I may perhaps be allowed to mention. I refer to my hon. and learned Friend the Financial Secretary to the 707 Treasury and the hon. Lady the Member for Liverpool, Exchange (Mrs. Braddock). We are grateful to them and to my right hon. and learned Friend the Solicitor-General, who was a member of the Commission for a time, for finding time for these long and useful labours.
In the main, we have been able to follow in the Bill the recommendations of the Royal Commission, but in some respects we think that we have been able to improve upon them. These divergencies, to use a neutral term, we can discuss as we go along. Our existing law and procedure are based on the certification of patients and the designation of hospitals for the treatment of mental illness and mental deficiency. Certification and designation are both discontinued in our new code.
We had two main principles in mind in the formulation of the Bill. The first was that as much treatment as possible, both in hospital and outside, should be given on a voluntary and informal basis. The second was that proper provision should be made for that unfortunately inevitable residual category of cases where compulsion is necessary in the interests of society or in the interests of the patients themselves. This involves applying appropriate safeguards for the liberty of the subject, on the one hand, and for the protection of the public, where necessary, on the other.
I will now seek to show how the Bill implements these principles. Even a casual reading of the Bill shows that, physically speaking, not a great part of this very lengthy Bill is taken up with the application of the first principle, but applied it is. It is implemented by removing the procedural formalities which are necessary at present for voluntary treatment. This is achieved by Clause 1, which repeals the two series of Acts which grew up in the nineteenth and twentieth centuries as the codes for dealing respectively with lunacy, so-called, and with mental deficiency.
It is also by the repeal of these Acts that the separate designation of mental and mental deficiency hospitals is brought to an end. Segregation is effected at the present time by Section 315 of the Lunacy Act, 1890, and Section 51 of the Mental Deficiency Act, 1913. These Acts forbid the recep- 708 tion of more than one person of unsound mind or mental deficiency except in establishments specially designated, certified or approved for the reception of these categories of patients.
By removing the necessity for designation, any general hospital will be legally empowered to receive patients suffering from any form of mental disorder. Outpatient clinics and psychiatric wards for the treatment of the milder forms of mental illness have been provided during the last ten years at many general and teaching hospitals. We hope and expect that such arrangements will be considerably extended as a result of the Bill.
Clause 5 (1) shows that, although so much of the Bill is concerned with provisions regarding compulsory procedures, it is set against the background of a general reliance on voluntary and informal procedures. In short, under the provisions of the Bill there is nothing to prevent a mental patient receiving treatment as a voluntary patient in the same way as in other hospitals. This is what we hope and expect will happen in the great majority of cases.
The Bill, therefore, signals the end of designation and the end of the principle of compulsory segregation. In their stead, it establishes the principle that mental health will be dealt with as an integral part of the work of the National Health Service and generally on an informal and voluntary basis.
Before dealing with the second main principle to which I have referred, I should like to deal with one or two other points of importance in Part I. Clause 2 dissolves the Board of Control. The Board has long been working towards the reform of our laws and the improvement of our procedures as now contained in the Bill. Indeed, it was the Board which proposed its own dissolution at the stage which we have now reached. Its dissolution brings to an end forty-five years of useful activity.
I should like to pay a warm tribute to the work of the chairmen and Commissioners over that period. We shall not, however, lose the skill and experience of the present members and officers of the Board, who, as will be seen from Clause 2 (2), will become officers of the Ministry of Health. The functions of the Board will be transferred to the Ministry of 709 Health, to local authorities, and, in respect of discharge, to mental health review tribunals, about which I shall have a word to say later. I shall say a word about Clause 3 in a moment in the context of compulsory procedures.
Clause 4 is a very important Clause, but is not very easy to understand. It consists of two main elements. The first is the definition of mental disorder contained in subsection (1), and the second is the definition of the three definable categories of mental disorder, which, together with mental illness, make up the whole. These definitions are contained in subsections (2) to (4).
The definition of mental disorder is of great importance. In the Seventh Schedule to the Bill, the definition of illness in Section 79 of the National Health Service Act is amended to include mental disorder. Thus, the term "mental disorder" as here defined is introduced into the National Health Service Act as one single term to replace the two present terms "mental illness" and "mental defectiveness". It will, therefore, describe the forms of mental ill-health for the relief and prevention of which hospital and specialist services, and, of course, local health authority services, may be provided under Parts II and III of the National Health Service Act.
The definition includes mental illness; arrested or incomplete development of mind, which includes, in turn, sub-normality and severe subnormality; psychopathic disorder and any other disorder or disability of mind. We have sought to make the definition of mental disorder wide and comprehensive. This is a correct approach, because it is in essence an entitling or qualifying definition, a definition of those states and conditions to which we may lawfully and appropriately administer the care and treatment which the National Health Service provides.
The definition of the three definable forms of mental disorder must, on the other hand, be narrowly drawn, with as much precision as the nature of the subject allows, and must be capable of interpretation and application by all concerned with the compulsory procedures and in particular, of course, by the doctors and 710 the new tribunals. They must be narrowly drawn because these definitions form the basis of compulsory admission to a hospital or guardianship under Parts IV and V of the Bill.
Their consideration brings me to the second main principle which I have defined. I said that there was bound to be a minority of residual cases in which compulsion is necessary in the patient's own interest or that of society. Under the new code, a person can only be com-pulsorily detained if, in the words of Clause 26 (1, b),it is necessary in the interests of the patient or for the protection of other persons that the patient should be so detained".The other prerequisite of compulsory detention is that the patient should be suffering from one or more statutory forms of disorder to an extent, in the words of Clause 26 (1, a),which renders him suitable to be detained in a hospital for treatment".What precisely these forms of mental disorder are bring us back to Clause 4. Mental illness needs no express definition in the Bill. The other three forms of mental disorder—severe subnormal, subnormal and psychopathic—replace the four categories of mental defectives in the present Mental Deficiency Acts—idiots. imbeciles, feeble-minded and moral defectives.
Subnormality is defined in subsection (3). The essential element of this definition and of that of severe subnormality in subsection (2) is that the arrested or incomplete development of mind includes a subnormality of intelligence. By contrast, psychopathic disorder as defined in subsection (4) does not necessarily include subnormality of intelligence.
The main criterion in the definition of severe subnormality which distinguishes it from ordinary subnormality is that the patient's arrested or incomplete development of mind is of a nature or degree which renders him incapable of living an independent life.
Clause 4 (4) defines psychopathic disorder. This is not an easy task. A psychopath is sometimes easier to recognise than to define. Indeed, there were those who said that it might be better not to essay any definition at all. For the reasons I have given, however, we felt ourselves bound to include as precise a 711 definition as we could. Therefore, the essential elements of psychopathic disorder are here defined as follows.
First, a persistent disorder of personality; that is to say, there must be signs that the disorder has existed over a considerable period of time before a diagnosis of psychopathic disorder can be made. Secondly, the disorder must result in abnormally aggressive or seriously irresponsible conduct—a stringent requirement not paralleled in the definition of subnormality. Thirdly, the disorder must require, or be susceptible to, medical treatment as defined by Clause 142 (1) of the Bill.
We consider that these three categories, together with mental illness, constitute an improvement on the Royal Commission's recommendation of only two categories other than mental illness. The Royal Commission's extended use of the term "psychopathic" was strongly criticised by the medical profession and others following the publication of its Report. This is not, perhaps, surprising as the Commission's use of the term "psychopath" would have been much wider than that already in general use and would have been difficult to apply and objectionable for that reason. Our definition of psychopathic disorder in subsection (4) approximates much more closely to the general understanding of this term.
To found a case for compulsory detention, a person must be suffering from at least one of these four forms of mental disorder and each of two medical practitioners must diagnose, and specify in writing, that particular form of mental disorder.
In addition to the basic safeguard of Clause 26 (1, b), to which I have already referred, we provide in the Bill substantial and important procedural safeguards. In particular, I will mention two. First, two medical recommendations will be needed in all cases except in emergencies, when one will be sufficient for the first 72 hours only. That is to be found in Clause 26 (2) and Clause 29 (3). Secondly, patients will be able to apply to a mental health review tribunal at any time within the first six months after admission. At present, although two medical certificates are necessary for mental defectives, only one is normally required in the far more numerous cases of persons of unsound mind.
712 We have sought improvements in respect of the liberty of the subject in qualification and method as well as in numbers. Clause 28 (2) requires that one of the medical recommendations shall be given by a practitioner approved by a local authority as having special experience in the diagnosis or treatment of mental disorders, while one practitioner must, if practicable, have previous acquaintance with the patient.
The method of procedure of medical recommendations is a decided improvement on the old practice of certification. This is apparent from reading subsection (2) of Clause 26. Under that provision, both medical practitioners must state their opinion that the two basic prerequisites are satisfied: that is to say, of suffering from a specified mental disorder to the required degree, and secondly, that detention is in the interests of the patient or of the public. These recommendations, however, must also specify—this is a particularly valuable safeguard—whether other non-compulsory methods of dealing with the patient are available and, if so, why they are not appropriate in the particular case.
Resort to a tribunal introduces, of course, an entirely new safeguard. Clause 31 (4) entitles a patient to apply to a tribunal within six months of admission if he challenges the necessity of compulsory admission. These tribunals will be constituted, under Clause 3, on a regional basis. That is to say, when the new Wessex Region comes into force, in April, there will be 15. Their composition is described in the First Schedule to the Bill. They will have legal and medical members, and also members with social or administrative experience, and will be presided over by a legal chairman. Their rules of procedure will be made by the Lord Chancellor under Clause 122. Lawyers will note the provision for a case to be stated to the High Court on questions of law.
Where application is made to them these tribunals have under the Bill a wide and sufficient jurisdiction to protect the liberty of the subject and to prevent abuse. If satisfied that the patient is not, in fact, suffering from mental disorder in the requisite degree, or that it is not necessary in his interests or for the protection of the public that his detention should continue, then the tribunal will discharge the patient. This is dealt with 713 in Clause 121, which also gives the tribunals the power of reclassification. Just as the right of application to a tribunal is one of the main safeguards against improper admission under compulsory powers, so it is a main safeguard against unduly protracted detention.
The renewal procedures for compulsorily detained patients are given in Clause 43 (1) and (2). In effect, patients' cases will be reviewed at the end of the first, second and fourth year, and thereafter at three-yearly intervals if they remain so long, instead of, as at present, for the mentally defective, at the end of the first, second and seventh year and thereafter at five-yearly intervals, with an additional review for the mentally ill at the end of the fourth year.
Under our new procedure each renewal of authority for detention, following on the prescribed review, gives the patient the right of application to the tribunal under Clause 43 (5). In addition, the patient and the nearest relative have the right to apply on any reclassification of the patient under Clause 38 (2).
In formulating these procedures we have sought to combine regard for the liberty of the subject with safeguards for the protection of the public. This, of course, necessitates some restrictions on the normal power of discharge where the patient is likely to be dangerous, but in every case under Part IV, with which I am now dealing, such restriction carries the right of appeal to a tribunal.
Under the Bill, broadly, the power of discharge is held by these people: by the doctor in charge of the patient's treatment, by the managers of the hospital or nursing home, by the patient's nearest relative, and, on application, by a tribunal.
§ Mr. F. J. Bellenger (Bassetlaw)
Does this apply to the criminal lunatic institutions, the three of them?
§ Mr. Walker-Smith
There are some restrictions on those, which I am coming to in a moment. I fear that this will inevitably be a long speech. I am trying to do my duty of explaining the Bill, and I am rather afraid, though I am anxious to give way if hon. Members so desire, that by trying to deal out of order with a point to help one hon. Member I may 714 only make it a longer speech and more difficult to follow, in its general pattern, by the rest of the House; so I hope that I shall be allowed to follow the pattern to which I have given great care, to try to do my best to explain the Bill to the House.
It is not only the introduction of the tribunal procedure which is new. The power of discharge given to the doctor is an improvement under the Bill. Another very important change concerns the nearest relative. At present, the nearest relative has the power of discharge for mental illness but not for mental deficiency. With the assimilation of the two codes these differentials will now cease and the nearest relative will have the power of discharge in all cases.
But we have not, in all this, forgotten our duty to the public in this context. Under Clause 48, a relative proposing to exercise the power of discharge must give 72 hours' notice of intention to the managers of the hospital. If the responsible doctor reports that the patient, if discharged, would be likely to act in a manner dangerous to other persons or to himself the discharge does not take effect, but under Clause 48 (4) the right of application thereupon arises to a tribunal at the suit of the relative.
There are, of course, other safeguards for the public in Part V; that is where patients are made the subject of hospital orders after conviction or being involved in court proceedings; but I am at present dealing with the ordinary run of cases under Part IV.
There is one other matter of importance under Part IV which illustrates both our concern for the liberty of the subject and for the protection of the public. I refer to the special provisions made for psychopaths and for subnormals. Under our new procedure they will be liable to compulsory admission under the age of 21 only, and will ordinarily be entitled to discharge at 25. The principle here is that the formative years for treatment and training are those earlier years and that it is not proper to deprive a person of liberty under these laws except for the purpose of treatment with a view to amelioration or cure.
But we have also to consider the position of the public. Psychopaths and subnormals subject to compulsory detention 715 will, therefore, be specially examined by the responsible medical officer at the age of 25, and if he considers that the patient, if released, would be likely to act in a manner dangerous to other persons or to himself he will so report and the discharge will not take effect. Here again, however, a right of application to a tribunal will vest in the patient and nearest relative if they wish to challenge the decision.
This, again, is a divergence from the recommendations of the Royal Commission, because they would have given all psychopathic patients an automatic release on attaining the age of 25. I think that ours is clearly an improvement, as there may obviously be cases where the protection of the public demands this procedure, but, again, we have been careful to safeguard the liberty of the subject by prescribing a right of application to the tribunal.
I have dealt now with the main substance of the compulsory procedures in Part IV, but there are a few other provisions in Part IV which merit a short but specific reference.
Clauses 33 and 34 prescribe the code of procedure for reception into guardianship. This procedure broadly parallels, mutatis mutandis, the hospital procedures I have described.
Clause 36 deals with the correspondence of patients. Ordinarily, letters to and from patients will come and go as written. There is, however, a necessary exception to this, where, on the one hand, receipt of a letter by a patient would cause unnecessary distress to the patient or interfere with treatment, and, on the other, where letters written by patients are unreasonably offensive to the recipients. There will, however, be no right of detention of letters written by patients to the Minister or to the other persons named in Clause 36 (2). This includes for the first time the Member of Parliament for the patient's constituency—a provision which I am sure will give satisfaction to the House.
Most of the rest of the provisions in Part IV, to which I have not referred specifically, deal with such matters as visiting, leave of absence, absence without leave, and transfers. But there are two further Clauses which merit special attention—Clauses 52 and 56.
Where a mental welfare officer applies under the Bill for the compulsory admis- 716 sion of a patient he must, if practicable, consult the nearest relative and may not proceed if he objects. This is under Clause 27 (1). But there may be cases where the nearest relative may not act in the best interest of the patient—or, indeed, of the public. For example, he may unreasonably object to the application, or he may be likely to exercise unreasonably his power to discharge. To meet these cases, the Bill gives jurisdiction to the county court to transfer the nearest relative's functions to a proper person under Clause 52 (1).
The other matter that arises under Clause 56 is that the Royal Commission recommended that the Minister of Health should have a personal power of discharge. The Bill does not give him that power of discharge, except in his capacity as manager of the State institutions. It seemed to us that such power would run counter to the principle of judicial approach and interpretation, which is the cornerstone of our tribunal procedure. If the Minister could override this decision by an administrative act, it would inevitably derogate from the standing and authority of the tribunals, and also possibly from the confidence felt in them by the public.
We have, however, sought to meet the case where special circumstances are brought to the attention of the Minister by giving him, in Clause 56, power to refer a case to the tribunal at any time without waiting for the renewal intervals or other circumstances normally necessary to found the right of application.
So far, I have been dealing with the ordinary run of compulsory detention procedure under Part IV. I now come to Part V, which deals with the procedures for mentally disordered people who have come before the courts. The Royal Commission recommended that the courts should have the power to send a mentally disordered patient to hospital, or place him in guardianship, in those cases where ordinary penal measures appear to be inadequate or inappropriate. Part V gives effect to this principle.
In dealing with Part IV. I have referred to the necessity to reconcile, as far as possible, the liberty of the subject with the protection of the public. In these court cases, the considerations affecting the safety of the public are, of course, likely to be of particular importance. This 717 is the reason for the main differences in Part V procedure from the ordinary procedures of Part IV.
Under Part V, the courts of assize and quarter sessions may make an order restricting the discharge of an offender from hospital if it appears to the court, having regard to the nature of the offence, the antecedents of the offender, and the risk of his committing further offences if set at large, that it is necessary for the protection of the public to do so. If an order is made, the patient will not be able to be discharged or given leave of absence from hospital without the Home Secretary's consent. This is provided for in Clause 64. But except in cases where the court makes such a restriction order, people sent to hospital under these Part V powers will be treated in the same way as those under Part IV. They will have similar rights of access to a tribunal.
The only difference will be that the nearest relative will not have the right of discharge, and that psychopaths and subnormals will be liable to detention after the age of 25. This is found in Clause 62. The differences in procedures are necessary in the public interest and are limited to what is necessary for that. But the places to which all patients go are hospitals, with treatment as their primary aim.
Next I come to the important matter of how, under the Bill, existing patients are absorbed into the new procedures. This is dealt with primarily in Clause 143 and the Sixth Schedule. Part III of the Sixth Schedule defines the classes of patients to whom the transitional provisions apply. In effect, the provisions are these: patients for whom an order is in force on the appointed day continue to be liable to be detained for six months.
During this period the responsible doctor will classify each patient in the terminology introduced by the Bill, that is, mentally ill and the other categories. At the same time, there will be a special review of certain subnormal and psychopathic patients. All patients, except those subject to the special review, will continue to be liable to be detained for the remainder of the term of their existing order. When this is due to expire it may be renewed under Clause 43, but the patient then has the right of application to a tribunal for discharge.
718 There is a further improvement for patients whose last order for renewal was for five years, where that period has not expired or has been renewed three years after the appointed day. These patients are given a special right of access to a tribunal three years after the appointed day. By these provisions all patients, not later than the end of the period of their existing order, are brought Into the new procedures for expiry and renewal at no longer than three-year periods.
In addition, further new rights are given to those patients who are the subject of the special review, that is, those subnormals and psychopaths who, by reason of their age, would not now, under the new law, be subject to detention. Those subnormals and psychopaths who have reached the age of 25 or were over 21 when first admitted, will, unless their original order was made by a court, or by the Home Secretary, on transfer from prison or approved school, be specially examined during this six-months' period by the doctor responsible. They may be discharged from compulsion, but, here again, we must consider public safety.
The doctor may think the patient unfit for discharge, or that if released he would be dangerous to himself or to others, or that he would be exposed to danger or serious exploitation by others, or that he would be likely to resort to criminal activities, or that he might be incapable of looking after himself, and there is no other establishment in which he could be suitably accommodated as a voluntary patient. If the doctor records such an opinion, the patient will not be discharged unless, of course, he applies successfully to a tribunal.
To complete the picture in regard to existing patients, I should explain the position of Broadmoor patients and of other patients transferred from prison or approved school whose original term has not expired. Until the term expires they will be able to be discharged only with the consent of the Home Secretary. After the term expires, however, they will be in the same position as patients originally admitted by order of a court, which I have already described.
§ Mr. Walker-Smith
My right hon. and learned Friend the Solicitor-General will deal with that point when he replies to the debate.
I should like to come to Parts II and III of the Bill. I am sensible of the passage of time, but before referring to their provisions I must make some prefatory remarks about the principles involved. One of the main principles which we are seeking to pursue is the reorientation of the mental health services away from institutional care towards care in the community. This is not, however, just a local authority matter. Hospitals and local authorities both have their part to play and neither can make the maximum contribution without the other, nor, indeed, without the co-operation of the public in accepting the presence of suitable patients in the community. There is still plenty of educational work required in this latter context.
As I have said, there has, happily, been a much greater public understanding of the problems of mental disorder in the last year or two, and public opinion has shifted away from the idea that the mentally ill need to be shut away. However, some of the change still amounts only to lip-service. The idea of caring for the mentally disordered in the community is still often accepted only as a principle. Too often it becomes a different matter if a hostel is to be provided in the house next door or even in the same neighbourhood.
I think that personal sympathy and help are still too often lacking when compared with the feelings of charity and understanding which are aroused by those who suffer from a physical disability. It is for those who can guide public opinion to show full support for the new attitude which will be required if the plans of the hospitals and local authorities are to succeed.
On the hospital side, we are making progress with the provision of out-patient clinics, and expect to make more. In particular, we are seeking to expand and improve the work of psychiatric outpatient clinics at general hospitals in the main centres of population. Such clinics now exist in most parts of the country, but the number of sessions and the quality of work done varies a great deal.
Much excellent work is already being done. Along with the out-patient work. 720 the hospitals are also developing other domiciliary services in close co-operation with the local health authorities and with general practitioners. Mapperley Hospital, Nottingham; Warlingham Park, Croydon; and Whitchurch, Cardiff, are outstanding in this connection, and so are Bootham Park and Naburn Hospitals, in York; St. Luke's, Middlesbrough; Graylingwell, at Worthing. And there are others.
The local authorities have a wide range of services in this field, but their contribution to community care does not, in fact, depend on new legislation. They already possess sufficient powers under the Mental Deficiency Acts, the National Health Service Act and the National Assistance Act.
Local health authorities have statutory duties under the Mental Deficiency Acts for providing training, occupation and general supervision for mental defectives living in the community and for arranging admission to hospital when necessary; and under the Lunacy and Mental Treatment Acts they have similar duties to arrange for the admission of mentally ill patients to hospital when necessary. Nowadays, these duties are being increasingly discharged as part of a more general service of social support, under which social workers visit patients in their homes and give advice to them and to their relatives.
In recent years the mental health services of the local authorities have been steadily expanding, as is evidenced by the progressive increase in their net expenditure on them. In 1954–55, the net expenditure was £2,292,000; in 1955–56, it was £2,627,000, an increase of £335,000. In 1956–57, it was £3,127,000, a further increase of £500,000. In 1957–58, it was £3,647,000, a further increase of £520,000, and this year, 1958–59, it is estimated that the figure will be £4,100,000. a further increase of £453,000.
§ Mr. A. Blenkinsop (Newcastle-upon-Tyne, East)
May I ask whether the figures which the Minister is quoting, which are important, relate purely to mental health support services or to general welfare support services?
§ Mr. Walker-Smith
These are estimates of the expenditure on services expressly provided for the mentally disordered. In addition, of course, the mentally disordered make considerable use of the 721 ordinary local health authority services which are available generally, such as home nursing, health visiting and domestic help. One cannot calculate the figure which ought to be added in respect of those.
In expanding these services to date, local authorities have concentrated mainly on occupation and training centres for children not suitable for education in school. Those who have visited, and know, these centres will be aware of the wonderfully skilled and patient work which is proceeding in them. The number of these centres for children has risen from 100 in 1948 to 264 at the end of last year. In addition there are 43 full time and seven part-time centres for mentally subnormal adults; and I look forward to a substantial increase in this type of centre now that the provision for children is becoming more adequate.
As the House knows, local authorities' powers to provide residential accommodation derive from Section 21 of the National Assistance Act and also from Section 28 of the National Health Service Act. Under the National Assistance Act they provide residential accommodation mainly for the elderly. During the last ten years they have made progress in the expansion of such accommodation to the extent of providing more than 30,000 new places. In the homes provided they already have numbers of elderly people who are mentally infirm.
We hope that in future people whose mental faculties decline in old age, and who cannot be cared for at home, will be increasingly accommodated in residential homes provided by local authorities. In many cases, of course, admission to a mental hospital for treatment is necessary and desirable; but many old people respond to psychiatric treatment as well as younger patients, and should not be kepi in the mental hospitals when they have recovered to the extent of needing no more than the care and attention which can suitably be provided in local authority homes—if, indeed, it cannot be provided by their own families.
Some of these patients are at present discharged from mental hospitals to local authority homes, but there is a need for many more places for this purpose. One or two authorities have set aside homes especially for the elderly mentally infirm. 722 Further experience is needed to show the extent to which special homes are needed, and also to show the extent to which old people, whose mental confusion is not serious enough to require specialist treatment, should be, in general, old people's homes.
Residential homes are needed not only for the elderly. Most of the patients in the older age groups in mental hospitals are not patients who entered hospital in old age. They are patients who entered hospital in middle age in days when treatment was often sought too late for a good chance of recovery, and who have remained ten or twenty years or more as chronic patients and grown old in the hospital.
We do not wish to uproot patients who have been settled in these hospitals for many years. Indeed, it would be quite impracticable and, in some cases, inhumane to do so. But, for the future, we want patients who develop illnesses in middle age to be treated early with good hope of recovery. Those whose recovery is not complete, but who cannot go to their own homes, may need hostels providing a semi-sheltered environment to which they can move when they have gained all the benefit they can from specialist hospital treatment. Local authorities have a part to play here, too.
Local health authorities using their powers under Section 28 of the National Health Service Act—and Clause 6 of the Bill puts beyond any doubt the fact that they have powers to provide residential accommodation under that Section—have made a start, though so far only on a pilot basis, with the provision of hostels for mentally subnormal persons. The few hostels which have already been opened or planned are mainly for those who have just left school and need special help in settling into adult life.
There will be a need, too, to cater for other age groups; for example, some residential training centres for children, some hostels for people of working age who, given a suitable home environment, can earn their own living. I am proposing, with the agreement of the local authority associations, to issue a circular shortly to local authorities indicating the ways in which their mental health services can be further developed.
723 So far as grant aid for local authority mental health services are concerned, we have, after discussion with the local authority associations, made a very generous allowance in the next two-year period for the expenditure on mental health services taken into consideration in arriving at the total of the general grant for those years. It is, of course, true that the Royal Commission recommended that there should be a specific grant, or other special Exchequer assistance, for capital development by local authorities. But this recommendation was made against the pre-general grant background, and could hardly have been implemented in that form in the new circumstances.
We cannot debate the issue of the general grant all over again in the course of this Bill. But I hope I am in order, at any rate, in saying that the estimated expenditure on these services exceeds the estimated expenditure of the current year by over £900,000 for next year, 1959–60, and by over £1¾ million in the year after that. These figures allow for an annual rate of development in each of the next two years at roughly two-and-a-half times the rate of real increase which has obtained in recent years.
These figures are for revenue expenditure. The expansion of capital expenditure which they imply—the cost of which is met by borrowing, with annual payments of the loan charges out of revenue—is very substantial. Already, in recent years, we have been authorising capital expenditure on local authority mental health services at a greatly increased rate. The value of work authorised in 1958 was, in fact, more than double that authorised in 1956; and, with local authorities anxious to discharge their extended responsibilities, I look forward to a very substantial further increase in the future.
Against this background, what does Part II of the Bill do? Its general aim is to give to the local authorities freedom to organise mental health services within the framework of their general health, welfare, and child care services, as seems appropriate in each authority's area. Some of their existing powers, however, derive from the Mental Deficiency Acts, which are repealed by the Bill.
Part II of the Bill, therefore, transfers to the National Health Service Act the powers now derived from the Mental 724 Deficiency Acts. It also makes appropriate amendments to the National Assistance Act and Children's Acts so as to remove some statutory restrictions, which would otherwise prevent local authorities from making full use of their welfare and child care powers for the benefit of mentally disordered people. Further, this part of the Bill, in Clauses 11 to 13, includes some provisions in relation to the care and training of children in lieu of education, which, broadly, give effect to the recommendations of the Royal Commission.
I believe that some disappointment has been expressed, or will be expressed, in certain quarters, that the Bill does not impose new duties on local health authorities to provide services for mentally disordered people. In fact, the transitional provisions of Part I of the Sixth Schedule provide that it will be the duty of local authorities to provide under Section 28 of the National Health Service Act services similar to those which it has hitherto been their duty to provide under the Acts repealed by the Bill.
What of the position of the other services which may be provided under the broad and comprehensive scope of Section 28? What, in particular, of the services for the care of the mentally ill in the community, and the provision of residential accommodation for all categories of patients? The answer is very simple. These powers can be converted into duties at any time by simple direction of the Minister. But the conversion of a power into a duty, as a paper transaction, does not automatically call the services into being, since regard has to be had to the logistical factors, which are, in practice, the limiting ones.
But these factors will not stop our progress. When the time comes, consideration will be given to converting some, or all, of these powers into duties. The powers exist in the local authorities. The power of direction exists in the Minister. It may have to be used, though in principle I prefer voluntary to directed effort; and in the meanwhile I have every confidence in the good will and public-spirited endeavour of the local authorities.
I come now to Part III of the Bill. This deals with the registration of residential homes and nursing homes—
§ Mr. Christopher Mayhew (Woolwich, East)
Before the right hon. and learned 725 Gentleman leaves local authority expenditure, may I put this point? He gave the percentage increase on capital expenditure between 1956 and 1958. Can he give the absolute figure for investment in 1958?
§ Mr. Walker-Smith
No, I do not think that I could give the hon. Gentleman that figure off the cuff, but I will see whether we can deal with the point in the course of the debate.
I was saying that the general effect of Part III is to make hospitals and homes for mentally disordered persons liable to registration by local authorities under the same Acts as nursing homes and disabled people's homes generally. These are the Public Health Act, 1936, the equivalent London Act, and the National Assistance Act, 1948. This replaces the various special systems of registration in force at present under the repealed Acts. In applying the general provisions of the Public Health Acts and National Assistance Act, the Bill introduces some necessary and useful additions and modifications. The Third Schedule of the Bill contains transitional provisions for applying the new arrangements to premises and persons already authorised to receive or care for patients under the present Acts.
I have now dealt with the general principles of the Bill, with its first five Parts, with most of its Schedules, and with some of the provisions of Part IX. My references to the rest can be mercifully brief.
Part VI requires no comment at this stage. To Part VII I will return in a moment.
Part VIII is concerned with property matters. The Royal Commission was, of course, not directly concerned with this; but it criticised the complexity and archaic language of the existing statute law and recommended the abolition of the obsolete inquisition procedure. Part VIII, therefore, provides a statutory code governing this particular branch of the law, which, without radically altering it, makes some useful improvements.
Part IX contains a variety of miscellaneous provisions to which time does not allow any detailed reference. I have, in fact, already referred to the provisions dealing with tribunals. Some of the other Clauses also contain important provisions. One I would point out—Clause 134—amends the Vacating of Seats Act of 1886. The Schedules, other than those already 726 referred to, deal mainly with amendments and repeals, and certain matters, relatively speaking, of detail.
This leaves only Part VII. This vests responsibility directly in the Minister of Health for the provision and management of State institutions for people, requiring:… treatment under conditions of special security on account of their dangerous, violent or criminal propensities.I—and, I am sure, future Ministers of Health—will seek to discharge this responsibility to the best of our ability. We shall in this—as in all mental health responsibilities—strive to do our duty by providing both security for the public and care for the patient. Security precautions will continue, and will be as efficient as we can make them. But the fact that the Minister of Health is responsible underlines the fact that these places are primarily hospitals, where we shall continue to treat the patients for the amelioration, and, wherever possible, the cure of their condition.
I apologise to the House for the time I have taken. It has been due to my desire to discharge my duty of explanation to the House. But I believe that, with this Bill, to explain is to commend: and so I need not trespass further upon the indulgence of the House for the purpose of commendation.
When we come to Committee, we shall come with no obstinate pride of authorship. We shall listen to suggestions, animated by the desire to make this as good a Bill as our corporate wisdom can achieve. But though we may alter the Bill in detail, I am sure that we shall approve it in principle.
On the Statute Book it will mark a notable chapter in the history of our social progress and reflect credit on the Parliament which enacts it. It will associate us, in our sphere, with those who toil in this human and challenging cause to illumine the dark corridors of the human mind with reason restored and hope reborn.
§ 4.41 p.m.
§ Dr. Edith Summerskill (Warrington)
My right hon. and hon. Friends welcome the Bill, which embodies most of the enlightened and humane recommendations of the Royal Commission on the Law Relating to Mental Illness and Mental Deficiency. I think it appropriate to recall on this occasion that both sides of 727 the House were represented on that commission and that the members of it were unanimous in their support of the Report. I join the Minister in welcoming those representatives, including my hon. Friend the Member for Liverpool, Exchange (Mrs. Braddock), who did such excellent work on that Commission.
Before I go any further, I would draw the attention of the House to the Title of the Bill. I think that the Title itself illustrates the striking change which has taken place in the attitude of society towards mental illness. The Lunacy Act, the Mental Treatment Acts and the Mental Deficiency Acts by their very names savoured of a mediaeval approach to the disturbed mind, and I feel that the Title of the Bill in itself is psychologically good, because it indicates a positive and preventive approach to mental illness, which, apart from the human suffering involved, places a heavy burden on our social and economic life. While we know of the therapeutic cost, nobody has yet estimated the loss to the country in working hours of the load of mental illness in all its forms.
In view of the immense amount of work to be done, I hope that nobody will regard the Bill as premature, for it was in 1951 that the World Health Organisation recognised that the most important piece of long-term work to which it must be committed was the promotion of the mental health of the community.
The Minister has mentioned the great changes which have taken place in the last few years in the treatment of those with a disturbed mind. One should remember that group and individual psycho-therapy, electro-therapy, modified insulin, occupational training, and so on, have been extremely important and have made a valuable contribution to the cure and rehabilitation of those suffering from mental illness. But, of course, the most important and striking change has been that these treatments can be given in out-patient departments and day and night hospitals. The great advantages of this are that patients are kept in close contact with their relations and the outside world and do not have suddenly to adjust themselves to hospital life and then, just as suddenly, reorientate themselves.
I fully agree with the Minister that the ideal towards which we must strive is a 728 community mental hospital service integrated with the local social services, so that at no time can the record of the patient escape those who are concerned with his cure. The work must form a cooperative enterprise in which the welfare of the patient must dictate policy. Having said that, I think it is most regrettable to discover, as was reported by the right hon. Gentleman's Department in 1956, that even in the London County Council area, where the machinery for after-care of the mentally ill has been carefully developed, it is used by hospitals for only 5 to 10 per cent. of the discahrged patients. I direct the Minister's attention to this important part of his work, which is to ensure integration between the hospitals and the local authorities.
As I see it, the success of the Bill will be determined by our ability to find the manpower and the finance and to educate the public. May I deal with the first, the shortage of psychiatrists and psychiatric social workers is general? Indeed, there are only 500 psychiatric social workers in the whole of the country. I think that those people who have been associated with this work will pay tribute to the magnificent work done by the psychiatric social workers.
I feel that this situation calls for the utmost frankness. The shortage of psychiatrists is in a great measure due to the failure to teach psychiatry adequately in the medical schools, and, furthermore, to the prejudice which obtains in the medical profession itself. In all the London teaching hospitals there are only 350 beds for psychiatric patients. There is no final examination and there is no compulsory question in the final paper. Curiously enough, Scotland takes the lead in this respect.
§ Dr. Summerskill
Edinburgh University devotes three times as long to teaching psychiatry as any other university.
This general failure to teach the medical student psychiatry is paradoxical, having regard to the fact that 45 per cent. of the hospital beds in this country are occupied by patients suffering from some form of mental disturbance. Although the education of the average general practitioner in psychiatry has been deplorably 729 limited, nevertheless—and I hope the Minister will agree with me here—it is clear that the participation of the general practitioner in a comprehensive mental service is very important. Indeed, he must be one of the key members of the psychiatric team. I hope that psychiatrists will not be jealous of this contribution which he can make, for, after all, it is he who knows the family, the home and the background of his patients, and he is ideally placed to observe psychological illness in its early stages and to give psychotherapy, if only he has the training and the time.
Who is responsible for perpetuating this omission in the education of the doctor? I think all of us will agree that mental disease is the illness on which we must concentrate in the twentieth century. I am expressing my own views here: academically, I believe that the fault lies at the doors of the universities and the Royal Colleges. There have, however, been other powerful influences in most unexpected quarters. I recently read a book by Robert Ahrenfeldt, formally Deputy Assistant Director of Army Psychiatry, on "Psychiatry in the British Army in the Second World War". I came across something which revealed the powerful adverse forces which psychiatry has encountered. I can assure the House that I do not quote this for any party reasons. I echo the last words of the Minister—so far as I am concerned we are only anxious to strengthen this Bill. My quotation is intended as an illustration of the attitude towards psychiatry obtaining at the very highest levels—I might say at the advisory levels. The author wrote:There has been placed on record a personal minute addressed by Mr. Winston Churchill to the Lord President in December, 1942, in which the Prime Minister referred to the use of psychologists and psychiatrists in the Fighting Services in the following terms.The then Prime Minister, in 1942, wrote:I am sure it would be sensible to restrict as much as possible the work of these gentlemen, who are capable of doing an immense amount of harm with what may easily degenerate into charlatanry. The tightest hand should be kept over them, and they should not be allowed to quarter themselves in large numbers upon the Fighting Services at the public expense.Later he said:There are quite enough hangers on and camp followers already.730 I understand that this Minute, which was written in the then Prime Minister's own hand, is to be found in Volume 4 of "The Second World War"—his own book. The right hon. Member for Woodford (Sir W. Churchill) can be exonerated because, so far as I know, among his manifold activities he has never studied psychological medicine. He was the recipient of prejudiced and ill-informed advice. It is very interesting that in 1944—I am sure it must be a coincidence—Dr. Ernest Jones, the eminent psychologist, who has a world-wide reputation, wrote:…progress in psychiatry has considerable opposition and prejudice to overcome, a trouble which I understand.…We know that this proceeds from the general dread of mental depths, from an aversion to psychological insight, and it is strongest in those whose mental integrity, often of a very successful order, has been built on defences against those depths. It is therefore to be expected especially in the apparently stable personalities of those who have achieved prominence, politically or otherwise, in life.I quoted that in order to reveal to the House that there are pressures, which are not necessarily observable in medical circles, which have been brought to bear, and which result in a lamentable shortage of technicians to operate the provisions of this Bill.
Now I come to the question of finance. No one can be dogmatic on this, for only as the pattern of administration emerges shall we see how far we can save on hospital accommodation. I have discussed this question of finance with many psychiatrists, and some are more optimistic than others. But, inevitably, there must be a saving of the time during which a patient remains in hospital. However, such saving will inevitably be absorbed by the local authority services, which, we hope, will be gradually expanded.
I am very surprised that the Minister skated so lightly over what most people believe to be the main weakness of the Bill, which is that the powers of the local authorities are permissive and not mandatory; with the result that there will be marked differences in the provisions in various areas. I am also astonished to learn from the Minister—he said it at the Treasury Dispatch Box—that he finds little difference between permissive powers and mandatory powers. For a Minister of Health to make such a statement is really surprising. I ask the right hon. and 731 learned Gentleman to examine the authorities which have operated Section 28 of the legislation which he mentioned. If some local authorities fail to provide for the mentally sick as they have failed to provide for the aged under permissive legislation, this Bill may well prove abortive—I go as far as that.
May I draw this to the attention of the Minister who has made that remarkable statement today? It is significant that for tuberculosis full provision was made compulsory subsequent to the 1946 Act, and since that time the death rate from tuberculosis has dropped from 26,000 to under 5,000 a year, while the suicide rate has increased to nearly 6,000. I suggest that a fixed period should be given during which local authorities should establish their mental health services. We all recognise the amount of work which has to be done. But from the end of that fixed period the powers should become mandatory.
We must recognise the inexperience of many medical officers in this matter, and we should all welcome the setting up of the liaison committee, formed between the Society of Medical Officers of Health and the Royal Medico-Psychological Association, for the purpose of helping the medical officer. If we are to have a comprehensive service, there must be a big initial expenditure. The Minister has already described the hostels and other institutions which will be necessary if the provisions of this Bill are to be implemented; and it is deplorable to reflect that from 1st April the percentage grant system of financing specific local authority services is to be replaced by a general grant under the Local Government Act, 1958. Although the care of mentally sick people will devolve in a great measure on the local authorities, the Estimates only allow for an annual rate of development in this important work at approximately two-and-a-half times that which has obtained in recent years.
The Minister has given the figures. It appears that development expenditure on the mental health services in the last year was about £300,000. I think this is how it works out—the Minister says the increase for the next year will be £900,000—
§ Mr. Walker-Smith indicated dissent.732
§ Dr. Summerskill
If the right hon. and learned Gentleman does a little multiplication sum, I think he will see how this works out. Two-and-a-half times £ 300,000 comes to £900,000—or is my multiplication wrong? [Laughter.] Well, let us say—the Minister said £900,000—it is two-and-a-half times—we are approximately right—it is well under £1 million. I think we are agreed about that.
I wish to ask the Minister how it is possible for the provisions of this Bill to be implemented throughout the country unless he is prepared to finance it and to be more generous. The right hon. Gentleman mentioned himself—I noticed that he was rather embarrassed about mentioning it—that the Royal Commission on the Law relating to Mental Illness and Mental Deficiency originally intended to recommend that for a limited period Exchequer grants of up to 75 per cent. of approved capital expenditure should be made available to local authorities on expenditure connected with mental health. How can the right hon. and learned Gentleman on the one hand commend to the House the proposals of the Royal Commission, which we all applaud, and on the other ignore the practical recommendation of the Royal Commission? The Commission was composed of sensible and practical people who knew that it was stupid to expound this great ideal to the people and at the same time refrain from allowing them to have sufficient money to put it into operation.
The introduction of the block grant absolutely quashed all these suggestions of the Commission. But the Commission—may I quote this to the right hon. and learned Gentleman—was specifically hoping, and so said,that some means can be found of providing such special assistance.Where is the special assistance that the right hon. and learned Gentleman is going to provide? This is to be part of the block grant. In my opinion, what he is suggesting is quite inadequate to meet the need.
I come to my third point, namely, that the success of these provisions will be related to the degree of public co-operation and the effectiveness of our public relations. Society has never been slow in extending its sympathy to people suffering from physical disease, but lack of 733 understanding of the nature of psychological ailments has prevented people from expressing sympathy and compassion for those with sickness of the mind. Let us hope that the proposals of the Bill will help people who are disturbed in mind to receive greater sympathy from their more fortunate brethren.
Unhappily, there are those who may be daunted by what I regard as the three enemies of the Bill—fear, ignorance and prejudice. They make the social adaptation of patients discharged from mental hospitals fraught with difficulty which only after-care services and the family can resolve. While I cannot over-emphasise the important role which friends and relations play in the rehabilitation of the patient, we must not impose a strain on the family. That would be bad psychiatry. We must attempt to adjust the family and the patient and be prepared to relieve the family for short periods when necessary.
The Minister has mentioned remedial propaganda. I agree with him. The things said in this House today could be taken to the families of those who have disturbed minds. They could be made known through television, radio and newspapers which cared to approach this matter in very serious fashion. The first duty of friends and relations is to ensure that a person who shows signs of strain or mental disturbance is afforded treatment before the red light shows and an emergency threatens. It cannot be stressed too much that the Bill must be used for preventive purposes.
The Minister mentioned the old people. The rate of admission of old people into psychiatric hospitals has risen in recent years. I agree with him that many of them have gone there because they have developed a form of senile dementia. They have been certified, and then it has been found that there is no way but to send them to a mental hospital. That is deplorable. It is a reflection upon us that we have allowed these things to happen and have not taken sufficient action at the time. The reason?—because this is a category of hopeless, inarticulate and old people with senile dementia. They cannot bring pressure to bear upon members of Parliament or form pressure groups. No, they are alone and unaided, and are very often not wanted 734 by their families. The consequence is that there has been a scandalous position of which we have known but about which we have been unable to take action because of the shortage of institutions. Undoubtedly, loneliness aggravates mental disturbance.
It is very important to realise that loneliness aggravates mental disturbance. Family life is more healthy than a solitary existence. It takes a lot for me to say this about the Welfare State, but I think the Welfare State can learn from the East that old age spent in the family circle loses much of its terrors. Indeed, affection, sympathy and understanding, prescribed in frequent doses by members of a family to each other, would considerably reduce the cost of the National Health Service bill, particularly in the mental field.
It has been estimated that, of about 90,000 admissions to mental hospitals each year, probably not more than 2 pet cent. or 3 per cent. will now be subject to compulsion. Nevertheless, the question of individual liberty must never be lost sight of. I am glad that the Minister stressed that point. I am coming to certain details. I see the Solicitor-General busily making notes, but I shall not ask him to answer on these details. In a Bill like this these questions need digestion and consultation with other people. Sometimes psychiatrists are not all of one mind about them, nevertheless consultation helps. I am putting these points, and when they are being considered in Committee the Minister may be able to present his point of view.
It seems that one of the two doctors who will examine a patient before admission can be attached to the staff of the hospital to which the patient will be admitted. Is it wise, in view of the patient's reactions—I do not question the abilities or qualifications of the doctors—to give a doctor the power to compel a patient to enter his own hospital?
All the psychiatrists of my acquaintance recognise the Bill as a notable advance, but there is still disquiet about the treatment of the psychopathic group. The right to refuse admission to a patient may bear very harshly on the psychopath whom nobody wants. I do not think the Minister mentioned this point. Hospitals have a right to refuse admission to 735 any patient. That may well cause some kind of machinery to be established to regulate admission. The fact is that we have done little research into the problems of the psychopath. I hope that the Bill will stimulate the Medical Research Council to action, because there is an urgent need for research in this field.
Here is an inspiring challenge to the research worker. The diagnostic criterion is a social one, and the fault may be more with Society than with the patient's inheritance or with his genes. There are some people who feel that the definition of "psychopathic disorder" in Section 4 (4) is inadequate and leaves the same deficiencies as in the Report of the Royal Commission, but I very much doubt whether one could find an alternative to satisfy everyone. We must realise that in this field our approach is still tentative and that we have nothing to apologise about. We must congratulate ourselves that we are making an approach and we must not be academic about this adventure. I must admit that when we discussed the Report of the Royal Commission I produced what I thought was the best definition, but now I realise that it is difficult to please everyone.
We shall have to amend Section 4 (3). The words:is susceptible to medical treatmenttend to imply that treatment for psychopathy will be effective, which is certainly not always the case. It is rather academic, but certain psychiatrists feel strongly about it.
I would ask the Minister why it is impossible to admit and detain in hospital under the application-for-admission procedure a subnormal person over 21 and why his or her medical treatment or other care or training, which by the Bill's definition he requires, cannot be continued past the age of 25 unless it can be shown that he or she islikely to act in a manner dangerous to other persons or to himself,if released?
Surely all patients do not cease to be abnormal at 25 and cease to require hospital care and supervision? The mental health review tribunal is generally welcomed, but it is important that both the patient and his nearest relative should be informed of his right at relevant intervals. I think that will need clarifying on 736 Committee stage. I am sure the intention is there, but I will quote this in detail on Committee stage and it will be seen that in a certain section it has not been clear that the nearest relative should also be informed of the patient's rights.
There is another point I want to make about the nearest relative. It is easy to dismiss this, but it is quite conceivable that the nearest relative is not necessarily the person most concerned to promote the welfare of the patient.
§ Dr. Summerskill
At the moment we are discussing certain imponderables, but I confess that I find it difficult to suggest an alternative. No doubt we are all thinking of our nearest relatives and that "But by the grace of God there goes…" some of us. We should be quite content that our nearest relative should be there to look after our welfare, but can that be said about all people?
Like the Minister, I must apologise for going on for so long. Some of my hon. Friends wish to speak, but this is a long Bill. In conclusion, on an occasion such as this we should also congratulate the pioneers in the field of psychiatry, particularly in the field of modern psychiatry whose efforts are being rewarded today in the way they would wish. It would be invidious to single out any individual—individuals have been singled out, I know—because circumstances differ in different parts of the country, but I believe our grateful thanks should go out to those dedicated men and women who have defied the scoffers and the doubters and, by dint of application, perseverance and faith in their work, have released our less fortunate brothers and sisters from the shadows in which they have lived.
§ 5.13 p.m.
§ Sir Hugh Lucas-Tooth (Hendon, South)
I am sure that the welcome which will be given to the Bill will be quite unanimous. The existing law is both out-of-date and chaotic. It was high time some such Measure was introduced. Generally speaking, I think everyone will agree with the principles incorporated in this Measure.
My right hon. and learned Friend spoke of Lord Percy's humane and progressive 737 outlook. I thought the Minister's speech this afternoon disclosed such an outlook. I wish to congratulate him, both on the clarity with which he explained the Bill and also on the clarity of the Bill itself. A Bill of this size is not often so easily read and digested as this one. I am glad, too, that my right hon. and learned Friend has made the Bill thoroughly comprehensive. I think it a good thing that Part VIII was included in the Bill, the Part which deals with the property of the patients. I was glad to hear my right hon. and learned Friend say that the main object of the Bill is the integration of the mental health service with the general health services. I am sure that must be the aim to go for and that the two principles to follow in achieving that aim are, first, the elimination of compulsion and, second, as the Royal Commission expressed it, the reorientation of the service away from institutional care.
I cannot believe that anyone will quarrel with those two principles. I should like to speak as warmly and sympathetically about them as they have been spoken of in the two speeches from the Front Benches. If I do not do so, it is because this afternoon there is a great deal to be said about this Bill which I hope will be valuable, and I must not spend time on eulogies. The Bill itself is one which can be more easily discussed in Committee than on Second Reading, but I have one general criticism to offer and I offer it in a constructive way.
The compulsion of the mentally disordered may be required on two grounds, either for medical reasons—that is to say, to secure their cure or, at all events, their stabilisation—or for social reasons—that is to say, to secure their care or possibly their safety, or the safety of others. Of course, both medical and social reasons often arise at the same time in connection with the same patient, but they are quite different. I think the procedures of the Bill should be very careful to distinguish between these two reasons because, if they do not do so, there will be injustice or wrong treatment or waste of our very limited existing assets.
I think there is a slight tendency to confuse these procedures in the Bill. I ask the House to look at Clause 4, to which the Minister, I thought rightly, devoted a great deal of attention. The 738 Clause defines mental disorder. What it does is to give a definition of those who may be deprived of their freedom under the Bill. It deals with the mentally ill and, I think rightly, does not attempt a definition there. It defines the severely subnormal, the subnormal and the psychopath in terms with which I certainly do not disagree, but there is a subsection of this Clause to which my right hon. and learned Friend did not refer, subsection (5):Nothing in this section shall be construed as implying that a person may be treated as mentally disordered, or as suffering from any form of mental disorder described in this section, by reason only of promiscuity or other immoral conduct.The first question which seems to arise from those words is, what is intended by "immoral conduct"? Does it mean immoral in the general sense of the word, "unethical" conduct? Is it intended that this subsection should oust from the general definition Clause drunkenness, perversion, drug-taking and suchlike conduct, or is it limited to the sexually immoral? I think it is the last, but I am not sure. If it is limited to the sexually immoral we have the rather peculiar position that the person who, for want of a better term, I will describe as a nymphomaniac—I do not know whether that is a term of art, but it is frequently used—will not receive treatment under the Bill, whereas the alcoholic will. I do not wish to be dogmatic, but this is a very important subsection, which has a general bearing on the Bill.
§ Mr. Sydney Silverman (Nelson and Colne)
Has the hon. Gentleman given sufficient attention to the phrase "by reason only"? It does not mean that these things shall be excluded, but that any one of them shall not be sufficient by itself.
§ Sir H. Lucas-Tooth
I think that the hon. Member is quite right. The purpose of the subsection seems to be to exclude conduct by itself from constituting a ground for depriving a person of freedom, but it is not clear what conduct that includes. The subsection is either too wide or too narrow. This is not a drafting matter, but something which is difficult and important. Are we to forbid any restraint being put on alcoholics, nymphomaniacs, homosexuals, and so on, even though such restraint might result in some benefit to those or others, or are we to 739 permit restraint and risk allowing it to be used for repression rather than cure?
This is a broad matter of policy to be decided by the House rather than by a tribunal or doctor outside it. I would sooner not have the subsection in the Clause. I would sooner see restraint permitted generally, but given a limit when imposed purely on the ground of conduct and allowed only in those cases where medical treatment is advised. There should also be a definite time limit, which might be six months or a year. Either way, the law should be made clear.
There is a similar obscurity in Clause 121. This is the Clause which gives powers to mental health review tribunals to discharge on appeal. A tribunal may direct a patient to be discharged if he is not then suffering in such a way that he would not be liable to be put under restraint originally; or it may direct a discharge in the case of psychopaths who are no longer dangerous; or, in any other case—and that must be other than the case of psychopath—it is not necessary in the interests of the patient or for the protection of other persons that the patient should continue to be liable to be detained or subject to guardianship, as the case may be…Necessarily, most of the patients mentioned here will be those mentioned in paragraph (a). The words must therefore give a tribunal some some rather larger right of discharge than is given in paragraph (a). What larger right is the tribunal to have? What is to be the difference between considering whether a person is to be put under restraint in the first place and considering whether he is to be discharged from restraint on appeal to the tribunal?
A similar problem arises with Clauses 26 and 27. Clause 26 requires the application to state that it is necessary in the interests of the patient or for the protection of other persons that the patient should be detained, but Clause 27 permits the nearest relative in effect to veto the use of compulsion and to do so quite arbitrarily. He need not give a reason, and even if he does, it may be a bad reason. The veto is nevertheless absolute.
The Royal Commission on the Law Relating to Mental Illness and Mental Deficiency recommended that there should be an application to a magistrates' court in a case where the nearest relative 740 objected to restraint being used. So far as I can see, that recommendation has not been incorporated in the Bill.
§ Mr. Walker-Smith indicated dissent.
§ Sir H. Lucas-Tooth
If it has been incorporated; I must apologise. It is a long and difficult Bill. If it had not been incorporated, the same dilemma which I mentioned would arise. It is a dilemma which must be resolved by the House. As drafted, the Bill tends to leave it to authorities, tribunals and doctors outside the House.
There are two matters which can best be discussed in Committee, but which it may be convenient to mention now. Why is there no reference to courts martial in Part V of the Bill? I should have thought that it might be convenient to allow those appearing before courts martial to be dealt with in the same way as those coming before other courts.
A second point in this connection arises from the meaning of the word "relative". I agree with the right hon. Lady the Member for Warrington (Dr. Summer-skill) that it is important to be careful in seeing who exercises the important powers given to relatives. Clause 49 omits what might be called de facto spouses. Very large numbers of people in this country are living together as man and wife without having been married. It would be wrong and almost inhuman to treat them other than as man and wife for the purposes of the Clause. Illegitimate relations are missed out. Clearly there is a case for saying that the mother of an illegitimate child, or the illegitimate child of a mother, should have the powers given to relatives by the Bill.
When the Bill comes into operation, compulsion of the mentally disordered will be greatly reduced. It could and would have been reduced already if the existing powers had not been used to secure the admission of patients to hospitals. When the Bill is passed, there will be no power to compel admission to hospital. If the hospitals continue to feel themselves compelled to admit in those cases where a recommendation is put forward, the Bill will have achieved nothing. An application will be just the same as certification, and it will not be very long before the word "recommended" comes to mean exactly the same as "certified", with all the stigma attached to it.
741 If the hospitals turn away patients and there is nothing else available for such patients, a very serious situation will arise. The Bill will work only if hospitals can be relieved of a substantial number of their present patients. It is easy to say, as the right hon. Lady said, that we should make the local health authority functions mandatory. I think that she herself recognised that simply to do that will not provide the buildings or the trained personnel, and will certainly not provide the necessary reorganisation.
In this connection, the first thing to get straight is the organisation. The National Health Service Act lumped together the social and the medical functions of the mental hospitals. I make no party point on this. It is a fact that is, I think, generally recognised. But they now have to be sorted out again, and it will not be easy. The present very large hospitals cover, and very often overlap, several local health authorities. I visited one a few days ago that covered the whole of one large county, part of another, and a county borough some fifty miles away.
It will not be easy to fit that kind of hospital into the local health authority scheme in such a way as to make a Bill like this work smoothly. If the local government and the hospital mental services are to be properly dovetailed, a great deal of reorganisation will have to take place. There will rot only be new buildings but the acquisition of old buildings, and transfers of buildings between various authorities.
More important will be the provision of trained manpower. Psychiatrists, therapists, nurses and social welfare workers are all in very short supply at the present time. The provision of these people can depend only on voluntary recruitment, and the service of the mentally disordered has not been attractive in this country in the past. We must recognise that. There are, of course, reasons for it. The work is exacting. Compulsion of patients has been psychologically repulsive to those engaged in the work. I think, too, that it is partly due to the fact that psychiatry has been a very imprecise science. It has not had the glamour that has been shed over many other branches of science.
But this should really have been the queen of the sciences. It deals with the most interesting and most important of all 742 terrestrial things—the human mind. I believe that the first thing to make the Bill a success is to give this science the glamour it needs and deserves. I regard that to be the first task of my right hon. and learned Friend, and of all of us who are concerned to make this Measure a success.
§ 5.33 p.m.
§ Mr. Christopher Mayhew (Woolwich. East)
I am sure that the concluding remark of the hon. Member for Hendon. South (Sir H. Lucas-Tooth) that psychiatry should be the queen of the sciences will find a warm echo in the hearts of many hon. Members, not only because psychiatry deals with the most important subject of all—the human mind—but because the suffering it attempts to relieve is by far the most widespread form of suffering there is at present in this country. However, if the hon. Gentleman will forgive me. I should like to talk about the Bill in a rather more general way.
Like previous speakers, I warmly welcome its general principles, but I think that there is a certain danger of overestimating what benefits will result from its mere passage. I suppose that it is natural that, as legislators, we should be particularly concerned with the legal aspects of mental health, but it is essential to remember that for the great majority of mentally-disordered people the unsatisfactory laws of past years have not been a source of major and immediate concern. Progress in research, in hospital conditions, in community services, in rehabilitation—those are the really important things for the great majority of mentally-disordered people, and my main point is that unless we regard this Bill as part of a general attack over the whole field we may be very seriously disappointed by its results.
Within the legal sphere it seems to me to be good. It is splendid to see a clean sweep made of the old laws. It is good to see how far it has been possible to go in the legislative field in equating mental and physical illness, and great ingenuity has been shown in doing that. It is good to have a new approach altogether to the question of detention in hospitals, although some interesting suggestions have been made in that connection—I saw one by the physician superintendent at Cane Hill in the Observer on Sunday - which may be instructive, and a way 743 of improving the Bill in an important respect.
The Bill, too, shows a freshness of style and approach that is in welcome contrast to the old lunacy and mental treatment Acts—but I do not agree that it is lucid, I do not say that it is readable—
§ Mr. Mayhew
No Bill is readable; not for persons of sound mind. That is what distinguishes us from lawyers, like the Minister, who find it readable. But the style of the Bill, like the style of the Royal Commission's Report, is fresh, and stamps the Bill as the work of people of good sense and humanity.
In my opinion, however, the Bill can succeed only if it is part of a broader attack. What matters is not passing the Bill but what comes after it. This is particularly true in the aspect already referred to by other hon. Members—the effort that local authorities will be called upon to make. A great deal depends on how they rise to the occasion, and I must say that in the past, and in general, the effort of local authorities has been disappointing. I was not relieved by the figures quoted by the Minister of the revenue expended on mental health by local authorities. Just over £4 million seems totally inadequate to present needs, and I would be very interested if the Minister would let us know the comparable figures for capital expenditure by local authorities.
With certain spectacular exceptions, the record of local authorities has so far not been encouraging. We need a new approach by ratepayers and by medical officers of health. To me, that seems to be absolutely essential if we are trying to assess the value of the Bill. I very much endorse the idea put forward—I think my hon. Friend the Member for St. Pancras, North (Mr. K. Robinson), originated it—that, as part of the Bill, local authorities should be required to put forward their plans for development in this direction over the next two years. That would stiffen the Bill where it is weakest of all.
Great strides might in this way be made in releasing from the hospitals back into the community thousands of people who really ought to have been in the community for a long time past. I have seen 744 it estimated that there are between 5,000 and 10,000 patients in mental hospitals, and the same number in mental deficiency hospitals who could today emerge from them if there were the proper community services to receive them. That is certainly a target well worth achieving.
The Bill, as it stands, does not ensure this. And, of course, even if that did happen, there is the question—which the Minister made clear—that the Bill assumes a very great deal of public support for the new approach to mental illness and mental deficiency. He mentioned local residents who may pay lip-service to the need to help the mentally disordered but who, when it comes to a new hostel, or a day hostel in their local residential areas, will not take a generous or sympathetic attitude at all. He might also have mentioned employers. This is another vital factor in the whole question of resettlement and rehabilitation of patients and ex-patients. Above all is surely the need for greater confidence, sympathy and knowledge on the part of individual members of the public, including relatives, friends and fellow workers in particular.
There are many kinds of human problem involved in all this. Perhaps hon. Members like myself get a very good picture of the variety of these human problems in the letters that are written to them by people who are affected by them. Perhaps the House would allow me to quote a few extracts from letters to illustrate the importance of some of these problems. One ex-patient, for example, writes:The mere thought of entering a shop to buy anything was sheer terror. The bustling crowds and busy streets were unnerving. To cross a busy street was a major operation in itself.Another writes:The worst part is when you come home; some people are all right, but others make you feel you're not safe to be around.Another writes:The average employer casts a suspicious eye on you at the mere mention of the fact that you have had treatment for mental illness.Then there is the person who ought to be a patient and who perhaps needs early treatment but is ashamed to take it. One writes:Last June. I was asked to go into a mental hospital for electric treatment; but I was 745 afraid to accept the recommendation, particularly as I am well known in this village.Then there are the relatives, good and bad. Here is another quotation:I know a case where the whole family just forgot all about their mother and if anyone mentioned her name they claimed her as being dead.Or this:I have found no test more revealing of human nature than the words 'My husband is a patient in a mental hospital'. It produces either callousness or indifference or sometimes the most generous and sympathetic understanding.Then there is the fact, well-known to all those who have had dealings with this matter, that relatives can suffer very greatly, too. I sympathise a good deal with what my right hon. Friend was saying. One of the most terrible effects of some of these mental illnesses is, of course, the way they induce their victims to hate precisely those who are doing most for them. Here is a letter which I have received which states:Relatives and fellow workers may also not be insensitive and can suffer great hurt and even grievous wrong at the hands of these unbalanced people, as I know only too well from my own experience.Of all these attitudes, the one commonest and most understandable, and perhaps most easily remedied, is that of people anxious to help but lacking confidence and knowledge as to the best way to go about it. For example, those who write:How should ordinary people behave towards mental patients? One must say something. What? What should be avoided?The father of a patient wrote:How should my son be treated when he comes home by friends and relatives? Can he be prevented from having further trouble?I feel that these anxieties and problems, revealed by letters of this kind, go very close to the heart of the problem that we are discussing today. They can have a great impact on the success or failure of the Bill. I do not want to exaggerate the problem because, as the Minister has said, there has been a great improvement in this kind of thing over recent years—there is no doubt about that—and the Bill will further improve I am sure the public attitude on all these questions. It helps to equate physical and mental illness; it takes J.P.s out of the business of certification and it alters the terminology. I think that in this way it helps.
746 We have, however, to be a little cautious about this, because while it is true that good laws and good terminology can create a better public attitude, it is even truer that a backward public attitude can frustrate good legislation, and can make words which in themselves are entirely acceptable into opprobrious words like "asylum", "lunatic", "idiot" or "imbecile". Public attitude can put a stigma on a word where, in fact, taken by itself, it is quite harmless.
So I am saying that in isolation the Bill may not have the promising effects we expect. Indeed, it may make things more difficult—and we must recognise this—the impact of the emergence of thousands of patients into the community from hospitals may be a very good thing, but it may create an extra difficulty as well. We have to bear that in mind. We hope that since we shall get more direct contact between patients and ex-patients on the one hand and members of the community on the other we shall get more understanding, insight and sympathy. I am sure that that will happen, because in the past, as we all know, part of the reason for the mystery and shame which have surrounded this subject and made reform so difficult has been the isolation of patients behind the high walls of isolated hospitals and the hiding away of mentally backward children. This has always contributed to an atmosphere of mystery and shame.
So we can ultimately expect that when the patient and ex-patient come into closer contact with the community that will probably have a very useful effect in increasing understanding. At the same time, while it lessens ignorance it will definitely increase the need for patience and generosity on the part of the community. It would be wrong to think that the difficulties of accepting and integrating patients and ex-patients into the community is simply due to the ignorance or prejudice of the public. That is taking too simple a view altogether. We shall not get anywhere unless we realise frankly that, by the very nature of their handicap, mentally ill and mentally deficient people are, and always will be, particularly hard to integrate into the community. The success, therefore, of the Bill depends on greater public acceptance of mental disorder and a great increase in enterprise on behalf of the local authorities.
747 One other thing which can ensure the success of the Bill would be a real breakthrough in research into some of our serious mental illnesses. My information is that such a break-through may be imminent. The effect, of course, would be magical in almost all fields concerned with mental disorder. Nothing can do more, for example, to abolish the stigma of mental disorder, and nothing does more today, than when a person openly goes to a mental hospital suffering from a mental illness and then comes back to his friends, family and fellow workers completely cured. That is really the way in which the stigma surrounding this subject will be destroyed, especially when as occasionally happens one of these people writes and broadcasts most helpfully and constructively about his experiences. So it is a little disappointing to see what has been done by the Minister in this field of mental health research. It is true that the Medical Research Council is now spending twice what it did in the last financial year on mental health research—£130,000—but it is a fabulously small amount when we consider the opportunities and the needs.
The Bill will help marginally to increase the opportunities for research. I think that the compulsory powers will help considerably research into the problem of psychopaths. It is a shame that the Mental Health Research Fund should be crying out for funds to finance worth-while projects and be held back for lack of money, as is the case. I ask the Minister lot to regard this Bill as a bit of legislation to go through the House but to remember the impact of it and the actions he can take in other fields in this matter. All these things are inter-related. We need action on all these matters to supplement the Bill if it is to be of use. We should encourage local authorities, and if possible we should put something into the Bill requiring them to submit their plans to the Minister for approval. We should encourage them administratively and financially. We want more occupational centres, hostels, special schools, psychiatrists and psychiatric social workers in particular.
In addition, we need to bring the conditions in our worst mental hospitals up to the standard of the conditions in our best. As the Minister said, more public enlightenment and more education are 748 needed. He himself can do a lot here. I was wondering whether we do enough in education among the older school children, whether teachers in the course of their training get the opportunity of a fully informed and enlightened attitude to mental disorder, and whether they have the opportunity to hand that on to the older children in the schools. A whole number of matters of this kind are worth looking into and are central to the purpose which we all have in common.
I do not wish to introduce any pessimism, because anyone who has been concerned with this subject can see that in every one of these fields there have been worth-while improvements over the past year or two. The fact that we have neglected this subject in the past means that now that we are beginning to get wise to it, there is great scope for advance if we really get down to the job. I ask the Minister to look on the Bill not as an achievement in itself but as a signal for an advance over the whole field. If he does that, I am sure that he will have warm support from all quarters of the House.
§ 5.52 p.m.
§ Mr. R. H. Turton (Thirsk and Malton)
As one who once held his high office, I wish to congratulate my right hon. and learned Friend the Minister of Health on the Bill. I am certain that however long and brilliant his political career, he will always look back on this day with great pride.
I believe there has seldom been a Measure in the House which has made more far-reaching changes in the law, and never has there been a Measure that has brought changes which were more urgently required. To quote the Report of the Royal Commission on the Law Relating to Mental Illness and Mental Deficiency, in paragraph 20, the mental laws are described asseriously out of date and unnecessarily complicated.My right hon. and learned Friend has performed a great service in introducing the Bill, and I congratulate him also on the manner in which he introduced it. I am sure that all of us, and especially my right hon. and learned Friend, realise that if this is a revolutionary Measure it is only here because of the revolution in the treatment given by the doctors and 749 nurses in mental hospitals. It is that background that has enabled the Minister to make this great step forward.
I rise chiefly to point out, rather in the atmosphere of the hon. Member for Woolwich, East (Mr. Mayhew), that this Measure in itself will require a revolution, a building revolution. I agree with the hon. Member for Woolwich, East that it will also require a revolution in the attitude towards those who are recovering from mental illness, but I want to stress that the Bill requires a building revolution. More than half of our mental hospitals and mental deficiency institutions were built before or in the reign of Queen Victoria. In my view, the majority of that half requires to be demolished, or, if not demolished, transferred to the Home Secretary for use as prison buildings if he requires them. I believe that is vital because it is not helpful to mental patients to treat them in large wards or in barrack buildings or in buildings secluded from the rest of the community. I ask my right hon. and learned Friend and the Chancellor of the Exchequer to pay attention to that aspect of the problem. The Bill will have great success if the right buildings are afforded for those who are being treated for mental disorder and also for those who have recovered.
I should like to reinforce what the right hon. Lady the Member for Warrington (Dr. Summerskill) pointed out, that a large proportion of the present population in mental hospitals are old people over 65. In fact, according to the 1956 figures, the proportion was about 32 per cent., showing that over 46,000 were of that age. I have no medical knowledge, but I should have thought that under Clause 26 (1) most of those old people could be deemed to be outside the need for compulsory detention. They are only in such institutions because there are not the buildings or the families to look after them. That is why we have got to think especially of this problem of the old people. I have never regarded senescence as a type of mental disorder, and I think the right hon. Lady was quite right to say that it is scandalous that such a large number of old people should be in mental hospitals. How are we going to put that right? It will mean a greatly increased building policy for homes, hostels, flats and bungalows for old people.
I am a little worried, not on the point that has been taken by the right hon. Lady 750 as to whether the powers under Part II should be permissive or mandatory—that does not seem to be the major point—but whether the local authorities and the Minister will have the money to construct the new buildings which will be required for the proper treatment of mental patients and for looking after them properly after they have recovered. Many of these old mental hospitals are buildings on which the local authorities in the past have spent large amounts of money.
As we develop from the care of the patient by the regional hospital board to the care of some of the patients by the local health authorities, I think it is reasonable for the local authorities to remind the Minister of that fact and to say that if they are to erect buildings and long-stay annexes for those who have recovered, especially the old people, it is only reasonable that Her Majesty's Government should be generous to the local authorities in view of the fact that so many of the mental hospitals which were taken over in 1948 were local authority built and maintained, for which they got no compensation on the takeover. I leave that point to my right hon. and learned Friend to ponder
As to this Part II argument, I cannot see how the Minister can make it mandatory in view of the tremendous shortage at the present time of psychiatric workers. I notice that the right hon. Lady asked why the Minister did not provide that it should be made mandatory in six years' time. Rather than that method let us wait those six years and then, if necessary, make the change. I would rather work with the good friendship of the local authorities, which I am sure are anxious to implement the Bill as far as their financial powers allow.
§ Mr. Blenkinsop
I do not remember my right hon. Friend the Member for Warrington (Dr. Summerskill) mentioning six years. What she did suggest was that plans should be submitted by local authorities within a certain period.
§ Mr. Turton
We can read it tomorrow in HANSARD, but that was the impression conveyed to my mind. I thought her speech was a very wise one, and I will leave it at that. Her attitude had, I thought, a great deal to commend it, and I hope that the hon. Gentleman will not think that I was criticising his right hon. 751 Friend. I was, indeed, praising her for her attitude.
I believe that it is wise for us not to establish too rigid a pattern in dealing with those who are recovering from mental illness. Great work has been done in the provisions of prevention, care and after-care by the hospital authorities, and we are still on the threshold of knowing how best to deal with the problem. It may be that the hospital authority, the family doctor, the local authority and the voluntary worker can each provide some part of the right solution. The Minister has been particularly wise to avoid too rigid a pattern under Part II of the Bill.
It remains for me to wish the Bill godspeed. I hope that the Government will give urgent attention to the problems which, I am sure, the implementation of it will reveal.
§ 6.1 p.m.
§ Dr. A. D. D. Broughton (Batley and Morley)
When the House discussed the Report of the Royal Commission on the Law relating to Mental Illness and Mental Deficiency some time ago, I took the opportunity then of welcoming the Report. Today, I congratulate the Minister on laying before us a Bill which seeks to implement many of the recommendations of the Report. It is best described, I think, as a humane Measure of reform. It is very easy to say that these reforms are overdue. To say so in this instance would be to offer unfair criticism, because it is usually unwise to legislate far in advance of public opinion, and it is only recently that public opinion has been prepared to accept the proposals contained in the Bill. Indeed, in some respects, the Bill is still ahead of the present views of many people, and it will take time for the country to accept and operate this legislation in all its aspects.
For example, important and responsible duties are laid upon local authorities. I believe that many local authorities have little idea of what their duties will amount to and how they are to be carried out. Some years will probably elapse before local authorities have grasped to the full the intentions of the Bill and are able to provide efficient services as their part in the care of the mentally ill. I was pleased to hear the Minister say that he is considering sending a circular to local authorities for their guidance on this matter.
752 The Bill is a major piece of legislation. It has 146 Clauses and eight Schedules. In my view, there are many details which call for improvement and require amendment, but those can be dealt with at later stages. Today, I wish to speak of the Bill generally and to touch upon one or two important points.
Progress towards the efficient treatment of the mentally ill has been painfully slow over many years. There was a time when mental patients were thought to be possessed of the devil. They were called lunatics. They were locked up in asylums, and the treatment given to them was brutal. The Retreat at York, which is a hospital founded by Quakers, is famous as the first to substitute humane for harsh treatment. Others followed suit, and the asylums became places where inmates were treated kindly.
A great step forward was made with the passing of the Mental Treatment Act, 1930. Asylums then became mental hospitals; lunatics became mental patients: and the mentally ill could enter mental hospitals voluntarily without incurring the stigma of certification. Since then, psychiatry has made rapid progress and the environment of mental hospitals has changed out of all recognition.
I can illustrate this latter point by a brief reference to a recent personal experience. There is an old mental hospital at Wakefield which, from my boyhood days, I remember as the West Riding Asylum for the housing of lunatics. I learned my psychiatry there more than twenty years ago, when the place was known as Wakefield Mental Hospital. During the recent Parliamentary Recess, I had the privilege of working there again, and I found almost unbelievable changes. It is now known as the Stanley Royd Hospital, and it is for the treatment of mentally ill inpatients and out-patients. Even the exterior of some of the old buildings has been changed by enlarging windows. Inside, the wards have lost their prisonlike appearance and atmosphere and have been changed to light, clean, comfortable hospital wards. The patients are different, too, partly, no doubt, as a result of modern methods of treatment, but also, I believe, as a result of their realising that, instead of being looked upon as outcasts from society, they are respected 753 as human beings with rights and privileges, and they are treated with nothing but kindness and consideration.
The structural alterations to the old buildings at that hospital are not yet completed, but they are going on apace. Finance and encouragement come from the regional hospital board, and enthusiasm is noticeable in the hospital management committee, the medical and nursing staffs and all the other personnel. I envisage that hospital as being a showpiece in a few years, and I regard the change as quite remarkable when I recollect what it was like twenty years ago. Other mental hospitals have changed similarly, as I know from having worked in them. I believe that the passing of this Bill will add impetus to these advances.
When the Minister has all the modern residential hospitals, day hospitals and out-patient clinics he may require, he will, I fear, be faced with the problem of staffing these services. As is well known, there is a shortage of psychiatrists. As I have said before in the House, psychiatry is still the Cinderella of the National Health Service. It is surprising that this should be so, since there is a wealth of interest in the work. More encouragement will have to be given by the Minister and by all others who can bring influence to bear in order to induce able men and women to enter this branch of the National Health Service.
My right hon. Friend the Member for Warrington (Dr. Summerskill) referred to the attitude of the teaching hospitals and I endorse what she said. I have two suggestions to put to the Minister. He will know that, in order to obtain a senior post in a mental hospital, it is necessary for an applicant to hold a Diploma in Psychological Medicine. The examination for this diploma is a difficult one, as I know from my own experience, but it is not a registrable qualification. Could it not be made registrable?
This may seem only a small point, but I believe that registration would add to the prestige and standing of psychiatrists. After all, the Diploma in Public Health is registrable, and has been so for many years. I have a diploma in public health and a diploma in psychological medicine. I found the work for the public health diploma easy. It was not a difficult 754 examination to pass, and when I had obtained the diploma I could register it as an extra qualification. I found the work in psychological medicine much more difficult and failed in my first attempt at the final examination, but when I did obtain it I could not register it.
Another possible way by which psychiatry may be made move attractive is by allowing and encouraging good psychiatrists to hold appointments after the usual retiring age. I can understand a policy which requires surgeons to retire because of the arduous work which they have to undertake and which entails so much physical strain, but I know of a number of very good psychiatrists in their late sixties and early seventies who have been retired and who would still be capable of first-class work. The National Health Service can ill afford at present to lose such men.
Good psychiatry demands wisdom and sound judgment, and it is improved by experience. Provided a psychiatrist does not suffer mental deterioration as he gets older, there is no reason why he should not go on working almost up to the time of his death. After all, we do not compulsorily retire politicians, and we have had able Prime Ministers at the age of 80. Whether the possible extension of the period of service should be applicable to medical superintendents who nave very heavy administrative duties would be a point for additional consideration. I feel sure that we are wasting some of our best clinicians in psychiatry through retiring them at too early an age.
Mention of medical superintendents brings me to one or two other points. Is the Minister aware that some medical superintendents, who in addition to their clinical duties carry a heavy burden of responsibility for the care and custody of patients, are receiving less salary than other senior members of their staff? This point has been mentioned before in the House. It has been raised on a number of occasions by my hon. Friend the Member for St. Pancras, North (Mr. K. Robinson). The time has come when the Minister should consider it.
The term "responsible medical officer" is used in the Bill. I take it that, from the point of view of mental hospitals, the responsible medical officer will be the doctor who is now the medical superintendent. But what will be the extent of 755 his responsibility? Under the Bill, mental patients can be admitted to other hospitals. That being so, who is the responsible medical officer in, shall we say, a small general hospital? Definition of this point is required.
§ The Solicitor-General (Sir Harry Hylton-Foster)
In order to make the point clear, the hon. Gentleman might find it helpful to look at page 39 of the Bill, where the gentleman in question is defined for relevant purposes.
§ Dr. Broughton
Yes, but I respectfully suggest that he is inadequately defined.
I should like to refer to Clauses 25 and 26. I can approve of Clause 25 because I think that compulsory admission for observation founded on the recommendations of two doctors is probably safe enough in view of the fact that the detention must not exceed twenty-eight days.
I am not so happy about Clause 26. Under that Clause, the patient could be detained for much longer periods. There would therefore be loss of civil rights for a longer time. I understand that justices of the peace are very glad to be left out of the Bill, but the doctors are not so happy about this responsibility. I know that patients will have the right of appeal to the Medical Health Review Tribunal, but I am not sure that that is enough.
I took the opportunity of discussing this matter with some of my patients, most of whom had at one time or another been certified. I was interested to find that they were very much in favour of justices of the peace being included. They said that they regarded certification as a very serious matter both at the time of certification and because of the consequences which may arise later. They wanted every possible safeguard and thought that justices of the peace should be included in the Bill.
§ Mr. Kenneth Robinson (St. Pancras, North)
My hon. Friend has told us what the patients think. Would he now tell us what he thinks—whether the justice of the peace was a real safeguard to the patient in the past?
§ Dr. Broughton
I should like the justices of the people to be included, for the 756 reason that a medical man is only qualified to give a medical certificate. When a patient is compulsorily detained, that person is losing important civil rights. I do not think that a medical man is qualified to rob a person of his or her civil rights. I therefore think that that responsibility would be better left with justices of the peace.
Another point in the Bill about which I am not happy concerns cases of psychopathic disorder being treated in general or ordinary mental hospitals. I hope that we shall have the opportunity, either today or in Committee, of hearing the views of the hon. Member for Gosport and Fareham (Dr. Bennett) on the subject, because he is an expert on it, having had many years of experience in that field. I have found that they can be a very disturbing influence, tiresome to the staff and harmful to other patients.
As the House knows, I have a personal interest in the Bill and there are many more points which I should like to mention. However, they can be safely left until we reach the Committee stage. I give my warm approval to a Bill which I am sure will bring an immense amount of good to many unfortunate sufferers.
§ 6.19 p.m.
§ Mr. Douglas Dodds-Parker (Banbury)
I start by joining in the praise of my right hon. and learned Friend for introducing the Bill. As he himself said, this is the most important chapter in social legislation which this House has seen fit to pass in the last 15 years. My right hon. and learned Friend's presentation of it to the House was excellent and he certainly made clear many points in a very long Bill. I suppose that there are few subjects which cause so much distress to so many people as mental health. This is, therefore, clearly a most important Bill.
The Minister was good enough last summer to show his personal interest in this subject by attending the opening function of a conference on stress held in Oxford. This conference underlined the disturbing fact that, with the advance of civilisation, mental disease shows an even more rapid advance. While most other diseases are now declining, mental illness and cancer show considerable increases. I think I am right in saying that in certain areas up to one-third of absenteeism in industry is due to mental rather than physical breakdown. If this is so, for 757 the material benefit of the country the subject is clearly of the greatest importance.
It is not any criticism of the Bill, excellent though it is, to say that I do not believe it will secure any marked decrease in the number of patients admitted to hospitals with mental illness. Indeed, it is not claimed that it will do so. Everybody, I think, is agreed that only research and the knowledge which flows from it can secure a decrease—or, indeed, can stop an increase—in mental sickness. I am sure that everybody in the House will support my right hon. and learned Friend the Minister in any steps he may see fit to take after the passage of the Bill to put forward proposals to increase provision for research into this subject.
From the figures which I have been able to find, only 4 per cent. of the budget of the Medical Research Council is set aside for mental health research. If this is so, it is indeed very small when these disorders fill 44 per cent. of all hospital beds. No doubt the Medical Research Council is greatly occupied in many important ways. Therefore, I suggest to my right hon. Friend that he set up a working party with the Medical Research Council, but not limited to it, to examine the whole situation with a view to stimulating research work in this direction.
As a rule of thumb which one applies in other activities, 1 per cent. of expenditure is usually allocated to research and development. Since under the National Health Service the hospitalised mentally ill cost approximately £100 million, I should like to draw the deduction that we should set aside £1 million a year, or 1 per cent. of that figure. If this were made available for research, it would be six times the amount which is set aside at present. When one considers the totals of money expended by the nation, this does not seem to be a very large sum.
It would be wrong to suggest, because it might raise false hopes, that money alone is required to solve these problems. To give just one example, it has been suggested that the chances of discovering, along biochemical lines, the causes and cures of, at least, schizophrenia and manic depressive disorder are now in principle good if sufficient organisational talent 758 as well as money is applied to the problem. I am told that that is so and I should like to know whether the Solicitor-General, when he replies, can give an answer on that. My suggestion is that after the Bill goes through the House, the Minister should consider establishing a research group on rather the same lines as Harwell has been established for research into atomic matters.
In no field, not even in cancer, are there such chances of reward for research, at the lowest conserving the material and mental resources of the country and at best saving so much suffering to so many people, not only those mentally afflicted, but their friends and relatives. I hope, therefore, that not only will the whole House support my right hon. and learned Friend, but that, after the Bill completes all its stages, he may concentrate on prevention rather than cure by increasing the funds available for research.
§ 6.24 p.m.
§ Mr. Austen Albu (Edmonton)
Like other hon. Members who have spoken so far, I welcome the Bill not only as a substantial advance in at least the legal position of those with whom it deals, but also as, perhaps, the beginning of another more substantial advance in what we are doing for them.
We are dealing with a wide range of conditions, some of them overlapping, with the distinctions between them not always clear. Some of the sick will never recover. On the other hand, some of the subnormal can undoubtedly be trained to become normal. Some of the illnesses with which we are dealing are severe only at long intervals, when people become violent or are withdrawn from society. Equally, there are some subnormal people and some neurotics and psychotics who never will be able to live normal lives.
We are dealing also with a whole category of people about whom the medical profession knows very little. I refer to the psychopaths. Even the definition that we are given covers a wide variety of behaviour, of the causes of which little is known and for which so very little is known in the way of cures. In these cases, the diagnosis is essentially a social judgment. This is also true in many cases of mental illness. Some value judgments are inevitably involved in the diagnosis and we must have some conception of what mental health is before 759 we can judge the degree of mental sickness. Although the Bill is described as the Mental Health Bill, it is a Bill about mental sickness or, rather, mental disorder.
When dealing with compulsory admissions, the more indefinite the diagnosis or the more uncertain it is, the greater the care we must take. This applies particularly in the case of the psychopaths. It is only in this connection, perhaps, that I would join those who say that there is a case for some lay participation in the admission procedure. Here we do not have a medical diagnosis, but a social judgment.
In Committee, we will be dealing with the composition of the tribunals. In addition to the people who are mentioned in the four categories in the Schedule, I am sure that the tribunals should include psychologists and sociologists, because of the social character of so much mental illness. Indeed, in many cases, the degree to which what we are dealing with is due to organic causes is unknown and the only evidence of the illness or of the disease is behaviour, not mental incapacity, but emotional disturbance, the inability to cope with relationships with other people, with one's family, with work, with one's place of work and with the community. My hon. Friend the Member for Woolwich, East (Mr. May-hew) quoted one or two letters which illustrated extremely well the social character of so much mental illness.
When the mentally sick person is living in the community, in the family, at work, or wherever it may be, the stresses to which he or she is put by his or her relationships with other people are cumulative and can increase his or her illness. This underlines the extreme importance of skilled support, not only for the patient, but also for those with whom the patient may come in contact in the community. This skilled support is probably more important than drugs, the effect of which may frequently be only temporary.
The object of our present policy, upon which we are all agreed, is to get the patients out of the hospitals as fast as possible, or to avoid the necessity for patients to have to go into hospital. Everybody agrees that the Bill makes the procedure of this in-and-out movement much easier. As other hon. Members have mentioned, however, there are two 760 sets of people to consider. There are the patients and there are their families and those with whom they are closely concerned in the community.
Unfortunately, in a large number of cases, the state of psychiatry is such that there is at present no certain method of deciding whether a patient is better inside a hospital or outside it. If one could imagine somebody from outside this planet who was able to draw an exact line to decide on which side a patient should be and could draw up a statistical distribution of the sides on which patients should be, it would be found that inevitably we err on one side or the other. Either we err on the side of making too many compulsory admission orders, in which case some people who ought to be outside the hospitals would be inside, or we err on the side of keeping in the community some who should be inside the hospitals. Some will be outside who should be in.
This is inevitable, and, of course, in the light of modern humanitarian and liberal ideas, which are illustrated by what this House is doing tonight, undoubtedly the tendency will be towards the second alternative. The tendency at the present time will be to leave outside or to move outside the hospitals those who, perhaps, should be inside. I am not saying that this will be done on purpose, but that it is inevitable that we should tend one way or the other and that on the whole in the future we shall tend more to leave or move people out rather than keep them in.
There is bound, therefore, to be a number of people outside who, by their very existence outside, will create serious problems for those with whom they live and for those with whom they work, and we may have a serious danger of creating real difficulties for the families of people suffering from these disorders, and for those with whom they associate. To take, for instance, an obvious case: that of the mother who is mentally sick, and the possible effect on her young children when she is left in the community outside a hospital when, perhaps, she would be better off inside the hospital.
I draw attention to this not to argue against the present tendency, but only again to emphasise the extraordinary importance of the community services, because people in this condition, and their 761 families, as well as their employers and everybody else, will need skilled help. They will need, as my right hon. Friend the Member for Warrington (Dr. Summerskill) said, to be educated to tolerate deviations and to be willing and able to assist the members of their families who are capable of functioning at reasonable levels of disability.
It will, I hope, be first the general practitioners who will have the task of helping these people and their families and those with whom they come in contact, and the general practitioners certainly need far more psychiatric training. The lack of psychiatric training they receive at present is shocking. Then we shall need more psychiatric social workers and case-workers. As has already been said, we shall certainly need to increase the provision of day and night hospitals, occupational centres and special training centres which must be staffed by psychologically trained people.
If this Bill is to be more than an expression of humanitarian ideals, then it is quite clear that these community functions, which come under the local authorities, will have to be mandatory within reasonable time. Not only must they be mandatory, but, any advance we can make, starting from the passing of the Bill, will depend on the resources which we as a community are willing to make available for this purpose.
I am not one of those who believe that the new procedures with which we are now dealing and the new techniques will lead to any financial saving whatsoever. As has been pointed out by other speakers already, the fact is that we are spending far too little upon these provisions, and if it is true that in future we shall spend less on hospitals we are sure to spend more elsewhere, because apart from what must be provided for out-patient treatment there must be an enormous increase in the number of trained staff.
The Royal Commission on the Law Relating to Mental Illness and Mental Deficiency, of course, drew attention to this. We were told the other day that out of 144 new senior registrar posts adveritsed only 117 could be filled. The Royal Commission recommended that there should be psychiatrists on the staff of every local authority health department. Therefore, the demand for psychiatrists, 762 in addition to those required in hospitals, will go up and should go up enormously.
As to the psychiatric social workers, my right hon. Friend pointed out that there are only 500 of these in the whole country and I believe only 35 are actually engaged in adult community care. I think we shall also certainly need more people to care for the subnormals; more trained teachers in special training centres. At present there are quite inadequate training facilities for these people and we shall need many more teachers with proper psychological education.
I want to turn for a moment to the administrative problems, which we must not overlook in entering into the new era. If we are to have the policy of making going into and coming out of hospital easy, or, if I may put it the other way round, going into and coming out of the community made easy, it is essential that the geographical areas in which all these provisions are made should be carefully drawn. The mental hospitals obviously must draw their patients from clearly defined areas which have close relationships with out-patients' clinics in those areas.
In passing, I should say that, of course, I have no expertise to judge whether there should or should not be wards for mental patients in general hospitals. We shall certainly need more medical advice on that. However, while we are short of resources I think it would be wrong to scatter them around in penny packets among general hospitals rather than to keep them concentrated in the mental hospitals.
Then the clinics themselves must be very closely integrated with the community services which come under the medical officers of health. The social services of the county councils will have to be rationalised so that the areas of the various functions correspond and so that responsibility for these functions is delegated to the area medical officers of health. I am thinking particularly at the moment of things like the clinical work of child guidance clinics, children's officers, mental welfare officers and so on. All these have got to work very closely together under integrated control if they are to help the families affected, so that the families who have patients among their number can very easily get advice and help and so that sickness can be quickly discovered. Thus we can help to preserve the family intact. For this it 763 is necessary that these integrated services should be in clearly defined areas.
I turn now to the responsibilities of the central Government. These are, in my opinion, more than are to be found mentioned in the recommendations in Part VI of the Royal Commission's Report which deals with the supervision and control of the local authorities in carrying out these functions, or even in Appendix IV, which deals with statistics.
First of all, as the hon. Gentleman the Member for Banbury (Mr. Dodds-Parker) and others have said, much more must be spent on research, and that is undoubtedly a function of the central Government. It is not only a question of spending more money, which is very important, but, of course, the Ministry of Health will have to lay down rules for the following up of cases by local authorities to ensure they are not lost sight of and so that clinical research can be continued. There is the necessity for an indexing system for identifying and following up patients, especially when they move from hospital to hospital or from one local authority area to another. But research is not only clinical research and it is not only concerned with drugs or biology. Much more research is needed on the social causes and effects of mental illness.
There is one aspect of this Bill and of our present policy which, I suggest, is well worthy of study. We are proposing to put a good deal more responsibility for the care and cure of the mentally sick on the family, and yet we really do not know a great deal about the resources, physical or emotional resources, which the family has available to undertake this task. I suggest that there is a case for saying that the Medical Research Council, perhaps with the assistance of the Social Survey, should carry out a study of families which would cover the extent to which they are able physically to take care of mentally sick patients. We really do not know much about it, and we really ought to know more, especially before we have the local community services fully in operation and adequate. We might do enormous harm if the families were not capable, for a number of reasons, of looking after their mentally sick members.
In dealing with the psychopaths we shall need observation centres staffed by 764 workers in different disciplines, including social psychologists and sociologists, so that we may study the varieties of their condition.
Undoubtedly the Ministry of Health must have responsibility for training. My right hon. Friend the Member for Warrington referred to the extraordinary lack of psychiatric training in our medical schools, for instance the lack of an undergraduate school and chair of psychiatry in London where 50 per cent. of our doctors are educated, and the generally reactionary attitude of the medical profession towards this subject. I would say to the medical profession that the public are getting a little tired of their always getting together when they have their vested interests to preserve and not getting together to give the layman advice on these subjects.
I speak advisedly as a member of a hospital management committee. I have been shocked by the fact that when medical advice is asked for it is generally given from the point of view of a vested interest. Rarely do we get members of medical committees getting together—and I do not suggest that they should come to a unanimous opinion—to give the layman any sort of agreed advice on medical matters. It is no good blaming the layman, who has to spend the money, for being bureaucratic or obscurantist and interfering if he cannot get adequate advice from the medical profession. In no field is this more important than in psychiatry and in psychiatric education.
I realise that to interfere with universities and Royal Colleges is something which we say we never do in this country, but we have a precedent and the present Government have created that precedent. I speak now of a matter of which I know more than I do about medical education, namely technology. It is said that we do not interfere with the University Grants Committee, but history has shown that the Government are able to make a substantial increase in the provision for the education of technologists, even to the extent of saying what particular college in what university should be expanded with what money. If that can be done in technology, I do not see why it could not be done with medicine and psychiatry. I cannot see why the Government cannot get the medical profession and the 765 schools to accept that it is their responsibility to found chairs of psychiatry and establish teaching at both undergraduate and post-graduate levels.
This is not the only way, however, in which those who are to be general practitioners can receive training, and we are all agreed that the general practitioner has to play a greater part in this field in the future. There are already some seminars and weekend schools to give doctors an understanding of psychiatric problems. The Government might see whether these cannot be subsidised. Then there is a lack of training facilities for psychologists and psychiatric social workers and those who work in child guidance clinics. We must be one of the most backward countries in the world in the matter of training of this kind.
If the Government mean business by the Bill they will have to do something to provide resources and, I regret to say, the resources are not money alone. They are also staff. I am not at all sure that if we could provide £1 million tomorrow for research we could spend it, because there are not the people capable of carrying out that research. My hon. Friend the Member for St. Pancras, North (Mr. K. Robinson) appears to be getting worried, but the two things really do go together. It is absolutely certain that if we do not train staff we shall not be able to spend the money, and I want both to be done.
By passing this Bill Parliament will have demonstrated its recognition that public opinion is now prepared for a completely new approach to mental disorder. But Parliament, having willed the end, will have to will the means.
§ 6.43 p.m.
§ Mr. Peter Remnant (Wokingham)
I want to refer particularly to what are called in the Bill "State institutions", but before I do so I should like to register with my right hon. and learned Friend the Minister that I entirely agree with the remark made by the hon. Member for Batley and Morley (Dr. Broughton) about the salaries of medical superintendents. I know that a year or two ago the number of candidates available for these posts was limited. About the only people available were those who had dedicated themselves to this aspect of medicine. It is very good to have 766 men dedicated to the branch of the profession in which they have been called upon to operate, but it seems to me that, in Broadmoor and Rampton, particularly, they carry an enormous burden of responsibility for which they should be adequately remunerated. I hope that my right hon. and learned Friend will look carefully into this matter and consider whether these people cannot be more generously treated.
The right hon. Lady the Member for Warrington (Dr. Summerskill) said that the Title of the Bill was psychologically good, and my hon. Friend the Member for Hendon, South (Sir H. Lucas-Tooth) spoke of "glamour" in this context. There is certainly nothing psychologically good or glamourous about the title "State institution", and I regret that that name still persists. No one who has had any contact with the responsible officials of Broadmoor, or indeed with the patients there, in the last ten years at least, has not had impressed upon him that Broadmoor must be referred to as a hospital and the inmates as patients.
It is true that in Clause 132 the name "hospital" is taken to include a State institution but if' we acknowledge that there is a difference between mental hospitals and Broadmoor, Rampton and Moss Side, I should be glad if my right hon. and learned Friend and his advisers could find some other title to give to those three places. Even these small matters are important from the patient's point of view and they affect him to some degree. I want to return later to another aspect of this matter as it affects the fact that Broadmoor is not entirely a hospital and not entirely a prison, but a mixture of the two which cannot be altered either tomorrow or next year but which I hope will be altered in the near future.
In the meantime, my right hon. and learned Friend mentioned security merely by saying that, now that he is solely responsible for the administration, he would endeavour to see that the greatest possible security is provided. I believe that to be his honest, sincere and firm intention, but we have had two unfortunate experiences with Broadmoor during the last decade. In one case a child was murdered, I believe largely because searchers for an escaped inmate were under some bond of secrecy not to disclose their business. As a result of 767 that case, there was the Scott Henderson inquiry. The Report made as a result of that inquiry laid down that certain arrangements should be made. In fact a procedure was agreed and it appeared to be highly satisfactory.
Then, recently, another man escaped and once again children were allowed to go to school on their own without parents and teachers having any knowledge that there was a dangerous person at large. No good purpose is served now by going back over these events, but there is no doubt that the procedure laid down as a result of the Scott Henderson Report was not carried out. It was, in particular, singularly unfortunate that when the siren was sounded three hours after the people at Broadmoor knew that an inmate had escaped it was sounded at a time when it was normal to have a practice sounding. The result was that the significance of that sounding was not appreciated in the neighbourhood at the time.
There are at least three different sets of people whose interests are closely concerned, namely, the people living outside, the staff and the patients. To put it in its right perspective, I, think it is true to say that practically every male member of that staff has at some time or other been attacked physically. Whether these people should be called psychopaths or not I am not worried about at the moment, because I think hon. Members will realise the type of patient to whom I am referring. I will call them Block 6 patients. They are small in number, about 50 or 60, but they are liable to turn aggressive at any time. There are also about 150 of what I call time servers who are the cause of a great deal of the trouble because they know when they are coming out.
Both those categories of patients need a much stronger and sterner discipline than the other patients in Broadmoor need or should have. Therefore, many of the staff must be interchangeable if they are expected to deal one week with the potentially aggressive and the next week with the docile. Let me add quickly, in case I am misunderstood, that the staff is a grand body of men and that I do not believe any of them has ever used more force than is necessary, and perhaps less than some of us would have used in similar circumstances.
768 During the last few months I have had reason to appreciate that in any case of serious illness, mental or otherwise, even the smallest improvement is an encouragement to more progress. If the report is correct that the Home Secretary intends to build more prisons, and since the treatment and discipline required by the two classes I have mentioned is more akin to prison discipline, I hope that there will be a wing in one of the new prisons where these people can be treated until, as one hopes, they lose their aggressiveness. After that, they can take a step forward into the more pleasant surroundings of Broadmoor which, it is true, is rather prison-like, having been built ninety years ago, but at least it is an advance, with its extra privileges, and progress can be made from there. This would not only hasten recovery but would ease the security difficulties of Broadmoor.
There is one other aspect to which I will refer. I am sorry that the Home Office is not represented on the Government Front Bench because I am quoting a case about which I have been in correspondence with that Department over a number of years. It concerns the release of a patient at Broadmoor. Let us assume that the patient has regained such a state of normality that all responsible medical advice, both there and at the Home Office, is prepared to see him released on licence under the care of a guardian. Let us also assume that the next-of-kin is regarded as an unsuitable person into whose care that patient should not be put. Whether that is the case or not does not affect my point.
At present it is extremely difficult for the Home Office to avoid putting such a patient under the care of the next-of-kin, with the result that he stays in Broadmoor for a considerable period, despite the fact that if the guardian were not unsuitable, the patient would have been out of Broadmoor a long time ago. If the patient concerned is young, it becomes all the more difficult for him to acclimatise himself to conditions outside, particularly if he entered Broadmoor in his teens. It would be a great help if there were more powers to provide a guardian in such cases or if there could be a half-way stage, such as a hostel, where similar types of patients could live for a probationary period under the 769 supervision of a warden appointed either by my right hon. and learned Friend the Minister of Health or the Home Office, until they become accustomed to being outside.
I join in the approval of the Bill and I have put forward these sugestions in the hope that my right hon. and learned Friend will consider them and will perhaps make alterations in the Bill at a later stage. As regards Broadmoor, not only are there two or three different types of patients there but two Ministers are responsible for certain things in that hospital, as I will call it. I have always been brought up to believe that, sooner or later, divided responsibility ends in no responsibility. I wish my right hon. and learned Friend the Minister of Health could be made wholly responsible for mental institutions, accommodating in the wing of a new prison those who should be under prison control.
§ 6.58 p.m.
§ Mr. Kenneth Robinson (St. Pancras, North)
The hon. Member for Wokingham (Mr. Remnant) devoted most of his speech to the problems of Broadmoor, and I hope to say a word or two about the State institutions a little later. I add my welcome to the chorus that has greeted the Bill. I have some reservations about it, but, by and large, I think it is a good Bill, as indeed was the Report of the Royal Commission on the Law Relating to Mental Illness and Mental Deficiency, on which it is broadly based.
In general, it is a liberalising and a civilised Measure which at any rate clears the decks of the antiquated legal machinery, the phraseology, the discredited terminology and the outworn concepts that have for so long handicapped all who have been trying to help and treat the mentally sick. I have always regarded clearing decks as a prelude to action, and action is urgently needed in this sphere, as speaker after speaker has said in this debate. Action is needed if we are to raise our mental health services to the level of the National Health Service, of which they form a part.
At the moment there are two standards—the National Health Service standard and the mental health services standard. The gap between these standards is wide everywhere and in parts of the country it is disgracefully wide. It is an unfortunate 770 fact, not only in Britain but nearly everywhere, that we have in the past wanted to get our mental health services on the cheap, and it may be for this reason that mental health is undoubtedly the most serious health problem in Britain today, and probably the greatest social problem.
It is also an economic problem, because there are thousands of patients in mental hospitals at present who could, with proper treatment, be returned to the community and enabled to earn a living, thus contributing to the productivity of the nation. I do not think that we are exercising a wise economy in economising on these services.
A very interesting piece of statistical research was carried out a year or so ago by Dr. Wadsworth, the medical superintendent of Cheadle Royal Hospital. He took a number of patients suffering from the same type of disorder who had been treated in three mental hospitals. He chose one of the most expensive, one of the cheapest and one around the average. He took the costs of medical care, nursing care and drugs, and he worked out the cost to the community of the treatment of those patients in those three hospitals. He found that in the better-staffed hospital the length of stay was significantly less, and if one added to the cost of treatment in the hospital the loss of the man's earnings for the time spent in hospital, the result was, in effect, that the most expensive hospital was in the end the cheapest to the nation. That carries a moral for all of us.
I turn to the detail of the Bill. As I see it, the Royal Commission had two main purposes. The first was to limit, so far as is humanly possible, differentiation between physical and mental illness. The second main purpose was to make provision for mental health services in the community so that as many patients as possible can be treated and cared for outside hospitals. Broadly speaking, the Bill serves the first of these purposes admirably.
It is in connection with the second purpose that my main criticism of the Bill lies. It is one which I do not propose to follow in any great detail because it has been mentioned not only by my right hon. Friend the Member for Warrington (Dr. Summerskill) but by almost every other speaker from this side of the House, it has been mentioned in most of the 771 newspapers which have commented on the Bill, and it has been the major disappointment of almost everybody concerned in the field of mental health. It is the failure of the Bill to follow the Royal Commission's recommendations about making these community care services mandatory on the local authorities.
It is no good the Minister coming here and saying that the amount that has been spent on the local authorities has been going up steadily and the rate of increase is to be increased. What will happen, no doubt, is that local authorities which have been providing some reasonable community care will do better in the future, but the very much larger number of authorities which have made little or no provision for mental health services will continue to do nothing, for they have had permissive powers for a long time and have taken no advantage of them. Unless the Minister of Health makes it clear that this duty will be placed on them as a mandatory duty a start will not be made.
Of course, there are not sufficient skilled workers to start a community care service over the whole of Great Britain tomorrow. We know that, and it is for that reason that I put forward the suggestion that we should give two years' notice, during which schemes must be prepared and submitted to the Minister for his approval. The Minister would have an opportunity then of expanding them if he did not think they were adequate, or, if he thought they were too extravagant, he could curtail them, though I hope he would not do so. It would mean, of course, that finance for this would have to be provided from central Government funds. This would be all the more necessary since the unfortunate introduction of the block grant. I say no more than that one of the main intentions of the Royal Commission is frustrated from the start by the Government's refusal to make the community care services mandatory.
The Bill has not had much criticism this afternoon, but I have one or two criticisms to make of some importance. There are one or two things I should like to mention briefly first. I see from the Bill that the mental welfare officer has a right of entry without a warrant on reasonable suspicion that some mentally ill person is lacking care and attention. Under a later Clause a constable has a 772 right of entry, but with a warrant. The constable can remove the patient to a place of safety. The mental welfare officer cannot remove the patient to a place of safety. I suggest to the Minister that there may be some argument for treating mental welfare officers and constables in the same way here. Perhaps they should have the same rights and the same obligations. Both should need a warrant to enter premises, and both should be empowered to remove a patient to a place of safety.
I should like a little more explanation about the precise considerations which led to the inclusion of the category of "subnormal" in the Bill, contrary to the Royal Commission's advice. I do not dissent from this, but it was not clear from what the Minister said how he will differentiate this category from the very much wider category of the feeble-minded which the Royal Commission was anxious to remove from compulsory powers altogether.
I should like to know why Section 57 (5) of the Education Act, 1944, has been repealed and apparently not re-enacted. It was a very useful provision which obliged local education authorities to report to the public health authority school leavers from E.S.N, schools. That provision seems somehow to have disappeared.
It seems to me that the "managers" have very onerous duties. I wonder whether sufficient thought has been given to whether they are equipped to carry out all these duties, as they are constituted at present? Are the managers really equipped to examine the forms of medical recommendation for compulsory patients and say whether or not they are in order? At the moment, the parallel duty is carried out by the Board of Control. I should like to know to what extent the managers can delegate this responsibility and other responsibilities that they have under the Bill to their officers, or alternatively to two or three of their number.
My hon. Friend the Member for Batley and Morley (Dr. Broughton) had some difficulty in understanding the definition of "responsible medical officer." I share that difficulty to some extent. As the Solicitor-General said, the term is defined in the Bill, but I think in somewhat vague and inadequate terms. In the case 773 of hospitals, is it intended that a "responsible medical officer "shall be of consultant grade? My hon. Friend thought it would mean the medical superintendent, but as I read the Bill the medical superintendent has been abolished in so far as his legal status goes. I should like a little clarification on this point.
I wish also to refer to the hospital inspectorate. I am not sorry to see the Board of Control as such go, but I think that most of us who have had anything to do with the mental hospital service would agree that the reports of the Commissioners of the Board of Control were extremely valuable and helpful. Most of us welcomed the fact that there was some fairly common yardstick which could be brought to bear on individual hospitals. I learnt a good deal about those hospitals for which I have some responsibility, from their reports, which I should have been unlikely to learn in any other way. I agree that it is somewhat invidious merely to have an inspection of mental hospitals. In future many patients will be looked after in general hospitals. I hope that the Minister will give consideration to the possibility of having a hospital inspectorate which will cover all types of hospital for which he is responsible.
Before coming to my main criticisms of the Bill, I want to congratulate the Government and the Minister on Clause 4 (5) on the unequivocal way in which it abolishes the category "moral defective". I hope we are all glad to see that go, because it has led to much misery, un-happiness and injustice. On the whole, the definitions of mental disorder contained in Clause 4 are very good. The definitions might be improved by a word here and there, and no doubt there will be attempts in Committee to do that. I am very pleased with the brave attempt in broad social terms to define the psychopath. I am sure that in this the Government are right and the Royal Commission wrong.
On this point, I want to strike a note of warning. We know very little about the treatment of the psychopath and we have very few facilities for treating psychopaths. One of the corollaries of the Bill is that it is absolutely essential that experimental units for the treatment of psychopahs should be set up, if the provisions of the Bill are to function at all for this category.
774 My main worries about the Bill are these. Because mental hospitals are now redesignated, it follows axiomatically that all hospitals have the right to refuse a patient if they are full, or if treatment facilities for that type of patient are not available. That may well lead to difficulties especially for the unwanted type of patient, including the psychopath. However, it is not only the psychopath who is concerned.
We all know about the present difficulties with the chronic sick patients, the difficulties of finding hospital accommodation, and how, sometimes, even in emergency cases, such patients have to be hawked around from hospital to hospital until there is found some hospital prepared to accept them. Bad as that is for the chronic sick, if that happens to the mentally ill it will be much worse. I hope that some arrangements are to be made to avert that possibility.
I do not suggest that mental hospitals should be designated. I welcome the dedesignation and I do not consider that an obligation should be put on individual hospitals to receive any class or category of patient. However, some obligation has to be placed somewhere, and the regional hospital boards seem the right bodies to shoulder that responsibility. The Minister—probably by circular—could require regional hospital boards to make arrangements to ensure that accommodation will be provided somewhere in their regions for compulsory patients.
My second main worry concerns the censorship of patients' correspondence. I dislike censorship of any kind, on principle. I remember very well the only time when my correspondence was subject to censorship, along with many other hon. Members, during the war. As a naval rating, I resented having my letters read by naval officers, and later as a naval officer I reckoned it a dismal chore having to censor the letters of ratings who were serving in the same ship. Those recollections were with me when I read the Bill.
I do not so much mind the provisions for withholding incoming mail in certain special circumstances, but the provisions for censoring outgoing letters, contained in Clauses 36 and 131, are wholly unacceptable, and quite contrary to the recommendations of the Royal Commission. I start from the principle that censorship is undesirable and justifiable only in exceptional circumstances.
775 Clause 131 extends the censorship of letters to informal patients. That is contrary to the whole spirit of the Bill. There is here a complete differentiation between the informal mental patient and a patient suffering from any kind of physical disability. That will be regarded as a disincentive to enter hospitals and accept treatment, and it will not be helpful to the treatment itself.
Additionally, it will mean considerable administrative difficulties. It will be necessary to look at every letter a patient writes, except those addressed to the categories of recipient set out in Clause 36. Even if the Minister responds to my plea, and the informal patient is excepted the difficulty will remain because the informal patient will, I hope, often be in the same ward as the compulsory patient. It will thus be necessary to censor all letters coming from that ward.
The grounds given for withholding letters are inadequate. It is said that if a letter is unreasonably offensive to the addressee, the responsible medical officer should withhold it, while in the same Clause the medical officer is obliged to pass unopened letters to the nearest relative. Surely the nearest relative is much the most vulnerable addressee, the person much more likely than anybody else to be offended or upset by letters from a mental patient.
If that is made a reason for stopping letters, what about protection of third parties? What about letters which are libels on third parties? I do not mean on people associated with the treatment of a patient, but on others. The Minister made some play with the fact that it is now necessary for letters to a patient's own Member of Parliament to be sent on unopened. Does he expect the responsible medical officer to check the constituency of every patient under his care to make sure that the letter is going to the right Member of Parliament? If there is to be such a decision, it is only reasonable that it should cover all Members of Parliament.
The censorship of letters ought not to be part of a doctor's job. If anything is calculated to injure the doctor-patient relationship, about which we hear so much from the medical profession, it is surely the knowledge that a doctor is reading his patient's personal correspondence.
776 Having said that, there is one justifiable ground for withholding correspondence, but it is not even mentioned in the Bill. It is when the sending of a letter would harm the patient himself.
§ Mr. Walker-Smith indicated dissent.
§ Mr. Robinson
The right hon. And learned Gentleman shakes his head, but I think he is talking about incoming mail.
§ Mr. Walker-Smith
I was talking about the passage in Clause 36 (1) about the treatment of a patient.
§ Mr. Robinson
If the Minister will read his own Bill a little more carefully, he will see that that is a reference to incoming and not outgoing mail. I am talking about outgoing mail, the sort of case in which a patient writes to his employer and confesses to a crime which he has not committed, or in which he encloses a cheque which wipes out his entire bank account and in which he orders some object which he does not need. In the last analysis, the power to withhold any letter must imply the censorship of all. On balance, I come down on the side of abolishing all censorship of patients' letters. That might mean a certain amount of distress to a certain number of people, but that is part of the price which the community must pay for the liberalising of the law.
Finally, I want to refer to special restriction orders, which are mentioned in Clauses 64 and 65, both of which I find unacceptable. I dislike the whole idea of special restriction orders. It is confusing hospital with prison. It is confusing the treatment of a sick person with the custody of a criminal. If an offender is sufficiently ill and in need of treatment as to be sent by the court to a hospital rather than prison, then one must regard the responsibility for his offence as being mitigated. He cannot be treated as if he were a prisoner, for if he had not been ill, he would have been sentenced in the ordinary way. But, in effect, that is what happens. In a curious way he is given a combination of compulsory hospital treatment and a prison sentence, because he is subject to special restrictions for a limited or an unlimited period.
As I understand the Bill, only the Home Secretary has the right to discharge such 777 a patient. He has lost the right to appeal to the mental health review tribunal which is open to all other types of compulsory patients. The responsible medical officer and the managers of the hospital can discharge him only with the consent of the Home Secretary. I feel that it is quite wrong that the Home Secretary should be the only authority able to discharge a patient from hospital. Even if the Government insist on maintaining the special restriction orders, I hope they will think again about this aspect.
The right of discharge from hospital should remain as with all other compulsory patients. If a court orders a special restriction order of five years' duration on a patient, the medical authorities of the hospital concerned should have the right to discharge the patient from hospital, if necessary to the custody of the Home Secretary; in other words, to prison. But I think it would be a great disservice to the move forward which we are making in this Bill, and the enlightenment that the public is beginning to show, if we muddy the waters by confusing the functions of hospital and prison in the way in which the special restriction orders seem to do. After all, if the offender is ill, it should be the primary responsibility of the responsible medical officer to decide whether it is safe to discharge him, a decision which he has to take in the case of all compulsory patients.
This brings me to the question of State institutions. I wish to ask whether it is envisaged that most of the special restriction order cases—or indeed all of them—will go to one or other of the State institutions. To what extent do the compulsory provisions of the Bill generally apply to patients in State institutions? The Bill is not very clear on this point; indeed, it is rather coy altogether about State institutions. There is the very brief Part VII which transfers the administration from the Board of Control to the Minister, but we know very little beyond that.
I do not know exactly how patients get to the State institutions. I do not know the basis on which they are transferred from an ordinary mental hospital—or what used to be an ordinary mental deficiency hospital—to, say, Rampton or to Moss Side. As the hon. Member for 778 Wokingham (Mr. Remnant) will be aware, Broadmoor patients were specifically excluded from the terms of reference of the Royal Commission on the Law Relating to Mental Illness and Mental Deficiency. I suggest that the time has come for a separate inquiry into the three State institutions; into the conduct of those institutions and their administration; the principles on which patients get there and the basis on which they are discharged. I think that such an inquiry would be welcomed by the staff.
Like my hon. Friend the Member for Woolwich, East (Mr. Mayhew) and other hon. Members who have spoken, I regard the Bill, not so much as an achievement in itself, but as an opportunity which is not likely to recur for many years. Unless we are prepared to seize this opportunity to build up the mental health services of this country to the level of the rest of the National Health Service, and provide the money, training facilities, and—perhaps above all—the necessary research, the time, the vision and the imagination of the Royal Commission will have been wasted.
§ 7.24 p.m.
§ Dr. Reginald Bennett (Gosport and Fareham)
Although I spent several years of my life working in the hospitals which are the subject of this Bill, I should be the first—indeed, I am the first—to express admiration for the speech of the hon. Member for St. Pancras, North (Mr. K. Robinson). His great experience and enthusiasm in this particularly trying field of endeavour has always been conspicuous, but never more so than on this occasion.
This Bill represents one of the greatest pieces of progress which has been seen for many years. It marks one simple transition in the field of mental medicine and administration—from the custodial to the curative. It has caught up with a step which has not long been taken in the medical world itself. Public opinion has followed fast, and Parliament has been right up with public opinion, as has been hinted this afternoon; and I think this a matter on which there is real cause for congratulation to those who have helped to push forward this reform.
The problem is huge; 43 per cent. of the hospital beds are occupied by mental patients, who thus represent two out of 779 every five hospital patients. Not only that, but what is more startling still, recent research by a former colleague of mine has shown that of the patients attending general practitioners 9½ per cent. can be established as coming largely or wholly because of some psychoneurotic trouble. They come complaining of physical trouble, but their trouble is really psychoneurotic. Those are people who will never see a mental hospital, but they represent 10 per cent. of the people who visit doctors. The problem, therefore, is simply colossal, and I am glad that in this debate it is receiving serious consideration on the basis—without, so far as I am aware, revealing any party difference whatever—of putting right and improving the mental health services.
Whatever may result from the introduction of this Bill, one thing is quite certain—there will be no fewer patients. The problem will be just as large; the distribution and the care of the patients will be different, and to that extent, as they are distributed among more authorities, so more staff will be needed. That is known to be one of the problems facing us. But I wonder whether Parliament realises how much Parliament itself is to blame in one of these respects; that is—I have heard examples mentioned twice today—regarding the medical psychiatrist staffs of hospitals.
Do hon. Members remember that, in 1950, the then Minister of Health cut short the further progress of senior registrars—of which there were so many in the mental hospitals completing their post-war training? That was an alarming disincentive. Their careers were terminated. They were told to go to general practice or to find other ways to occupy themselves. How many people will go through this long and fearful course of training if they think that such a thing can happen again? I am not surprised that at present there are not many applicants for the position of senior registrar in our our mental hospitals.
The concept underlying this Bill is clearly a search for additional freedom from the many restrictions and compulsions which so far have attended the treatment of those who are mentally ill. This pursuit has gone forward with enthusiasm, but I am wondering whether we are not leaping ahead of public 780 opinion in this respect and stressing too much the freedom from compulsion. Not many hon. Members of this House may know how difficult it is to, shall I say, wrestle mentally with a patient who is disordered, alarmed and frightened and who has no intention of going to hospital.
Has that really been given as much thought as it deserves? It is frightfully difficult to persuade a mental patient to accept hospital treatment, and even now it is only when they are deemed to be a danger to themselves and to others that they can be put under compulsion. That is now to be made more difficult. There is to be less of the compulsion. I wonder whether we shall be able to get these people into hospital, especially in the light of one additional difficulty which is about to be put in the way.
At the other end of the scale, the discharges, the "open-door" system is being very widely practised. It is, of course, most beneficial, but I must say that it seems to be running away with itself a little too fast, because in the interests of favourable annual statistics hospitals treat their patients, quite properly, for periods as short as possible and discharge them. The figures look marvellous at the end of the year, but the facts come home to roost if one studies the statistics over the years, because one then finds so many that have come back again. It has been said that the open-door system is becoming the revolving-door system, which benefits neither patient, hospital, nor Exchequer.
Another thing that will, to some extent, add to the difficulties of persuading the mentally disordered to enter treatment, let alone hospital, is something that has been welcomed by many—and I know that it has not been undertaken without serious consideration. I refer to the elimination of the justice of the peace as the committing authority. That will certainly remove the conception which has obtained for some time of the justice of the peace acting merely as a rubber stamp. He is by no means a rubber stamp. I have known very recalcitrant J.Ps. who, quite properly, have proved extremely difficult to persuade. However, if the compulsory sending to hospital of a patient who is basically bound to be pathologically suspicious is to come invariably as a result of a visit to the mental specialist, one can imagine 781 how difficult it will prove to get the patient to go to the mental specialist. I hope I am not glamorising the doctor-patient relationship, but from now on it will be very difficult to get patients to the specialists.
We certainly ought to make the doctors entirely responsible for committing persons to hospital under compulsory powers, for the 28-day observation period certainly, and for other such periods as are necessary for any immediate treatment that can be envisaged or to allow ideas about treatment to be worked out.
On the other hand, we may have the long-term schizophrenic who, alas, is so unlikely to be cured by any methods known to us at the moment; the long-term patient whose initial treatment has failed and who may have had a leucotomy which has not been successful. The further holding of that patient in hospital once again becomes a custodial matter, and that should not be a matter for the doctor's certificate. As the hon. Member for Batley and Morley (Dr. Broughton) said, the certification of such people must be done by the authorities who are concerned with a man's freedom.
How it is to be done, I cannot immediately suggest. All I would ask the House to notice is that we are to have the mental health review tribunals, which will act on a sort of negative procedure such as is familiar to this House. Could they not instead be involved in some kind of affirmative procedure in cases of committal to hospital? Could they not, at the end of the 28 days, be called on to give a positive confirmation? That would satisfy most people—it would certainly satisfy me—and remove this objection which continues to worry me. I have taken as wide medical advice as I can on this point and have found that opinion as suspicious as I have found official opinion sanguine.
I have been on duty in a mental hospital, perhaps just before Christmas, and have seen coming in these poor old people whose families can no longer have them round their necks. In a manner of speaking, they are a danger to themselves, according to the Act. They may be in danger of falling downstairs, or they are no longer able to cook for themselves and would starve if left to themselves, but I have been at the receiving end when they 782 have come in under certificate and I know that it is a pathetic thing, and a very wrong thing. I hope that we shall now see the end of that, but what about those who are there now? Their cases will be reviewed, but I doubt if they will have anywhere to go; they will just stay in.. I do not think this Bill, promising and hopeful though it is, will make any immediate difference to them—and they are the people of all people who really should be got out.
One thing I should like my hon. Friend to discover for me is this. In the course of this debate I have heard it mentioned that one-third of the long-term inhabitants of mental hospitals are over 65 years of age. Has that been a stable proportion over the years? Is this a relic of the custodial era, when no treatment could be undertaken I know of many cases of breakdown in the First World War who are still patients in county mental hospitals. Is this proportion the result of no attempt being made either at scientific or even—and to my mind much more profitable—empirical treatment of the mentally ill, or is it a percentage that just silts up for ever?
Incidentally, someone, I think it was the hon. Member for Woolwich, East (Mr. Mayhew), referred to some wonderful new revelation in treatment that was about to be released to the world. I am bound to say that that is news to me; I have not heard of anything just round the corner.
It would be good to know whether the inroads of science were reducing that proportion. Over the last ten, if not twenty, years it might be possible to see a reduction in that proportion, reflecting the use of treatment. Otherwise, we must assume that in the population there is always that proportion of incapable elderly people who have to be cared for.
Then we come to the psychopaths—the gentry who in one way or another have occupied a great deal of my time in the past. I join with the hon. Member for St. Pancras, North in congratulating the Government on their brave effort in finding a definition, even if it is in social and not in medical terms—this in a field where all the sectarians in the psychological field have failed and even the Royal Commission has thrown up its hands. But for these chaps, I am afraid, I do not think the Bill will mean a great 783 step forward. Clause 26 (1, a) says that the application for admission has to certify… that his disorder is of a nature or degree which renders him suitable to be detained in a hospital for treatment…while Clause 4 (4) describes "psychopathic disorder" as a condition…which results in abnormally aggressive or seriously irresponsible conduct on the part of the patient, and requires or is susceptible to medical treatment.I think that without any hesitation we can say the psychopath is almost entirely unsuitable for hospital treatment. That is one thing. The other trouble is that I very much doubt whether anyone would be likely to confirm with any confidence that he is in any way susceptible to medical treatment. There we run up against one difficulty straight away. What should the treatment be?
I have had lots of psychopaths through my hands, and I cannot say that their treatment was very successful. The treatment, so far as I can make out, is custodial, and that is all that is intended. Perhaps the only other thing is the one that treats many other phenomena in the sphere of the mind and not only those recognised as medical, and that is the lapse of time. It is no exaggeration to say that certain distinguished men in this field have discovered that the electrical brain waves as recorded from the psychopath are almost always those suited to a child or an adolescent, and the psychopath's development, as shown by that one means alone, is that of somebody variously immature. A very happy way of defining any one conception of the psychopath, if one knows them at all, is that they are childish in all their ways.
Another thing is, if it is true—and I think it is established without any shadow of doubt—that the psychopath, when he gets to the age of thirty or so, is likely to be mature in something like the way, shall we say, of the undergraduate type of citizen. So perhaps the treatment intended for the psychopath is simply ageing in custody, in which case it seems unnecessary to commit him to hospital.
One thing certain is the danger which has been mentioned once or twice this evening—I think by the right hon. Lady the Member for Warrington (Dr. Summer-skill) and by the hon. Member for St. Pancras, North—the danger that the patient will be refused. No hospital can stand more than one or two psychopaths 784 in the whole hospital, let alone in one ward. The place becomes a bear garden. They put the other chaps up to tricks and they are frightfully clever in finding out bright ideas for perhaps the duller members of the community or the more disturbed ones. The hospitals are going to refuse these chaps. Even if regional boards have an organisation for indicating where compulsory patients shall be admitted in their area, that may apply to those certified; but I do not think that we can really compel any hospital to admit more than it chooses to say is its maximum allowance of these appalling people.
The answer is that we must have some new sort of institution yet again for psychopaths. I am not saying that it should be the East-Hubert Institution for Criminal Psychopaths, which operates under the benefit of a court order, but some institution, or branches or wards of other institutions, which are staffed by very particular doctors and others who may perhaps be more than a little psychopathic themselves and will look after these people and put up with them until their time is up. That is the only suggestion which I have to make on that matter. I know that it is not a very constructive one, but that is the problem which is revealed.
In that connection, there is one other matter which I think is relevant. What about the alcoholic? The alcoholic is very commonly said to be within the psychopathic field. The alcoholic in the fullest flowering period of his life is very commonly over the age of 21, if not always, and therefore no compulsory powers can be used to make the alcoholic stay in hospital for treatment, which he knows very well is good for him and for which he may have asked.
I would put this to my right hon. Friend. Can we not in this Measure authorise compulsion to be used at the request of the patient because, at the outset and when really suffering from boozer's gloom, the alcoholic may ask to be detained and compulsorily given the full treatment? A few days later all that is forgotten and the trouble starts again. If these powers may be used it may be possible for the treatment to be given that the patient requested. Cannot we hope to do something for these particular sufferers, because it is a very real problem and they do suffer, in spite of many people's ideas to the contrary?
785 That is all I want to say about the Bill. I am sure there will be only too many other opportunities to discuss it. We have taken on a very great responsibility in bringing this Bill forward, a responsibility wholly praiseworthy, and I hope that we shall discharge it completely to everyone's satisfaction.
§ 7.46 p.m.
§ Mr. Norman Dodds (Erith and Crayford)
I would at the outset say that I welcome the Bill because it makes several important proposals which, if adopted, will be a big step forward to a much more humane system. It is not my intention to take up the time of the House by referring to the good points. I think that it is much more important that I should deal with what I consider to be the greatest weakness in the Bill. It is a weakness that alarms me and should alarm everyone else, including the Minister and particularly the doctors, whom I am certain will live to regret it, if the present proposals become law. The hon. Member for Gosport and Fareham (Dr. Bennett) referred to it and it has also been referred to by my hon. Friend the Member for Batley and Morley (Dr. Broughton).
I believe that the Bill is largely the result of dissatisfaction over the years with the ease with which the liberty of the individual has, in many cases, unnecessarily been taken away. I would claim that that amounts to the greatest social scandal of the twentieth century. The hon. Member for Gosport and Fareham referred to the number of old people who are being taken to mental hospitals. There is plenty of evidence by the greatest experts before the Royal Commission that these old people are being taken there for social rather than medical reasons.
It is said that if they were not taken to mental hospitals the limited amount of medical skill for mental illness would be able to operate in the way it should. They are there because we, the community, have failed to provide the necessary accommodation or services for them. I well remember the Minister of Health giving figures which showed, as a result of a survey, that there were over 10,000 old people in mental hospitals who should be put, and could be put, in other places, but there are not those places for them. What a scandal it is that in this age they should have to associate with the insane in mental hospitals.
786 In referring to this great weakness in the Bill in the matter of the liberty of the individual, I believe that it was largely as a consequence of this dissatisfaction that the Royal Commission was set up. I should have thought with the experience that we have that the Bill would have been primarily concerned with improving those safeguards, and, quite frankly—and I do not think anyone would disagree—it is nonsense to say that it will do that.
There is a danger if radical changes are not made in connection with the proposals in the Bill that we shall have a good deal of talk—and we have had some already—about welfare and about the best interests of the patients and so on. If we are not careful, authority, which has fallen down so much in the past and is still falling down, will have even more power than it has over the individual in a way that inevitably will lead to more social injustice of a serious character perpetrated in the guise of progress.
Many have been led to believe that the Bill will contain stronger and better methods of safeguarding the liberty of the individual. I have here a typical report in a national newspaper following the hand-out from the Ministry of Health. The Bill requires a lot of reading and, therefore, a hand-out was issued by the Ministry. The headlines in this newspaper state:New rights for mental patients. Safeguards of liberty.The newspaper then says:… much-needed safeguards for the liberty of the individual are key points of the Government's new Mental Health Bill.That is nonsense, and anyone who examines the Bill will find that that is so. The safeguards, instead of being strengthened, have been weakened. One of the greatest authorities on this subject in the country, writing to a Member of Parliament and commenting in a letter on this point, refers to the Bill in the connotation of personal liberty as a bogus prospectus.
I was very interested in the editorial in the Manchester Guardian, which stated:… it will make it rather easier to get mentally disordered people into hospital compulsorily when necessary, and perhaps easier for them to get out again.It is a comfort to know that it will be easier to get out, but one of the great problems associated with mental illness, and particularly with certification, is that 787 once a person has been certified, whether as a mental defective or under the lunacy law as being of unsound mind, it is immaterial whether it has lasted for one week, one month or one year. The fact is that the person has been certified, and once that has been done, as I know from many cases of which I have all the details, it is very difficult for him to find his place in the community once again. Whilst it might be good to know that it is easier to get out of a mental hospital, I believe that the Manchester Guardian is correct when it says that the Bill makes it easier to be certified compulsorily. In this respect the House would be well advised to give more thought to the provisions dealing with compulsory detention.
From the point of view of detention, the patient has fewer safeguards under the Bill than he had previously. People are to be detained as mentally disordered without any form of judicial process. This is putting the clock back. The Bill throws aside the well-tried and generally accepted legal safeguards which I believe to be vital. It is deadly dangerous and must be opposed with the utmost vigour, and I am hoping that in Committee many more Members will speak on this point.
There is already evidence to show that the doctors are getting very worried. I can imagine that doctors resent laymen interfering in what doctors believe to be a medical matter. It has seemed to me that throughout the years during which debates on mental illness have taken place in the House there has always been a desire to ensure some collaboration with the civic authorities when deciding whether to take away the liberty of the individual. The Board of Control was set up primarily to safeguard the liberty of the individual. Justices of the peace were felt to be in a position to play an essential part in ensuring that persons received a square deal in connection with their civic rights.
As the Minister has said, we have swept aside the old provisions and we have started altogether all over again. Now it is possible to take away the liberty of the subject purely on medical grounds. Those of us who have studied these cases in the last year or two have grave doubts about leaving solely to doctors the question whether the liberty of an individual should be taken away. I know there has been considerable criticism of the way in 788 which J.P.s have acted in this matter, but, as the hon. Member for Gosport and Fareham said, there are J.P.s who have done a jolly good job. I know they have done so in my own area. The welfare authorities are aware of those J.P.s who take the job seriously. It is not good enough to say that because the system did not operate as well as we should have liked it, it should be swept aside altogether. I suggest that the system of J.P.s should have been continued, but that they should have been selected specially for the job and given encouragement and help which would have made the task one well worth having.
Anybody can become a J.P. One has only to become a chairman of the local authority or the local mayor and one becomes a J.P. I have said to many of them, "What did you do when a certain person was certified?" and they have said, "Well, the doctor knows best. "There are those justices of the peace who have not lived up to the job, but there are many others who have taken their work seriously and have done it exceedingly well. I should have thought that an effort might have been made to select the right kind of J.P.s put them on a panel and see that they carry out the job properly. That would have been a better method, and the doctors would have felt much happier.
On the mental health review tribunals, as the Minister has said, the chairman will be a legal expert and with him will be sitting a medical man and a layman, similar to the Board of Control before the Ministry of Health took over, on which were legal men and laymen. I should have thought that the tribunals, whose only task is to inquire whether or not a person has been certified correctly, should be brought in much earlier. It can be left to the medical profession to decide whether to detain a person compulsorily for twenty-eight days, but the decision of certification is terribly important and should be the last resort after everything else has been tried. Why cannot the mental health review tribunal be brought into the picture at that stage? It is vital that something in the nature of the review tribunal should be introduced before anyone is certified so that a person with legal training may study the case.
789 We have recently had the experience of the Kathleen Rutty case, as a consequence of which it was found in the High Court that she had been illegally detained, and there were 5,000 other people in that category. The result was, as the Minister explained just before the Christmas Recess, that nearly 2,000 people were discharged because there was some doubt about whether they were held legally or not. There are the other 3,000 to be discharged, but, either because they are not fit for discharge or because there is nowhere else for them to go, they must stay in mental institutions.
Much evidence is revealed by the High Court of a conflict of medical opinion in cases where, if there had been a proper supervision of documents, people would soon have been free. I should like to think that, in this country, nobody is certified and his liberty taken away without, in addition to the medical testimony, adequate legal advice to ensure that what this House of Commons determines is carried out even by the medical men when they are concerned with the liberty of the individual.
As it is now, the sole requirement for detention under Part IV is the receipt by the managers of the hospital of an application made either by the nearest relative or by a mental welfare officer, with the consent of the nearest relative if practicable. The documents are to be addressed to the hospital with two medical recommendations in the proper form. It is at this stage that they should be very carefully scrutinised, and I suggest that a legal rein should be brought to bear before anything further is done. The sole right of the individual lies in the mental health review tribunal after the detention has commenced.
I ask that much more should be done to avoid certification, because, whether it be done by a J.P. or by doctors, it is something which the world outside looks upon with great disfavour. I know patients for whom I have been able to get jobs, people of great ability who when discharged from mental hospitals did their jobs quite well until it was discovered that they had been certified. Then, almost without exception, they were sacked—not because the employer understood what certification meant in their case but because of the fear that 790 once a person had been certified he could do something dreadful. It is worse to have been certified than to have been in prison. I urge again that much more care should be taken about it.
The definitions of the terms in the Bill justifying the taking away of an individual's liberty are much too wide. I stress the words of the present Home Secretary when he addressed the conference of the Mental Health Association. The right hon. Gentleman said:Unless a person is detained under provisions that are clearly defined, he cannot enjoy the protection of the law.Clear definition of everything involving the taking away of a person's liberty is of paramount importance. Clause 26 provides that compulsory detention may take place on two grounds, (a) mental illness, and (b) thatit is necessary in the interests of the patient…I have heard those fine words" the interests of the patient "before, but, having seen how they have been interpreted and operated by the medical profession, I feel that there is great need to make the definition much clearer than that. I notice, that a psychopath is to be released at 25 years of age unless—and this is the definition—hewould be likely to act in a manner dangerous to other persons or to himself".That is much more easy to define. I suggest that such words as "in the best interests of the patient" are very wide and, largely because they are wide, it is vitally necessary that there should be a person with knowledge of the law in co-operation with the doctors to examine what they consider to be the best interests of the patient.
In asking psychiatrists for a definition, I have been surprised at the different interpretations which they put on these matters. The hon. Gentleman the Member for Carlisle (Dr. D. Johnson) who, unfortunately, has not yet been called, has made the very good suggestion that the requirement should readin the interests of the patient's safety".That, by itself, would be a valuable addition to the words which are there, bringing into consideration the question whether the patient would be a danger to himself or whether the protection of someone else required his detention, as in the case of the psychopath, where the 791 definition is much clearer. It seems to me that, in order to safeguard the liberty of the individual, there should be some other control and some other interest should be taken into account before certification takes place.
Those of us who are not medical men cannot help but be alarmed by the opinion expressed by Dr. W. S. Maclay, a principal medical officer of the Ministry of Health, when, at a conference, he said that doctors' reasons for certifying patients as being of unsound mindoften make one wonder whether it is the doctor or the patient who should be certified".I know that the Minister of Health said that that was a facetious observation. I regard it as dreadful that, on the subject of certification, with all the misery and unhappiness it creates, a principal medical officer of health should go on record with a facetious remark of that kind. We speak about the behaviour of psychopaths as being anti-social, but statements of that kind can be very dangerous in the context of the new laws which are being suggested.
That statement does, however, underline what many people believe. In the light of human failings, one cannot leave completely to the medical profession the responsibility of deciding when a person shall have his liberty taken away, even if his intelligence quotient does happen to be low. I hope that I have made the point that there is a need to bring in at an earlier stage somebody with a knowledge of the law to ensure that the medical profession does not abuse its position in this respect.
Some very significant observations were made by Dr. Alexander Walk, one of the greatest doctors in our mental hospitals, in a letter to the Observer last Sunday. Dr. Walk said—and I thoroughly agree—The real weakness of the Bill, as I see it, is that after demanding a high standard of competence at this point, it provides no means of ensuring that this is maintained, since the recommendations will be seen only by the committee or officers of the hospital to which the patient is sent, and not by anyone in a position of independence and authority. If the Government is insistent upon abolishing the present central scrutiny of the documents, could not this function be entrusted to members of the review tribunals, who if not satisfied with the recommendations could call for an immediate review of the case?I brought out this point many days before I read the Observer, but surely the Parliamentary Secretary and the Minister 792 cannot ignore what has been said by Dr. Alexander Walk, by my hon. Friend the Member for Batley and Morley and by the hon. Member for Gosport and Fareham. I believe that the Minister, the Parliamentary Secretary and their advisers are anxious to do a good job. Because I believe that I appeal to them to take this matter seriously and to give it further consideration. If the Government have some fears on this point I hope that we shall hear a clear statement about them tonight.
I should like to say more about psychopaths, but, having talked to many experts about the definition of "psychopath", I can only come to the conclusion that it is terribly wrong to include them in the Bill. Too little is known about the subject and there are experts who would have given more evidence before the Royal Commission had they not understood that the terms of reference of the Royal Commission did not include psychopaths. The Royal Commission made its recommendation. The Government did not accept it; they have gone further. Some grave injustices will be caused if the liberty of the individual is taken away in spite of what I would call professional disagreement as to the definition of a psychopath. It appears that it will be left almost wholly for the welfare officers to sort out.
Over and above that consideration, almost anybody can be considered as a psychopath under the Bill. It may be a Teddy boy who has kicked over the traces. Now, if a person offends in a social way or against the law, if he is believed to be mentally disordered, he can contest it. If a person under the Bill commits anti-social acts without being brought before a court he can be put away without good reason being given for it. It may be that a person living on a council estate refuses to get rid of the weeds in his garden. The definition of a psychopath can cover almost anybody who is considered to be a nuisance to the authorities. This difficulty might almost apply, I was about to say, to Members of Parliament; I myself, who wish to protest against the Executive in a way which is not nice to them. Far too little is known about the psychopath and before power is taken to detain compulsorily on purely a medical definition, we should consider it very carefully, because we are on very dangerous ground.
793 I was very pleased to hear the reference made about correspondence now allowed to Members of Parliament. Patients have not been prevented from sending letters before. A little bit of bribery with cigarettes always ensures that patients can send out such correspondence. I do not see why Members of Parliament should be protected from getting abusive letters from mental patients. I am sure that the experience of most of us is that we get abusive letters even from those who do not qualify to be mental cases.
Finally, I was pleased that the hon. Member for Wokingham (Mr. Remnant) mentioned the point about State institutions. When I visited Rampton I was soon put in my place when I called it an institution. It is not an institution, and the authorities are trying to live it down. It is a hospital. The authorities correct those who call it a State institution. Why, then, should it be included in the Bill? Clause 95 reads:The Minister shall provide such institutions as appear to him to be necessary for persons subject to detention under this Act, being persons who, in the opinion of the Minister, require treatment under conditions of special security on account of their dangerous, violent or criminal propensities".Those words have appeared before but they do not seem to have had very much effect on those who send people away, particularly to Rampton.
I welcome the suggestion of my hon. Friend the Member for St. Pancras, North (Mr. K. Robinson), who said that a special inquiry should be made into State institutions. The point he made about how some of the patients got there would make a very interesting story. I have read the speech of the Home Secretary which led to Moss Side and Rampton being brought into existence. He made it clear that they were not for people who were guilty of petty thefts. I am satisfied that there are many at Rampton who are there for no other reason than that they were a nuisance through running away from other mental hospitals. I welcome the suggestion, therefore, that there should be a special inquiry into what are called state institutions.
I have said that I hope some parts of the Bill will be remedied in Committee. There are many other points which could be made which are better left to the 794 Committee stage. I sincerely welcome the Bill because I believe that it is a big step forward. Nevertheless, I believe that individual liberty is in grave danger from the provisions in the Bill.
§ 8.17 p.m.
§ Dr. Donald Johnson (Carlisle)
It gives me great pleasure to follow the hon. Member for Erith and Crayford (Mr. Dodds). He and I have worked together on this subject over two or three years. I am sure that both of us feel that the Bill can be a fruition not only of the efforts of ourselves but of all who have fought and longed for mental health reform over the last few years.
Before I echo what the hon. Member has said, as I intend to do in a different form, I should like to pay my tribute to the spirit in which the Bill has been produced and brought before the House. I disagree with the hon. Member for Woolwich, East (Mr. Mayhew), because this Measure is a clarification of the law, difficult though the Bill may still be to read. One of the main troubles has been that, in dealing with these matters, the law hitherto, in its amended, reamended and antiquated form, has been so incomprehensible that not even those whose job it is to understand it have been able to understand it, and nobody has been able to get proper advice, even from legal advisers. On general lines, the law as put forward in the Bill is in clear and understandable form, even if there are points here and there which perhaps need clarification and, in some cases, amendment.
Neither is it out of place to pay tribute to the vast steps that have been taken in recent years in treatment and administration, even within the framework of the present outdated laws. These methods are not yet as universal as we should like them to be throughout the country, but many of the places which have been mentioned in this debate are notable pioneers of better methods.
It is invidious to mention names, but it has been one of the most encouraging experiences during my term in this House to have been round the more modern mental hospitals with the newer methods, not only of treatment, but of administration and handling of patients, and to have seen the open ward system, the redecorations and the like, which have transformed 795 what previously were gloomy prisons, with idle patients hanging around, into homes, not only of rest, but, what is equally important, of useful work. Before passing to any form of criticism, one must pay tribute to the Mental Health Section of the Ministry for what it has done to encourage this progress since the Section took over these hospitals in 1948.
We have the other extremely welcome sign that at last we are getting a reduction in the number of certified patients. When I first asked a Question in the House on this subject back in 1955, I was told that in 1953 no fewer than 20,579 patients were certified. That figure had been static for twenty-five years, despite the increase in the number of voluntary patients in hospital. The voluntary patients had been superimposed on a static number of certified patients. Now, however, the most recent figures, those for 1957, show that the number has been reduced by no less than 6,000 to 14,500, which represents a reduction of 2,500 in comparison even with the previous year. This, therefore, is the encouraging context in which we debate the Bill. One has to pay particular tribute to the redesignation of mental hospitals. People really will be able to go in, as they have not done previously, without any form of legal procedure or stigma.
Nonetheless, what the hon. Member for Erith and Crayford said was quite right. It is seventy years since we have had any major legislation on this subject. The Bill must be tested not only in the light of what is happening now, but as to whether it will hold water for another seventy years. This applies particularly to the question of compulsory powers.
If we look back on the history of mental illness and its treatment, it is an unhappy history. It is not one of steady progress, but of waves that go up and down. A period of reform such as the present one has been followed in the past by a relapse into indifference. This is disconcerting, particularly when we realise that mental patients were treated in a more enlightened fashion even in the 1850's than they were up till the time of the present wave of reform. There were some most enlightened experiments in those days which relapsed over the next twenty or thirty years. There was then 796 a row, which resulted in the 1890 Act, which we are now repealing, and there was then a further relapse, with the effects of which we are only now catching up.
The 1890 Bill was the result of exactly the type of events of which the hon. Member for Erith and Crayford spoke. He is right in saying that, in these new provisions, we are putting the clock back, because the 1890 Bill was produced as a reaction to wrongful detentions purely on medical advice. It was that Bill that was responsible for introducing the justices of the peace.
As we consider a long-term measure, the second consideration is that in administration as well as in economics, a type of Gresham's Law prevails whereby the bad procedures drive out the good. For this remark, I have to pay tribute to none other than the late Lord Percy, who made it in response to certain questions that were asked during the time he was on the Royal Commission on the Law Relating to Mental Illness and Mental Deficiency. Indeed, we have no better example of this Gresham's Law in administration than the Lunacy Act, 1890, which we are about to supersede.
One of the most difficult false beliefs that we have had to dispel in our campaigning in the matter of mental health reform was the general belief, still prevailing even until recent months, that two doctors were needed before a person could be certified. That, of course, was the case in the 1890 Act, in the early parts of which there were careful provisions concerning procedure and the use of two doctors in the certification process.
What has happened now? We have been brought right up to the minute by an Answer given by my right hon. and learned Friend the Minister in answer to a Question by the hon. Member for Erith and Crayford. My right hon. and learned Friend was asked how many people were certified by procedures with only one doctor and how many with two doctors. The answer was that during 1957, under Section 6—that is, the petition procedure designed in the 1890 Act—only thirty-eight people were certified. On the other hand, my right hon. Friend admitted that the vast majority of the remaining 14,381 certified direct admissions were by one-doctor certification. That has happened by precisely the procedure of which I have spoken. There was, so to speak, a 797 Loophole in the complicated provisions of the 1890 Act whereby Section 14 provided for the pauper lunatic. In the Victorian days, the pauper lunatic was not worth two doctors. So there was just one doctor to certify him.
Gradually the use of this provision for the pauper lunatic consumed, as it were, the whole of the rest of the Act, so that, by various amendments of the Act, everybody certified, right up to the present day, has been and is being certified, with very few exceptions, under provisions originally designed for the pauper lunatic. That is why we have to look with the greatest of care at all the provisions in this Bill, with a view to what might happen through the process of time, through relapse into indifference, through the use of procedures easy to administer rather than through the use of more difficult and complicated ones.
Considering the question of liberty as a whole, we cannot do better, I submit, than look to legal principle for guidance. That was laid down by Lord Goddard as recently as 1956, in his judgment in the Rutty case, in which he said:Persons of whatever age are not to be deprived of their liberty just because officials and doctors think it is good for them.I commend to the House this perhaps slightly old-fashioned dictum: a dictum none the less worth listening to.
In the Rutty case he referred, of course, to the capricious exercise of power by a local authority, but there are other cases in which there is evidence of more nefarious incentives at work. Let us appreciate that these compulsory laws relating to mental illness contain a standing invitation to people of various kinds to get rid of inconvenient people. Those of us who are interested in this matter see it, perhaps, in correspondence which comes to us, but do not always get the proof on which to put the cases forward. We do, however, get proof when on occasion there is a slip up and we see from the papers an evil case appearing.
I have details here of two such cases. There is not time to quote them in detail, but the cuttings are here. One is of a duly authorised officer of Lancashire County Council. It came to court because his action failed. He arrived with an ambulance with an urgency order. It was said in court that the action was 798prompted entirely by the animosity which existed between the patient and the duly authorised officer's wife.There was a case in Somerset a year later. The officer accompanying the ambulance was unable to find the house, and called at a public house where he saw the husband of the lady he was going to call for. It was recommended by the Divorce Commissioner that the mental health department of the County Council should look into the matter. These are two cases in which the curtain has just lifted for a moment, because they were cases which came to court.
I am aware that the duly authorised officer no longer is to have under the Bill the power which he has had previously. Now, very wisely, it is provided that it does need a medical certificate to send a person into hospital. I should be extremely flattered to think that angels' wings were distributed with medical diplomas. Alas, I am afraid that is not the case; otherwise we should have no need of such a body as the General Medical Council with its various proceedings. Doctors are as fallible and human as the rest of mankind, and we are bound, as we look at the Bill, to say in criticism that the provisions for detention are in direct contrast to the dictum of Lord Goddard in his judgment that doctors and officials alone should not be responsible for taking away a person's liberty.
At the same time, it seems to me that the provision that mental illness alone is a qualification for detention is in contrast to the declared intention of the Bill, which is that mental illness should be treated in exactly the same way as physical illness. A surgeon does not detain a patient because he thinks that he ought to have his appendix out. At this moment as I stand here I have been advised that it is in my interest to have the nail of one of my big toes removed, because I am having continuous trouble with a big-toe nail. I am rather resistant to the suggestion and fortunately nobody can compel me to have that operation. But if a person has a mental label and it is said that he needs electrical treatment, insulin therapy or a leucotomy, powers are given in the Bill to the doctor to detain that person for just that reason—for treatment. There is, therefore, automatically this difference between mental and physical illness by reason of this one fact alone.
799 How do we define mental illness? The House will have appreciated the importance of definitions from the quotation from the Home Secretary which the hon. Member for Erith and Crayford made. Indeed, it seems even from what the Minister of Health said today that the definition of mental illness is rather wide and vague. It is appropriate in this connection to look at some of the certificates which doctors have issued in which they have stated that a person is of unsound mind and is a fit person to be treated and removed to hospital. I have accordingly brought two or three certificates with me.
I have here one certificate in which the doctor forms the conclusion of insanity on the grounds that the patient wasunstable in that she would suddenly burst in a temper with her husband, would become suddenly quiet and harp upon the 'official line' taken by us. Accused her husband of being against her.Those are the total signs of insanity according to this certificate.
According to the next certificate, the patient hadan obsession that his wife is in dire straits after an operation and that the hospital is to blame. He cannot get it off his mind and repeats it continuously. He produces sheaves of letters 'proving' his point.Those are the total signs of insanity in that case.
The third certificate states:She states among many irrelevancies that everyone was against her and that all doctors were stupid and not helpful. She states that she had reported them all to various Government bodies. She was extremely aggressive to the present officers.Those are the types of certificates one finds. They are, fortunately, exceptions. I am not saying that they are by any means in the majority or exist in large numbers, but those are the types of certificates on which it has been possible for patients to lose their liberties and be sent to the hospital.
My right hon. and learned Friend the Minister is wise enough in the Bill to bring in a second doctor, who must be a psychiatrist, to endorse the certificate as a protection against that sort of thing. We welcome that innovation very much indeed. However a psychiatrist, who is accustomed to interpret human behaviour in his own terms, may in turn give a very wide interpretation to the phrase "mental 800 illness". An enthusiast may be an obsessive, anyone with a bee-in-his-bonnet may be a case of paraphrenia, one who resists detention may be seen as someone with dangerous paranoic trends who does not appreciate the kindness shown to him.
These phrases tend to become synonymous, and I was incautious enough to say so in a letter published in the Observer about ten days ago, to which there was a reply yesterday from Dr. Alexander Walk, who accused me of saying that psychiatrists were going around chasing the more eccentric of their fellow men. My reply to that might interest hon. Members, so I will read from the British Medical Journal of 8th September, 1956. At a meeting of the World Federation for Mental Health Professor Stransky, fortunately of Austria, said that he had long advocated:… the psychological investigation of those who aimed at becoming leaders in politics, industry or any other field which involved the handling of human beings.I hope hon. Members are listening to me. He went on to say:Only too often those who sought to lead others were motivated by a desire for power which derived from a sense of their own personal inferiority and inadequacy or had paranoic trends which made them aggressive.We have to be careful of psychiatrists now and then perhaps running amok amongst us. We have to be slightly on our guard. I have not quite finished the quotation, because I see that Dr. Chisholm of Canada thought that, though what Professor Stransky had said might be theoretically desirable, it would be extremely difficult to put into practice. He felt that:the most important thing was to understand the motivations of those who became followers, and that the type of leader chosen depended on them.So we, as back benchers, have to be rather careful of running into psychiatrists from other countries.
As has been said already, the interests of patients are easily misinterpreted when compulsory powers are available. This is particularly important as regards physical treatments which admittedly have made an immense advance and have done great good in the case of mental illness, but I have been deeply impressed by letters from former patients after they have had these physical treatments, and of course it is the more unfortunate ones 801 who tend to write. One has often found that they have traced their troubles back to perhaps excessive doses of treatment under conditions of compulsion. Physical treatments are far more effective when there is a spirit of willing co-operation than when they are given under any form of compulsion.
The provision in the Bill for two doctors appears at first sight to meet those of us who have been extremely critical, and I think rightly so, of the one-doctor certification. But then we get the further Clause in the Bill which allows that one of these doctors can be on the staff of the admitting hospital. The question then arises—I hope that my right hon. and learned Friend will clarify the position today or during the Committee stage—whether the signature of the second doctor will be given before or after admission. That is an extremely important point. If it is after admission, we tend to be back where we started. What happens now is that the patient is sent in with one doctor's certificate and is seen by a doctor in the hospital. There is a risk that under the wrong circumstances, such as I have described, the second certificate will become merely an endorsing certificate of the one on which the patient was admitted. If that is so, we shall be no further forward than we have been hitherto.
There is also the question of the applications and their fate and the inspection of the documents. I have not always agreed with the hon. Member for St. Pancras, North (Mr. K. Robinson) in these matters, but I agreed very much with him tonight when he asked whether hospital management committees were suitable recipients for the application documents and whether it would not be better if the documents went straight to the tribunals as independent bodies of inspection.
If that does not happen, we tend to get a closed circle. We get a second doctor in the hospital signing the documents and the only destination of the documents that we have at the moment is the managers of the hospital. We do not know what happens to the documents after that. We do not know whether, under the Bill, the patient will see the documents again or whether it will ever be possible to produce documents of that kind in this House or elsewhere. I hope we may be assured that people who are 802 deprived of their liberty will in one way or another have an opportunity to see their own documents and know the reason why they have lost their liberty.
Our criticism is that up to the time of detention the defences of individual liberty are fewer under the Bill than they are at the present time. Two doctors can sign the original application for treatment for twenty-eight days. Then two doctors can also sign the continuation document whereby a patient can be kept in hospital longer, and there is then only the appeal to the tribunal within six months.
A great deal depends on the mental health review tribunals, and the Bill does not tell us a great deal about them and their working, except that they will consist of three members and that there will be one tribunal in each region which will be staffed and accommodated and have its expenses paid by the Minister. There is some point as to whether the tribunals will be situated at the headquarters of the regional board or elsewhere. For the patients to have confidence in the tribunals, it is important that they should have an independent location. They will be bodies of appeal, and they will be in the invidious position of having to endorse, or otherwise, an authoritative opinion already given in which they had no share originally.
Going back over our experiences, we must ask whether in those circumstances they would be capable of giving an independent decision on the side of the patient. Considerations such as the prestige of the signing doctors are bound to arise. Those are basic things and the fault of nobody. They are things which have to be considered, and there will be considerations such as whether turning down too many certificates by doctors will damage their reputations and undermine confidence in them, and so on.
I strongly urge, as have others, that the tribunals should act as bodies replacing the justices and that they should take the original decision, that is, after the reasonable detention for observation of twenty-eight days. There are a number of very cogent reasons for that. It is undesirable in principle that one should depart from the rule of law that no citizen should lose his liberty except through some intervention of the civic authority. We depart from that at our 803 peril. Another consideration which I have mentioned is that it is very difficult to accept an appeal without in some degree disagreeing with the doctors who have given the original certificate.
An even more important reason is that when patients are already in detention, as they will be when they make appeals, there are bound to be clogs and delays in their access to the tribunals. A patient may be in a closed ward and the first person from whom he will have to get his application form and to whom he will have to give it will be the charge nurse. Unless something or other happens, it will have to go from the charge nurse to the hospital office and then to the tribunal, with the possibility of delays on the way. There may be six months for those delays to operate, since, so long as it is made within six months, the appeal will be legal. There are bound to be time losses. Meanwhile, a patient will be fretting and becoming more and more paranoic, in the opinion of those in whose care he is, and a thoroughly bad situation will arise as contrasted with what would happen if the application automatically went to the tribunal at the end of twenty-eight days.
Another factor is that people of better calibre will clearly be attracted to tribunals if they have the power and responsibility of an original decision as distinct from considering an appeal.
It is said that the objection to such a procedure would be the increase in the work of the tribunals beyond what was visualised. However, it is obvious that every patient detained against his will will appeal to the tribunal in any case. That will be his next step after having expressed his unwillingness to be a patient. The tribunal may as well tackle the job to start with.
It is helpful to estimate the amount of work which the tribunals will have to do. With that in mind, on one or two visits which I have paid since the Bill was published, I have specially asked medical superintendents and others—and there was a meeting at this House at which I asked the question—in how many cases they thought it would be necessary for compulsory powers to be used, and what proportion of patients, given a detention under observation of twenty-eight days, would have to become com- 804 pulsory patients. In all cases the answers have been very encouraging. Out of 100 patients originally admitted under observation there would be not more than five whose cases, at the end of a suitable period of observation and treatment, would be put up for permanent detention. That reduces the problem to about one-third of the figure of the annual number of patients at present certified, so that the tribunals would be able to manage the job.
Immense complications under present arrangements arise regarding legal action, or the possibility of legal action, by patients. One could devote a whole speech to this subject and the complications which might result from a patient being discharged by a tribunal after an appeal and then—doubtless mistakenly—wishing to take legal action for wrongful detention. There seems to be no answer to that problem.
There is the additional important point about extended detention beyond a month on a medical certificate. From what has been said today by professional colleagues in the House and from the discussions which I have had with professional colleagues, it is quite clear that doctors do not want the responsibility. Doctors would be only too glad to pass on the responsibility for detention to some other authority as quickly as possible. They fear that if they have to be gaolers as well as doctors the doctor-patient relationship will be affected. They find it difficult or impossible to secure the confidence of patients if they are considered as gaolers in addition to being doctors. I hope, therefore, that my right hon. and learned Friend will give serious consideration to making a change in the Bill which may be achieved by a comparatively small number of Amendments without affecting the Measure as a whole.
If the Bill goes through unamended, one is bound to welcome the addition of the provisions, contained in Clause 138, relating to the defence of the individual and the power of the Minister to make investigations. Nothing disturbed me more during the past three years than the information I received when I initiated an Adjournment debate regarding an individual case and was told that the Minister had no power to investigate. Under the provisions of Clause 138 my right hon. and learned Friend will have such 805 power, and I am sure that he will be interested in the number of cases with which he may have to cope. On examining my correspondence, which includes letters from several hundreds of people, I found that in 1956, when this matter started up, there were 45 cases which seemed to reveal prima facie reasons for investigation. In 1957 there were 20 cases and even in 1958, when excitement lapsed as people were looking forward to the introduction of legislation and so restrained their grievances, there were 12 or 15 cases.
If there is disappointment over the Bill; if people feel that they are being wrongfully detained, they will write to us again, and we will then have no alternative but to press for Ministerial inquiry into this, that and the other, which is something, I can assure the Minister, that we are as anxious to avoid as he. For the reasons I have given, I hope that the Minister will consider putting on the tribunals the responsibility for any detention beyond the observation period.
I wish in conclusion to say something on the local authority point. I was disappointed when I saw that the Minister did not intend to take mandatory powers here, but my consolation, and it is a big consolation, is that during the period of development now taking place it is most essential that we should keep the whole thing fluid, and capable of being used for different kinds of experiment. The most enlightened experiments at the present moment are not being done by local authorities but by regional hospital boards. There is, for instance, the Worthing experiment, and others are being undertaken by other hospitals that have not, perhaps, the same fame.
Money comes into it, naturally—in anything that I have said, I do not wish to imply that money is not needed—but I do not think that money is either needed in the first instance or is the most important factor. The most important thing is propaganda, and education of the public. That does not necessarily mean money. In our campaigning, which has led to some comment, the hon. Member for Erith and Crayford and I may not have had a great deal to do with constructing the Bill, but what we have done has been to make propaganda throughout the country. We toured the country and I think that we have helped to put mental health on the map. That tour did not cost real money. 806 For the two of us, it cost between £70 and £80.
We need new methods, but here, again, we do not necessarily need money. The Worthing experiment consists of just a very nice house on a very nice side road, at a total cost of £15,000. In terms of the money we think of in relation to the National Health Service, that is just small change.
We also need sympathy and understanding, not only of mental illness but of the broader principles of individual liberty, social life and that sort of thing. The most vivid thing that has stuck in my memory during the last two or three years is associated with one of the ordinary green cards which we are used to receiving in this House. It reads:Object of visit: with reference to an article published today stating he will help anyone in danger of loss of freedom by a State Health Department.We do not want our mental health services to be turned into a direction that people fear, so that they will come here for individual Members of Parliament to protect them. In this case, I went out to the Central Lobby and saw a very frightened young man. As a result of his appeal, I took him to the Terrace to talk to him. I said that I could not do anything for him as a Member of Parliament. He said, "You are a doctor, aren't you? Will you not give me a letter as a doctor to say that you find me a reasonable person to talk to?" Indeed, he was a perfectly reasonable person to talk to. He said, "I want that letter because the local authority are after me. They want to put me into hospital and I know that if I go in the hospital I shall never get a job again as long as I live."
That is the sort of thing that happened two years ago, and it could conceivably happen today. We do not want our mental health service to be something of which people are frightened and which spreads a sense of insecurity. The greatest thing that we want in the service is sympathy and understanding.
§ 9.7 p.m.
§ Mrs. E. M. Braddock (Liverpool, Exchange)
May I add my thanks and congratulations to the Minister on the production of the Bill? I do so, in the first place, as a member of the Royal Commission and as one who is able to 807 express an opinion here without being tied down by Ministerial position or anything else. Two hon. Members were members of the Commission during its term of office. I am very sorry indeed, like other hon. Members, that the Chairman and another member of the Commission have passed away and are not privileged to watch the passage of the Bill.
I have listened to the whole of the discussion on the Bill and I think that some hon. Members have not read completely the Commission's Report and the reason for the decisions to which it came. We were asked to look at the law in relation to mental illness and mental deficiency. We were not asked to look into the conditions of mental hospitals or State institutions or mental deficiency institutions. We were asked to look at the law to see if it needed amending.
After three years and four months, taking evidence on everything that was considered to be in line with its terms of reference, the Commission came unanimously to the decision that the present law in relation to both mental illness and mental deficiency could not be amended and required repealing, and a new code put in its place.
I listened to the speech of the hon. Member for Carlisle (Dr. D. Johnson) and I think that he missed completely the point that the Commission requires mental illness to be treated on exactly the same basis as physical illness. Listening to his speech, one would imagine that medical superintendents and doctors were desperately anxious to catch patients and keep them in hospital. That is quite untrue. I know of doctors working in mental hospitals and mental deficiency institutions who are desperately anxious that their patients should be treated and given an opportunity of living, if they can, outside in the community. They are not anxious to collect and hold them; they want a turnover of patients to show that the treatments which they are using are the treatments which are giving relief to those mentally ill.
I think that some hon. Members have not completely read either the Bill or the Report, because the question of certification and the question of hospitals specifically designated for mental illness and mental deficiency will go under the terms 808 of the Bill. All hospitals will be required to provide services to deal with those people who are prepared to take mental illness treatment voluntarily. So long as there is any question of the law being involved in any way in the treatment or detention of patients we shall get that suspicion and hatred of the word "certification" that has been linked with the law in the past. It is because of the conclusive evidence that we were given that we said that mental hospitals should go, and compulsion should go, with the exception of those people who could be a danger to themselves, or to the community. If we are superseding legal action, who else would be the best people to decide whether a person was a danger to himself or to the community?
§ Dr. D. Johnson
Does the hon. Lady appreciate that what she is saying is quite different from what is in the Bill? The Bill says:in the interests of the patient".She say "a patient who is a danger to himself or to the community", and we thoroughly agree.
§ Mrs. Braddock
Oh yes. It refers to a person who is considered to be a danger to himself or to the community and who, because of that, requires treatment for his mental illness. The hon. Gentleman and I must read the Bill differently. Perhaps we can discuss what it means in Committee.
§ Dr. Johnson
May I read these few words from the Bill, because it is important that we should understand what we are talking about. Clause 26 (1, b), which deals with admission for treatment, says:that it is necessary in the interests of the patient…If that provision contained some reference to the patient's safety it would have my wholehearted support. At the moment it merely says:in the interests of the patient".
§ Mrs. Braddock
Of course it is in the interests of the safety of the patient or of the community. That is what the Royal Commission has said in its Report. What we and the Royal Commission are 809 anxious to do is to get legislation that will persuade people to take treatment voluntarily. I think it is agreed that there will be very few people indeed who will need to be compelled to go into hospital for treatment. If that is so, what is the need for all these detailed questions about legal certification? That is what we want to get away from.
I do not know whether the House appreciates that evidence was given that the present method of certification has great drawbacks not only to a person certified but to every member of his family. No other member of the family may emigrate to Canada or America, for instance. No member of the family may be considered for a post in the Civil Service. Matters of this sort have given concern to people who have had relatives requiring to take treatment but who have had to be certified in order to get into a mental hospital. I believe that in carrying out the recommendations of the Royal Commission the Government have taken into account these points. By making the process a legal one, the matter is tied down and the person concerned is put into an entirely different category from that of a patient who requires treatment. If certain people are dealt with under legal authority, they are immediately isolated and put into a different category from those taking other forms of treatment. It was for this reason that the Royal Commission was so anxious about the matter.
The Royal Commission was very concerned about old people who had never had any mental illness before in their lives, but who, because there was nobody to look after them, because they had become senile and needed treatment and attention, had to be certified because there was nothing else to be done and no other place for them to go. We thought that was completely wrong and we said so.
After the dedesignating of mental hospitals and when the ordinary hospitals are required to provide treatment for mental illness, we shall do away at once, immediately the thing becomes law, with the present circumstances in which those hundreds of old people are at the moment certified. They will then be in hospital or in accommodation for the purpose of treatment, because they need looking after and caring for or they need medical or 810 nursing attention. They will be there having the same sort of treatment, but not certified; they will be ordinary patients.
Those are what I regard as the main factors concerning certification. I hope that the Minister, even during the Committee stage, will not be either cajoled or forced into taking any steps which will bring back the possibility of legal certification for people who need treatment for mental illness. That would be a backward step. The terms of the Bill are in line with the unanimous suggestion of the Royal Commission. I hope that we shall retain them and I hope that the necessary functions will be performed to establish the necessary services, so that a person can take treatment for mental illness voluntarily. I am certain that nobody, however mentally ill he is, unless he is unable to decide for himself, will refuse to go into hospital voluntarily to take treatment for an illness which he believes the hospital can deal with.
The provisions in the Bill providing for the mental defective and his training are very important, but they have not been referred to today. The Commission was given evidence which showed that, had there been the necessary local authority services, as many as 2,000 of the people at present detained in mental deficiency institutions need never have gone there at all. In view of the emphasis laid by the Royal Commission in its Report upon the training and accommodation of mental defectives in local authority areas, I feel that a grave omission in the Bill has been made in that local authorities are not required to have, at any rate to begin with, the minimum services ready.
The Government are at fault for not taking the recommendation of the Royal Commission and saying that, because this will be an extended service or a new service, a service which, we hope, will prevent people from becoming inmates of an institution, a 75 per cent. grant over a limited period should be made to local authorities for the purpose of establishing or extending their services.
What will happen under the terms of the Bill as they stand is this. Progressive local authorities who want to carry out the terms of the Bill will, as my local authority will, put into operation additional services to meet these requirements. But in scattered areas and country areas local authorities which are not 811 so progressive or compact as city councils or local borough councils simply will not bother to put the services into operation unless there is some form of compulsion and extended financial assistance from the Government.
The Royal Commission made great play of that point. I know that I speak for every member of the Royal Commission when I say that we were keen to ensure that occupation centres, training centres, hostels and the like were set up and that every type of training was available for those whom it was decided were mentally deficient in order to find out what work they could do so that they could become useful members of the community instead of being put into institutions indefinitely.
Practically no training used to be given at all. Many scrubbed floors or worked in the laundry, which was all right if they could do that, but many thousands have been taught nothing. They have stayed in institutions, have been looked after, kept clean and fed and have been given a little recreation; but many mental defectives can do much better work than some normally-minded people if there are the facilities to discover what they can do and they are trained to do it.
I am sorry that there has not been more comment on the question of training and that the Government have not agreed that this is one of the services, to which the Royal Commission made reference, which is of vital importance. Everybody can do something, and we on the Royal Commission believed that it was much better that people should remain in the community with their relatives and friends, be taught to do something and given as much training as possible rather than say, "They are mentally defective and will never be able to do anything. The best thing is to have them certified as mentally defective and sent off to an institution and kept there for the rest of their lives." Even when the Bill is in operation many will have nowhere to go to. Many have no relatives and no one who is responsible for them. Although the Bill lays down that in those circumstances the local authority can take them over under guardianship in exactly the same way as deprived children, we shall still have many mental defectives whom it will not be possible to bring into 812 the community again because they have never known what it is to live in the community. We must find some other way to deal with them.
Recommendations were made by the Royal Commission on this matter. It should be possible to put such people in hostels near to places where they have lived, but it is the fresh cases which will arise which will cause concern. Local authorities should begin to establish the services which were stated by the Royal Commission to be necessary so that people can be prevented from having to live in institutions.
I hope that when the Minister winds up he will indicate that it will be possible in Committee to alter one word in Clause 6 which I think will make all the difference. Clause 6 (2) reads:The purposes for which arrangements are authorised or may he required to be made by a local authority",and so on. If "shall" could be substituted for "may", and minimum requirements laid down, I am certain that the effects of the Bill, good as it is, would be greater than if local authorities were merely permitted to do the job. As the Clause stands, there is no compulsion for them to reach a certain standard. I agree that this change of wording would, perhaps, alter the whole requirements concerning local authorities, but it is a necessary change. I impress upon the Minister and upon the House that the Royal Commission considered it necessary that there should be some minimum standard with which a local authority should comply in the requirements of the new approach to mental deficiency.
Up to a certain point, I am quite happy about the Bill. It meets most of the requirements of the Royal Commission, with the exception of those things to which I have referred. I would, however, refer to the Second Schedule, on page 93. The Minister did not refer today to the question of changes in the Education Act. I think I am right in saying that during the evidence that was given to us in the Royal Commission, one organisation referred to the question of when it is decided that a child is mentally deficient or mentally abnormal.
The Second Schedule states:If it appears to the local education authority that any child in their area who has 813 attained the age of two years is suffering from a disability of mind…What I am referring to is the 'two years". I do not know of any education authority which has control over a child aged two. It is usually the local health authority. Not until a child reaches school age does the education committee come in contact with it. What is meant by this "two years"? Is it merely the re-enactment of a provision in the Education Act? It may be possible to decide that a child is not developing properly at the age of two, but it is impossible at that age to decide its educational ability. I should like an explanation when the Minister replies. I have read the Bill carefully and I cannot get the sense of this provision. If it should be a higher age than two years, that can be discussed in Committee.
§ Mr. John Barter (Ealing, North)
Will the hon. Lady bear in mind that whilst every effort is obviously being made to humanise the transfer from the education authority to the local health authority, when the provisions of the Second Schedule come into the hands of the clerks' departments of local authorities they will be completely inhuman in their translation to the parents? I am sure that the hon. Lady would join in a plea to the Minister to request the local authorities to explain the terms of the Schedule to the parents as humanely as possible.
§ Mrs. Braddock
The whole question of explaining the position to parents when a decision is taken requires careful handling. It can be done in various ways. I have always found that local authorities and local education authorities who have to deal with this problem are careful in the way they put the position to the parents. We have to remember that parents do not like to accept the view that their child is educationally subnormal or mentally deficient and unable to take the education and training that every other child can. Of course this requires very careful handling. I believe that local authorities generally—certainly those that I have known—carry out this job in a very personal way. It is not done impersonally, by brutal people, but in a personal way, and the whole position is explained to the parents.
Since the Royal Commission's Report was published, from many doctors and psychiatrists with whom I come into con- 814 tact, I have found that, contrary to the expressions of opinion which have been aired up to now in the debate, most of them welcome the opportunity of being able to deal with these cases medically, rather than have them regarded only from the legal point of view. Most of them believe that their training qualifies them to decide whether or not a person needs treatment for mental illness.
One thing they pointed out, and which I hope we shall take notice of, is that the Bill is only to determine the law in these matters, and its application, when it becomes an Act, will make demands on other services, if it is to make the greatest step forward that has ever been taken in dealing with mental illness.
The general practitioners will have to take very much more interest in the mental health of their patients and in the matter of noticing the commencement of mental illness. I think the general practitioner is the one who should at the initial stages be able to know what causes his patient to become mentally ill. The general practitioner must be able to draw on the services of the local authority and of the hospitals and of all the medical services in trying to prevent his patient from having to go to hospital at all, or. if the patient has to go to hospital, in sending him in as soon as possible for the earliest possible treatment, so that the patient need be detained no longer than a person suffering from an ordinary illness.
At the moment, at the universities and post-graduate courses and during their training general practitioners do not get sufficient opportunity of seeing mental illness. They ought to see much more of the patients who are suffering from mental illness. I hope that the hospitals, and the teaching hospitals, will be required to have wards to which patients suffering from mental illness can be admitted voluntarily.
I believe that it has been the segregation in designated hospitals of people suffering from mental illness which has held up progress, because it has meant that those patients have not been seen by the doctors in other hospitals or by general practitioners. I think that perhaps doctors, other than the specialists, have not been interested in patients suffering from mental illness because they have 815 not had to deal with the cases when they became hospital doctors.
I am sure that if every hospital in the country were to have its share in the treatment of mental illness, and were to provide its share of accommodation and services for the treatment of mental illness, for patients entering those hospitals voluntarily, it would give an impetus to the doctors generally to take more interest than they have done in this fascinating subject.
In opening the ordinary hospitals to people suffering from mental illness and in redesignating the mental hospitals, as they are known at the moment, there is no need to destroy their original use. Some of the mental hospitals could be opened to patients suffering from ordinary illnesses because that would free accommodation in the general hospitals. It may be that that will be done by the whole service. I am sure that that is what the Royal Commission would have wanted to see done.
I am certain also that, although the Bill will require to be amended in Committee, the acceptance of the Royal Commission's Report and its implementation by the Bill will give to the mentally ill and the mentally defective a new deal, with the result that in a short time everybody in the medical profession and all those who are interested and concerned in any way with this problem will find their difficulties very much eased.
§ 9.35 p.m.
§ Mr. Richard Fort (Clitheroe)
I find myself very much in agreement with what the hon. Lady the Member for Liverpool, Exchange (Mrs. Braddock) said, particularly her reference to the disadvantages of the remoteness of many mental hospitals from the nearest general hospital. I am sure, however, that she appreciates that one of the difficulties about getting a closer approach between the two is the length of time which most mental diseases take to run their course, with the following concomitant difficulties in administration.
The hon. Lady made an eloquent plea for the training of mental defectives, and throughout the debate stress has been laid on the problem of securing the personnel needed to improve enormously the mental health services. It is a problem of train- 816 ing, to which several hon. Members have referred. The hon. Member for Edmonton (Mr. Albu) discussed at some length the problem of training psychiatrists at hospitals. We are backward in this respect in this country, as backward probably as most European countries. It should be well worth considering some of the reasons why we have not done as much in the past as we might have done about either training in hospitals or research work. We might also consider some of the reasons why we believe that we may see a change as time goes on.
The Bill is our contribution towards making that change, but it should be remembered that 100 years ago there was a similar outburst of optimism about methods of curing mental illness. Haslam, starting at the Bethlem Hospital, and other alienists of that time, as they were then called, introduced what seemed to be promising methods, but it should be noted that it is a commentary on our ignorance of mental diseases, as well as on their complexity, that in the last twenty-five years those of us who have followed these matters have heard of many different kinds of treatments and claimed cures. One has followed another, and all, except electrotherapy, have fallen by the wayside or are now being taken with a considerable grain of doubt.
The uncertainty of this matter, as shown by what has happened during the last quarter century of great activity, makes understandable why those who have been training to be doctors have not felt as full a sense of drive to study mental illness as they have felt in training themselves and doing research work in other fields of medicine where the causes of diseases have been so much better elucidated during the same period and the methods of curing them have had scientific and rational bases.
At this late hour of the evening I will not go at great length into the problems of medical education, about which we are still doing depressingly little. It is true that there has been a large increase in consultant posts. This sounds splendid percentagewise—52 per cent. more than ten years ago—but there are still only 615 consultant psychiatrists in the country. There has been a marked increase in the senior registrar posts, from 113 to 144 but, unfortunately, only 117 of those 817 have been filled. My hon. Friend the Member for Gosport and Fareham (Dr. Bennett) dealt with one of the reasons for this.
London is the principal teaching centre for doctors in the country. Here there are 11 teaching hospitals with psychiatric departments, and of those 7 have from 20 to 70 beds, the rest have fewer than 20, and most of those are not attached to the teaching hospital but are anywhere up to 20 miles away. The only teaching hospital with a reasonable number of psychiatric beds attached to it, and that not immediately alongside, is in Glasgow where there are 200. Many psychiatric consultants over the age of 40 have had no university training but have had to learn by what they have taught themselves through attending courses, because there has been so little systematic training in the past. Indeed before the war there were only two chairs of psychiatry in the country, one in London and the other in Edinburgh. That number has now been increased to eight, but of those one chair has been unfilled for many months now and the other one has never been filled. So there is still a long way to go.
In London, in contrast to Scotland, doctors are not obliged to take psychiatry as part of their final examinations, as the hon. Member for Edmonton (Mr. Albu) pointed out. One of the reasons I am apprehensive about the new admission procedure is the thought of this being undertaken by doctors who will have had no psychiatric training. I am impressed by the fact that my friends in the medical world would like to have magistrates alongside them so that their own opinion can be fortified by those with common-sense and experience. When we talk about medical certification, as the Bill does in Clause 26, it is worth remembering that most of those who will have to undertake this work will have had no more training than most hon. Members of this House.
There is one point which no one has mentioned yet. I am sure the hon. Lady the Member for Liverpool, Exchange will appreciate this at once since she talked about training. We have not talked about the occupational therapy and other instructors. Judging from the large mental deficiency hospital in my own constituency, which she knows well because 818 some of her constituents are there, or the very large mental hospital just outside it at Whittingham, I doubt if we can have any confidence that we shall have the necessary number of instructors or male nurses unless we change their wages and conditions of work much faster than we have changed them so far.
I know of no other occupation where a man can work up to six hours' overtime and not be paid for it. I have been in discussion with the Minister about it, and the matter has been considered by the Whitley Council, but Whitley Council consideration takes a depressingly long time. I should be glad if the Minister could say something about recruitment and the wages and conditions of those engaged in occupational schemes and nursing generally in the hospitals.
I wish to refer to expenditure on research. My hon. Friend the Member for Banbury (Mr. Dodds-Parker) and the hon. Member for Edmonton mentioned figures. It is worth while to get them right so that we have a yardstick to judge what we shall be doing in the future. The total amount being spent on mental research in this country is just short of £370,000 a year from all sources. Of that, the Medical Research Council is spending about £127,000, which, as the hon. Member for Edmonton pointed out, is almost exactly double what was being spent two years ago. Of that £127,000 £54,000 is being spent on entirely new projects.
The Medical Research Council has tried to divide the money granted to it for research work almost equally between the fundamental side—biochemistry, neurophysiology and pharmacology, the underlying scientific disciplines—and the clinical and social work. In addition, between £60,000 and £70,000, depending upon what is included or excluded from the sum, is being spent on defence and industrial projects, particularly in psychology. The Medical Research Council has members on the relevant committees or generally supervising the work.
I think it will be a very long time before we see fundamental research work being done in mental hospitals. One of the reasons for that is their remoteness, which is usually given as an excuse for the inadequacy of some of the fundamental work done in them. There is also the shortage of psychiatrists. My feeling is that the 819 psychiatrists that we have would be better engaged on fundamental work in the universities than in working in mental hospitals where the facilities in the way of laboratories and equipment are very much fewer.
I hope we shall not see research work being held up by disagreement about definition. That has undoubtedly happened in some instances. Those working in the medical disciplines and those in the disciplines of the social sciences have been unable to agree, purely from the point of view of definition, on what they were looking into.
All our knowledge is enormously held up by much too little follow-up work on the results of treatment. One of the reasons treatments have varied from emphasis on one form to emphasis on another has been that we have been woefully inadequately informed about how many people are improved by one form of treatment or another six months, a year, three years or five years after treatment. It is very important that this fundamental work should continue.
There is one final point about which I hope the Minister will say something. With the disappearance of the designated hospitals, it will be much more difficult to maintain the Mental Health Register, which has contributed so greatly to our knowledge of such fundamental matters as the parts of cities where mental illness is prevalent, the genetics of mental illness, and other information needed in what is in part a medical complaint, but which is greatly influenced by social environment. I hope that we shall be told that despite the disappearance of the designated hospitals—which is to be welcomed for almost every other reason—this important source of information will be continued.
§ 9.51 p.m.
§ Mr. E. L. Mallalieu (Brigg)
Even at this late hour, I am deeply conscious of the privilege it is to a back bencher who does not profess to have any special knowledge of this wide and important subject to be able to speak, not least because so many of those who have taken part in the debate, including the hon. Member for Clitheroe (Mr. Fort), who disclaimed any special knowledge, have displayed such profound knowledge of the subject, whether it be the knowledge given by professional experience and 820 training, or the more robust knowledge shown by my hon. Friend the Member for Liverpool, Exchange (Mrs. Braddock), or my hon. Friend the Member for St. Pancras, North (Mr. K. Robinson). It is a great privilege and one which I shall not abuse by speaking too long.
Those of us who are lucky enough to have avoided close contact with mental ilness in our own families must have observed from our work in our constituencies the havoc which can be caused by it. There is the distress caused to parents who have to see their child born mentally defective. Apart from suffering from mental illness, there is the distress of seeing a child in that state, and there is the sheer physical burden of having to look after him. We have seen the effects on other children of the family of the presence of a mentally defective child or one suffering from mental illness. Those children are almost invariably deeply disturbed by the presence in the family of one so difficult to deal with, perhaps very similar to them in most respects and yet so different. It is a tragedy which we have all seen.
The tragedy, of course, is there for the person who suffers, the one who is afflicted with mental illness; but the tragedy is even greater for other members of the family, especially the mother in the case of a child born mentally defective in some way. For some reason I have never been able to understand, the mother often suffers from a sense of guilt for having brought the child into the world. Why she should suffer from guilt when it is no conceivable result of her own actions which can be said to have caused that state of affairs, I do not know; but that is the way it appears to be. Which of us has not seen the girl who has been ashamed to bring into her own house her own boy friends for fear of what they might see in the way of a brother or sister who is mentally defective?
One of the main objects of the Bill is to provide for this state of affairs; to remove the stigma of mental illness and to de-institutionalise those who suffer from it. One result of this Bill, it seems to me, will be that a large number of people previously cared for in institutions will be let loose upon families. Enormous harm may be done unless adequate preparations are made for their reception, and I feel that such preparations as have been made are wholly inadequate.
821 Who on earth will look after these people when they are out of institutions, and they will be out in far greater numbers than ever before? It seems to me that no adequate preparations have been made to prevent them from becoming a burden and, it may be, a danger to society. The onus of dealing with these people is to fall upon the local authorities who are to act in a voluntary capacity, if they are prepared to accept that onus. Ex-patients and those who would normally be in institutions, will have to be visited in their own homes by trained psychiatric workers.
If families are to be saved from the chaos which may result from the presence of a mentally disordered person they must receive skilled advice and guidance. Families can do the most extraordinary things to help such sufferers provided that they have received the necessary guidance and help from skilled persons. But I was horrified to learn in the last few days that even in the area of the London County Council—a local authority which, I imagine, is as progressive as most—there are only three trained psychiatric workers at present employed. There is provision for four, but only three are actually employed. Considering the amount of work likely to be thrust upon such people in the near future, that seems to me a horrifying state of affairs. I add my plea to those made to the Minister to reconsider the permissive nature of the duty to be imposed on local authorities. We all know that it is impossible for local authorities to act in the very near future as we should like to see them act, because they will have neither the staff nor the "know-how" nor the money to do so. But there should be a time-limit imposed, at the end of which local authorities must be prepared to take on this duty.
Formerly, mental hospitals serving almost all the centres of heavy population were situated far from the homes of the people whom they served. Take Bermondsey as an example. Heaven forbid that I should speak for Bermondsey in this House, for in my hon. Friend the Member for Bermondsey (Mr. Mellish) we have an energetic, able and alert Member. I refer to Bermondsey merely because is it an example of which I have knowledge. The hospital serving Bermondsey is at Coulsdon, a long way away. People leaving that hospital and 822 returning to Bermondsey would not be willing to go back as far as Coulsdon as out-patients. It will be all the more necessary, therefore, to have trained psychiatric workers on the lines of the Amsterdam experiment—which I understand has been a tremendous success—who will visit people in their own homes so that damage to families may be averted.
The G.Ps simply have not the time, even if they had the capacity and the training, to deal with such people. It is horrifying to hear, as I heard for the first time in this debate, that more than half our doctors come through London, where there is not even a single obligatory question on psychiatry in their examinations. Something must be done about that, as well as about more provision for psychiatric workers.
What is to be done about the employment of the people who come out but who would, in other circumstances and but for this Bill, be cared for in institutions? Are they to be treated as disabled persons and have the green cards and the help that such people receive in finding employment? If not, I fear their chances of employment will be slender indeed. What about the youth employment service? Is that to have special people attached to it—people of special understanding and training? Are there to be more special hostels to which these people can resort, and from which they may attempt to make some guided effort to battle with life as it is? Is there to be some kind of sheltered shop on the Remploy model? On all these matters the Bill is virtually silent, yet to me they seem to be vital matters.
This is a very good beginning, but the House having made this good beginning by passing the Bill—as I hope it will—I hope that it will at least continue and do the equally vital follow-up work, even if, as may very well be the case, it is not given to many of us in this House to see the true glory and the end of the good work begun tonight.
§ 10.2 p.m.
§ Mr. A. Blenkinsop (Newcastle-upon-Tyne, East)
I think that most of us in this Chamber tonight will echo a good deal of the anxieties expressed by my hon. and learned Friend the Member for Brigg (Mr. E. L. Mallelieu) about the ability of the local authority services to 823 meet the challenge that this Bill is putting upon them, but I do not think that we should approach this matter in too pessimistic a strain. Rather, we should welcome the fact that the challenge has been made and do everything we can to ensure that it is fully met.
The Minister is, indeed, a fortunate man this evening to be introducing a Measure which has such wide possibilities and opens up such a wonderful new opportunity; an opportunity which, I believe, can bring a great deal of new hope, not only to patients but also to staffs who have been working in very difficult conditions—which, inevitably, will continue for some time to come—but who may, if we make a reality of the Bill, get new encouragement and rather wider horizons offered for their work. It is upon that aspect that I want to concentrate some of my remarks.
We have had an extremely good and constructive debate, as, indeed, we might have expected from those who have contributed so much to it—with the experience that they have been able to offer. I should like to pay my tribute to the Ministry staff; to those who have for years been concerned with this problem and have always been eager to bring such a Measure as this on to the Statute Book. I remember that seven or eight years ago there were discussions about the practicability of bringing a Measure forward to the House at a fairly early stage, and the argument then was whether or not it was necessary to have a Royal Commission before doing so. At that time, we were rather hoping that it would be possible to short-circuit things and to get a Bill before the House even without the prior examination of a Royal Commission.
In practice, it has been shown that the Royal Commission has done an enormously valuable job, both in getting rid of a lot of the difficulties that otherwise would certainly have confronted us and in preparing public opinion for a considerable change. We certainly owe the Royal Commission an enormous debt. But a very remarkable thing that has gone almost without comment today has been the great value—as, I think, all members of the Commission would admit—of the evidence submitted, right from the beginning, by the Ministry itself. 824 Certainly, the Commission's job would have been much more difficult had it not been for the far-seeing and imaginative form of the material submitted by the Ministry right at the start of the Commission's operation. It was not a question of the Commission dragging the Ministry along in this regard. The Ministry were eager to see a Measure of this kind on the Statute Book.
It is a complex Measure. I hope that the Minister will give reasonable opportunity for expert views and ideas to be submitted to us all as the Bill goes through. It is very important that we should have an opportunity of hearing the views of many bodies that have not yet had much chance of expressing an opinion upon the Bill as it stands. I hope that there will be that opportunity given both before the Committee stage and as the Bill goes through Committee. In a Measure of this kind, we are naturally anxious to get the widest concensus of opinion that we possible can.
I have been struck with some of the comments that have been made from both sides of the House on the question of civil liberties. It is a very important matter. I do not share the view of those who have advanced the opinion that the Bill actually reduces these liberties. That does not mean that we should not examine extremely carefully the proposals that are made in the Bill. I think that there is some justification for saying that we ought to look particularly carefully at the provisions of Clause 26 for compulsory admission to hospital for treatment and whether or not any lay advice is required at that stage. I think that we want to examine that carefully. We want to think of it even more perhaps in the special and difficult case of the psychopath. Therefore, I think that the arguments for lay views to be heard are very strong indeed. I hope that there will be full opportunity to pay regard to that point as the Bill goes through Committee.
I noticed that we have been emphasising that Clause 25 refers to observation, but many of my medical friends, in discussing this matter, hope that it will be made quite clear that it is observation and treatment that we intend to carry out within that 28 days. Indeed, there may be many patients admitted compulsorily whose treatment will be completed even within that period and also those who may be in a much fitter state to accept 825 continued treatment voluntarily after the period of 28 days has expired. I think some of my medical friends have been a little anxious that by using the word "observation" that does not, of course, rule out the development of treatment in that period of time.
I certainly agree with my hon. Friends that we must look with great care at this question of whether or not we should bring back lay representation into the admission procedure when we are thinking in terms of the long-stay case and particularly when thinking in terms of the psychopath. Many of my hon. Friends have mentioned this point and it has been emphasised from both sides of the House, quite rightly, that the definition that is advanced in the Bill is not a medical definition nor would we expect it to be. It is a social definition and, therefore, for that reason it would seem to be logical that there should be lay views when the question of admission is being considered.
Naturally we hope—and this hope has been expressed from both sides of the House—that the provisions of this Bill and their implementation will make for great changes in the hospitals. We hope that it will be so, above all, in the sense that it will enable the hospitals to carry out more active treatment than they have been able to do owing to their overcrowded conditions. We hope it will mean that many patients who have been in mental hospitals in the past will no longer need to stay there and, because of that, that much more treatment will be possible for others.
We are envisaging a further development of what has been going on for some time in the treatment of cases in general hospitals—a most happy development which was greatly encouraged by the National Health Service itself. I refer to the fact that for the first time we were able to think of mental treatment as part of the wider field of the Health Service.
I share the anxieties of the right hon. Member for Thirsk and Malton (Mr. Turton), a former Minister of Health, who said how eager he was that we should take the earliest opportunity of getting rid of some of the worst old mental hospitals. I hope it will be generally agreed that hospital treatment in the future should encompass the idea of new units which will be flexible, and which, above all, will have their clear links with the 826 community services outside. This might, indeed, be one way of helping to break down the isolation both of the mental hospital and of other sections of the hospital service from the wider fields of the Health Service. There are some very interesting new ideas architecturally, as the Minister knows, and I hope that he will take full advantage of them. These ideas prevent us from becoming static, and I hope that we shall take full advantage of the work that is going on.
The Minister should take note of the point which was mentioned by my hon. Friend the Member for St. Pancras, North (Mr. K. Robinson) on the question of admission to hospital, and should consider whether or not the requirement should be laid on the regional board at least that accommodation should be provided for patients in suitable cases, so avoiding the possibility that although they might be suitable for treatment in general terms by those recommending admission, it might be impossible to find a hospital which would admit them under the provisions of this Bill.
I agree with the warning that was uttered by the hon. Member for Gosport and Fareham (Dr. Bennett), who has so much experience in this matter, with regard to the danger of taking discharge rates at their face value. One should consider the question of readmissions with great care. A friend of mine, a psychiatrist, told me that he could, if he wished "cook up" for me any kind of discharge rate that I liked, if that was what I wanted, but that there would not be much honesty or use in it without examining the developments over a period of time. On the other hand, I do not think that we should be too much afraid of the idea of a fairly regular check-up in certain types of cases. It might be a sensible thing if patients were to go into hospital for periods of observation and then return to the community. We must keep this kind of issue in balance.
We are, of course, all delighted at the experiments which have been going on in day units and other forms of what one might call semi-hospital care which, again, help to link the hospital work with the local authority, welfare and other services. This is closely in line with our ideas about future developments in regard to other problems as well as those of mental health—for instance, the problems of old 827 age and so on which are, after all, closely linked.
The emphasis on the need for wider community care has been in everybody's mind. As I have said, it is this which provides us in Parliament with an opportunity to encourage the growing together of our whole Health Service which it so badly needs. It is a wonderful opportunity to encourage the bringing together of the three separate elements of our National Health Service. I very much hope that the opportunity will be fully taken.
But, of course, as has been rightly stressed, it is no use providing these things on paper unless we tackle the real problems of manpower and training in all parts of the Service. There is the need for trained psychiatrists. There is the problem of the lack of psychiatric social workers which has been frequently mentioned. Here, as in other parts of the Service, we must consider whether, in order to make progress, there is a need for special training of some existing social workers. I know that the dread word "dilution" comes in here, but we must face problems of this kind and consider whether we are using to the best advantage the social workers who are available.
Here we immediately take issue with those who suggest that it is adequate to leave much of this provision on a basis of choice for local authorities. I cannot quite understand why the Minister could not put into his Bill the mandatory provisions which I am sure we all regard as desirable while recognising, of course, that things will have to be done in stages. After all, such a procedure is commonplace in many Measures brought before us. For example, in the Clean Air Act, although many provisions are made mandatory, there are dates by which they will come into force, and it is within the power of the Minister to make orders declaring a precise date by which different provisions of the Bill will become operative.
We have envisaged that every local health authority would be required to prepare certain plans about how, in its area, it proposed to carry out these provisions, in full co-operation with everyone involved—this would be absolutely essential—after first consultation and careful joint planning with the hospital authorities and, 828 indeed, with the representatives of the general practitioners also in the end. This is part of the opportunity to bring the three arms of the Service together. It seems obvious that a procedure of this kind would be absolutely essential in order to have a clear programme of advance developed all over the country. The speed of advance, of course, would depend upon the staff actually available. But we will not be able to do this properly unless the local health authority brings in, as it must, the staff which are attached to the hospitals and universities. I hope that this will be done.
The Royal Commission was very clear on this matter, and I do not see why the Government should depart from its view. Paragraph 715 of the Report reads:And if the general re-orientation of the mental health services which we have recommended, in the direction of a considerable expansion of local authority community services, is to be achieved, we have no doubt that the provision of community services for all groups of mentally disordered patients should be made a duty".I do not believe that the Ministry is properly discharging its function by leaving the matter as it stands. There are plenty of examples of ways in which we could ensure that we had a steady programme of development throughout the country instead of being left, as I am afraid we shall be, with occasional examples here and there of action which we would welcome and support, but in many parts little or no action at all.
I am glad that so much reference has been made to the question of research. I have been concerned about the number of highly qualified scientists and doctors who have left this country to go to America in order to carry out research which, apparently, they find they cannot carry out here. That is particularly noticeable in this sphere, and it is a matter of great concern. In addition to the working out of the Bill, I hope that a real attempt will be made to ensure that more adequate funds are made available both for scientific and general medical research and also for a great deal more work of a social and welfare character in order to make sure that the plans which we develop are on the right lines.
A large part of this problem lies among the old people. Yet, in the many inquiries made up and down the country into the conditions and care of old people, 829 there has been little careful examination of the problem from the mental health angle. This is a question which we hope will be investigated. Among other places, we are eager that an inquiry should be made in Newcastle-upon-Tyne, where there are some extremely well qualified people to undertake it.
All this research largely depends upon finance. The questions about the financial position have not just come from this side of the House; they have come from supporters of the Minister as well, and very naturally. We must understand that if there is to be the kind of development of trained personnel which we must have if the Bill is to be effective, then more money is needed. Even though, in the long run, we can make great savings and, I hope, close clown large sections of the old hospitals, nevertheless, in the short run, at any rate, considerable expenditure will be involved.
I cannot understand how the Minister can say that he feels he is being generous in being able to offer in the House what we think are totally inadequate sums—£4 million has been mentioned—for the whole country. Although that may sound a fair sum of money in comparison with the past, when we realise how little has been done in the past it is terribly small. That is why we must come back to the question of the great disaster—for such it is—that at the same moment as we should be discussing this hopeful new enterprise, we should have been put in something of a new financial strait jacket by means of the block grant. If ever there were a form' of financing for local authorities that would discourage initiative, new work and imaginative new ideas, surely the block grant was just it. This is in danger of wrecking the possibilities and creating great frustration among all those who are so eager and so happy at many of the provisions of the Bill.
One has only to look at the new proposals that it is intended local authorities shall carry out in domiciliary care, the provision of hostels for the severely subnormal, the provision of residential homes for the elderly mental cases, hostels for the younger mentally ill, training centres, social care and all the rest. This inevitably assumes a special financial provision to meet it, but we have no sight of this being done. We do not ask 830 for the impossible. We realise that this is a scheme that must develop in a planned way, dependent upon resources, but this form of financing does not offer the opportunity even of using the resources that, I believe, could be made available to carry this a stage further.
We have rightly had emphasised again by hon. Friends of mine and by hon. Members opposite that the Bill cannot be made a reality unless there is great development of understanding on the part of the general public. With that I agree. This is a tremendous opportunity if we can all seize it. In the past, however, the Ministry of Health has not made the fullest use of such avenues of education about health matters as might have been thought to be available. There is the central Council for Health Education and there are the other bodies. I would like to know something more about the intentions of the Government to embark upon an imaginative campaign to educate the general public more fully than has been the case in the past.
When we come to examine the Bill, as we shall do, with great care to detail as the Bill goes through Committee, we will be brought back more and more upon the difficult problems of the provision of staff, the fact that we do not at the moment have the staff to meet the need and that the finances will not be available to encourage the training of the additional staff that we need.
I would apply to the Bill and to the Minister the comment made by a psychiatric social worker, who in a recent article, when referring to the Commission, said:For if the trumpet give an uncertain sound, who shall prepare himself to the battle?Is the Minister satisfied that this Bill is really the rallying call that we want it to be? How can we ensure that people will prepare themselves for the battle of the new opportunity for the mentally sick unless he also makes sure that his right hon. Friend the Chancellor of the Exchequer gives him the resources with which to do it?
§ 10.30 p.m.
§ The Solicitor-General (Sir Harry Hylton-Foster)
I should like on behalf of my right hon. and learned Friend and the Ministry to thank the hon. Gentleman the Member for Newcastle-upon-Tyne, East (Mr. Blenkinsop) for the words he 831 spoke about those who have worked on the Bill. This is a big job, this Bill, and I should suspect that most right hon. and hon. Gentlemen would be willing to think that those who have worked on it have done very well indeed. I was a little unhappy to hear the judgment of the hon. Member for Woolwich, East (Mr. Mayhew) when he said he did not think the Bill was lucid. I confess that, speaking from a mere lawyer's point of view, I thought it was rather exceptionally lucid. I say that in order that the House may perhaps think it right to congratulate the draftsmen who got so much complex matter into a really convenient and comprehensive form.
The hon. and learned Member for Brigg (Mr. E. L. Mallalieu) apologised for being a lawyer talking on the Bill without expert experience of its medical subject matter. I hope the House will not want me to do that because I confess myself second to none in interest and enthusiasm about the Bill, and, after all, there will be some lawyers' work about it because, as the hon. Lady the Member for the Liverpool, Exchange (Mrs. Braddock) emphasised, I think with extreme correctness, what we are doing with this Bill is just creating a code: we are setting right the legal foundation for the things we want to have done in terms of care and treatment and prevention and after-care and all the rest of it. We are setting right the legal foundation for what we want to have, but I would respectfully agree with all those hon. Members who have been busy emphasising that the effect of getting the law right in relation to the patients and the community will depend really upon those things which are done in the execution of the law and they are matters which are outside the lawyers' realm.
That is why I thought the House would probably forgive me, having many points to deal with, if I devoted myself, in seeking to wind up this very good debate, to matters which are really outside the Bill rather than to those which are within it, because no doubt we shall have—for my part I shall be most interested if we do—detailed discussion of all matters of interest in Committee hereafter, and that, perhaps, would be the best opportunity to consider what is in the Bill. I say that by way of excusing myself for any kind of discourtesy if I do not answer the whole 832 number of relatively small but none the less important questions which have been asked of me.
The right hon. Lady the Member for Warrington (Dr. Summerskill) was good enough to explain that she did not want an answer to those matters she had in mind this night. I am greatly obliged, and I hope that the hon. Member for St. Pancras, North (Mr. K. Robinson), who made a very good speech, if I may so so, will think I may in the circumstances keep the question of defining "subnormality" until we get upstairs.
I should like to say in answer to the inquiry by the hon. Lady the Member for Liverpool, Exchange about the Second Schedule of the Bill that, of course, my right hon. Friend would be willing to consider that point with the Minister of Education, whose responsibility it is, but I think I can explain to the hon. Lady why she does not remember the matter cropping up, as it were, in the Royal Commission's Report and in her studies. It simply comes from the existing law on possible ascertainment at present under the Education Act, 1944, at the age of 2. It is the minimum age, and no doubt the right age varies with the condition of the child. If the condition is a very drastic one, no doubt ascertainment can be possible.
§ Mrs. Braddock
My comment was that it was referred to in evidence and that it was wrong that a child so young should be ascertained as not being able to accept education.
§ The Solicitor-General
I am obliged to the hon. Lady. I do not want to misrepresent what she said, but the reason why it is there is only that it is in the existing law, and my right hon. Friend will, of course, discuss it with my other right hon. Friend.
The right hon. Lady the Member for Warrington was thinking about psychopathic disorder and its susceptibility to medical treatment, and I venture to hope that before we get to Committee, while she is thinking about it with those who are concerned with her, she will bear in mind what I hope is right, not being a doctor, that certainly there are some psychopathic disorders which are so susceptible to medical treatment in the ordinary sense of the word. Certainly there are some which are not, but in that 833 case it is a matter for question whether they ought not to be kept out of a Mental Health Bill—so I submit as a point of view.
§ Dr. Summerskill
I do not want to cross swords with the right hon. and learned Gentleman, but I would remind him that a psychiatrist on the other side of the House said that in his opinion the doctors cannot approach this subject at all. In fact, they have no cure for it. That is just an illustration.
§ The Solicitor-General
I am obliged. This is a question which I suggest we keep for a later time. I merely desire to lay a foundation for the matters we have to consider before we get into Committee. A matter to be emphasised to the layman is the definition of medical treatment in Clause 142. I do not know—we can examine it later—but though there may be some kind of psychopathic disorder which is not susceptible to medical treatment, it might be a rather tougher thing to say that it is not susceptible to medical treatment in the sense of includingnursing, and… care and training under medical supervisionwhich is the definition as it now stands.
My hon. Friend the Member for Hendon, South (Sir H. Lucas-Tooth) asked about subsection (5) of Clause 142. May I make a point preliminary to discussion in Committee? I submit to the House that that is, from a lawyer's point of view a purely declaratory subsection. It leaves the law exactly as it would be if the subsection were not there. It is put in for the assistance of those who have to administer the Bill. My hon. Friend also asked about the meaning of the word "term" in those provisions of the Bill which relate to persons sentenced to a term by a court. In the context it means the term which the court pronounces. That is to say, in computing the operation of the provision, account is not taken of any remission which the person serving the sentence might have earned in other circumstances.
I think that it was the right hon. Lady the Member for Warrington who pointed out, with her usual wisdom in these matters, that sometimes the nearest relative is not exactly the best specimen one might find of a person pursuing the interests of the patient. That is true, of course, but it is a matter of puzzlement 834 how better one can deal with that problem than by the provision in Clause 52 whereby, if it is found that a particular relative is not functioning in the right way that such a relative should function, one can go to the county court and ask the court to transfer the function to someone who can serve better the interests of the patient. I do not know how better it could be dealt with.
I turn to the problem of whether the local authority provisions in the Bill should be made a matter of mandatory duty, or should remain as they are, a matter of authorisation, subject to a power in the Minister to make them into a duty at a later stage. I should like to indicate why we think it wise to leave them for the moment as they are in the Bill. There is no lack of grip in the Minister. He can at any time direct and thereby impose a duty under the Bill. He also has, in the last ditch, as it were, default powers, so there is no danger that at any time he will lose hold of the situation.
What is the object of imposing a duty? I submit that it is to deal with reluctance or negligence in the field in which one is authorising. We do not know of any evidence of reluctance at the moment. I think that no one suggests or would suggest that at once, in the Bill, we should make these provisions a matter of duty. I shall have to say a word about the staff situation, but staff in itself would make moderate nonsense of attempting forthwith to do that. Therefore, the choice is between leaving it as it is in the Bill or suggesting, as the right hon. Lady the Member for Warrington and other hon. Members have suggested, that some term should be set to the period of time within which it should become a duty. I submit that practical experience does not show that that is a wise or good thing to do.
The right hon. Lady made the point that the only creation of a duty pursuant to Section 28 of the National Health Service Act was the one in relation to tuberculosis, and she referred us to the great improvement in the tuberculosis death-rate. I do not not know whether that is cause and effect. I think the vast improvements in medical knowledge about tuberculosis may have played a large part. I do not want to make any silly party point in a non-party matter, and I am not trying to, but it does not 835 look as if hon. Members opposite had found that this was the right way to proceed when the Labour Government were in office.
The right hon. Lady gave the instance of provision for old people as something which had been neglected. That seemed to me to be a little strange. That duty was imposed by the Statute; it does not depend on any direction. On the other hand, when hon. Members opposite had to deal with Section 29 of the National Assistance Act, which does not impose a duty, the only instance in which the matter was made a duty was in relation to the blind, and all the other persons for whom provision had to be made have been left all this time on a voluntary basis. I do not know whether anyone has ever found that that has resulted in an unsatisfactory position. It looks as though successive Governments have found that the necessity of making it a duty may or may not exist. It is worth looking to see what happens.
§ Mr. Blenkinsop
Do I understand that this is a matter to which the Minister will be prepared to give some further thought during the Committee stage?
§ The Solicitor-General
I will tell the hon. Gentleman what has been happening. He and others have been advocating that it is right to get the commencement of a scheme going. We have given the House figures representing the estimated expenditure of local authorities in this sphere, and they have been based on fact. By now all the local health authorities in the country have submitted their schemes for what they want to do under Section 28 as clarified by the Bill, and the Minister proposes by circular to ask them to review all their arrangements and, if necessary, amend their proposals. There is not in the whole of that any indication of reluctance. Indeed, it was because the authorities had submitted their proposals in this way that it was possible to give the House the expenditure figures which were contemplated. We would rather wait to see whether there is any reluctance or negligence. The matter can then be made one of duty by direction of the Minister. We prefer at this stage to see whether it can be done without direction. While the staff position is as it is, it seems best to proceed in that way.
836 I turn now to the grant, to finance. I refuse to go back to some discussion of the merits or demerits of the block grant. It would not assist discussion of the Bill again to cover ground which has been adequately covered already. The general grant order deals with the next two years, and the next two years only. I do not wish to make a silly joke when I say that the future is entirely open, because it is, in relation to whichever party will form the Government at that time.
What we allowed in considering the general grant provision was more than the sum which the local authorities were proposing to spend in respect of new local health services in relation to mental health. It might assist if I were to express in percentages the past and contemplated growth and to show the proportion of local authority health expenditure to be devoted expressly to mental health services. This is an imprecise operation, because no one knows the figures with precision, owing to the fact that mental health patients make use of other local health services. Subject to that, in 1954–55, the expenditure exclusively related to mental health services was 5.6 per cent. of the whole; in 1958–59, it is 7.1 per cent.; in 1959–60, it is to be 8.2 per cent.; and in 1960–61, 9.3 per cent. That represents a healthy pattern of work done and to be done in the first two years.
The hon. Member for Woolwich, East expressly asked for some figures. When my right hon. and learned Friend said that the work of a capital nature authorised in 1958 was double that authorised in 1956, the hon. Member asked for the actual figures. They are that in 1956 the figure was £290,000; in 1957, £460,000; in 1958, £750,000. Those figures precisely bear out what my right hon. and learned Friend was saying.
The brake in this matter is not so much finance as staff. The right hon. Lady said that we are all to blame for that and I dare say that she was quite right, that is to say, for the fact that there is not enough specialist staff for this work at the moment. One can get what can be done in the next two years into proportion only if one recognises the extreme limitations. I need not spend too much time on this topic, because so many hon. Members have emphasised the 837 matter. In the eloquent phrase of the hon. Member for Edmonton (Mr. Albu), resources are staff. The hon. Member for St. Pancras, North, and the hon. Member for Batley and Morley (Dr. Broughton), the hon. and learned Member for Brigg and many others pursued this topic.
At present, the resources are small and the smallness will be a hindrance against any rapid development. To begin with, there are only about 600 full-time mental welfare officers. Of those, 200 do not do the duties of a duly authorised officer. There is no recognised qualification for them. Local authorities usually ask for a social science degree or diploma, but in 1956 about half of them had no academic qualification whatsoever. Of course, many of them have very great practical experience and have been former relieving officers and the like. However, there it is.
The position about training is that the National Association for Mental Health and various universities run short courses for them, but there are no accepted courses. As many hon. Members have emphasised, psychiatric social workers are very scarce, that is to say, persons for that purpose who have a social science diploma added to a year's case training in actual work.
We have had to wait and wait for sensible reasons. Hon. Members will remember the Mackintosh Committee of 1951 or, to give it its full name, the Committee on Social Workers in the Mental Health Services. That Committee recommended that new entrants should have a course of in-service training for two years and that existing officers should have the same. Clearly, their position ought not to be treated in isolation. The Younghusband Committee, as the Royal Commission recognised in paragraph 723 of its Report, is now busy and it is hoped that its Report will be available to Ministers early this year. I hope that from that Committee's recommendations we shall have the pattern of what should be done in the training of more of these people.
I take the point about instructors and about more numerous occupation centres and training centres. There are various schools and there is now going on a course for 14 students at Newcastle. But, 838 as far as we know at the moment, there is no gross shortage of staff for occupation centres. On the other hand, so many local authorities look to craft qualifications and perhaps some teaching qualification rather than to psychiatric qualification. It may be that as standards improve and centres become much more numerous there will be a much larger shortage than there is at the moment.
I was asked by a number of hon. Members about research. I should like to share in the expressions of the importance of research in this field. Of course, one of the troubles is not money but that of finding the right people to do the research. That is one of the difficulties of the time. If one talks about figures, about only £130,000 and only 4 per cent. of the Medical Research Council's total budget, I think it fair to remember that there is a large range of varieties of other kinds of research—into nutrition, genetics, and so on—which have a direct bearing on the particular problems in this field.
The important matter about which I wanted to tell the House the present position is that the Medical Research Council has already undertaken a full-scale review of its research in this field with a view to considering what precisely its future development shall be. That review is actually in hand now. In addition to what the Council is doing, there is an immense amount of work going on in National Health Service hospitals, mainly as research done as an integral part of the clinical practice there.
My hon. Friend the Member for Banbury (Mr. Dodds-Parker) asked whether there might be some new hope for the schizophrenic, particularly by biochemical remedies. My other hon. Friend emphasised the need of not raising hopes of cures. Bearing that in mind, while I am authorised by the information before me to say that the prospects of the schizophrenic today are infinitely better than ever before, I do not think it would be right to give the House an assurance with regard to these biochemical remedies. Schizophrenia is a label attached to such a wide variety of troubles, the actiology of them all being different, that it is undesirable to tie oneself to any one remedy in relation to that matter.
The hon. Member for St. Pancras. North asked about this point—that the 839 abolition of the Board of Control should not result in the total ending of visiting for inspection purposes. Of course, they will not be the old statutory inspectors performing the same function, but it is the intention of my right hon. and learned Friend the Minister that his experts shall be going round and fertilising ideas, as they do, by carrying out that kind of visiting as between hospitals.
Questions were also raised about the obligation of hospitals to accept patients. The essential point here is, as the hon. Member for St. Pancras, North at once recognised, that once we de-designate—that ugly phrase—these hospitals it becomes a necessity not to impose the obligation. Indeed, the Royal Commission gave the best possible reasons for thinking that compulsory admission had resulted in certain abuses of the process of certification.
I hope that I can give the hon. Gentleman an assurance almost exactly in the terms in which he was speaking, namely, that it is the intention of my right hon. and learned Friend the Minister that the burden should be placed on the regional hospital boards and that they should introduce arrangements to ensure in cases of urgency that a patient requiring psychiatric treatment should be admitted to the hospital best able to give him that treatment.
It is obviously right that the arrangements should vary from region to region because circumstances would be different. It is not desirable to have anything but the fullest flexibility by leaving these matters out of the Statute altogether.
I regret that I have not a moment to explore the large number of extremely interesting topics which have been raised, but I shall have to leave them. In particular, there is the question of why the judicial order had to go, a matter which was abundantly discussed by the Commission. Why Part V is in the Bill is another interesting matter which we shall have to deal with later. I confess that I share the view expressed by all hon. Members about the supreme importance of getting public reaction right to the things which we are trying to do under this Bill. Owing to shortness of time, among other things, I am not in a position to make any declaration of Ministerial intention, but I hope all hon. 840 Members will be taking part in that process.
There is a region beyond human understanding and sympathy in this field, I know, where we have to hand these matters over to the experts. But I am certain that there is no practising member of the Bar who does not feel his sympathies deeply involved in these matters. The saddest cases with which we have to deal are those in which mental disorder is involved in some way or another. No hon. Member of this House, when striving in his constituency, has not had his emotions wrung to their depths by the powerless-ness which one feels sometimes when trying to help in cases relating to mental disorder. The best that we can do must be the relatively cold-blooded business of proposing legal provisions of lawyers as contained in this Bill. It is because they are there to help, and because I believe them to be good, that I am so glad that the whole House has given the Bill a generous welcome.
§ Question put and agreed to.
§ Bill accordingly read a Second time.
§ Bill committed to a Standing Committee pursuant to Standing Order No. 38 (Committal of Bills).