§ Mr. David Griffiths (Rother Valley)
I beg to move,That this House welcomes the progress made in the provision of services for the mentally disordered and urges Her Majesty's Government to take steps to encourage further development.I know of no better occupation for the energies and efforts of both the medical fraternity and all public-spirited men and women than to work on behalf of mental defectives. According to the latest figures, it costs over £130 million per annum to care for mental patients. While this seems to be a huge amount of money, it is infinitesimal compared to the amount of good which can be done to alleviate the suffering of these poor souls. There is no service more important and vital. We must do everything possible to minimise human suffering, particularly of mental patients.
When one looks through the history of Lunacy Acts from the middle of the last century, one has to take into consideration the Lunatics Act of 1845, the Lunacy Consolidation Act of 1890, the Mental Deficiency Act of 1913, the Mental Treatment Act of 1930, and finally the Mental Health Act of 1959 which revoked all preceding Acts. Even in the old Board of Guardians and Poor Law days—which many of us remember with sorrow—and especially now that the service is in the care of the Ministry of Health and such advancements have been made, constructive efforts have been made by all Governments through the ages. The very titles summarise the changing outlook of the community on mental disorders and treatment over this century. It has been remarkable, but I urge the Minister of Health that there is much more which needs to be done.
1646 For instance, when mental hospitals were administered by the old Boards of Guardians, it was my misfortune or fortune, in the 'twenties, during my public duties as a member of a Board of Guardians to pay annual visits to major mental health institutions in the West Riding of Yorkshire. The thought of what took place, and what is taking place now, in these overcrowded institutions makes one's heart bleed, especially when one sees them and considers the conditions which they have to undergo. I not only had the experience of visiting these institutions; fortunately or ununfortunately, I had to go to Broadmoor on one occasion. I signed the register. It was not the signing to get in which worried me; it was the signing to get out. That is the position with many poor unfortunates in these institutions at present.
Much has been done, which we welcome, and much more needs to be done in ensuring treatment in the early stages of mental illness, and today we are regarding institutions as places of treatment rather than as places for the lifetime custody of patients. Improvements have been made, which we welcome. We welcome the efforts which have been made not only by Ministers, but also by the medical profession. The psychiatrists dealing with these cases have done and are doing a remarkable job. I urge the Minister as far as possible in his Department to give more encouragement and to help provide more facilities for this type of treatment, because if the patient can have treatment in the early stages we can prevent his being in the institution for a life-time. One sees deplorable cases of little innocent children in these institutions, which would tear the heart of any parent, indeed of any human being. We must leave no stone unturned to try to remedy this social evil, and we urge the Minister to do all that he possible can to assist in this direction.
Since 1955, remarkable strides have been made in new tranquillisers, particularly with chlorpromazine, reserpine and later anti-depressant and other psychotropic medicines which have reduced the time spent by many people in these institutions. This is a good step forward and we hope that many more will be taken in the near future. Instead of being long-staying patients it 1647 would then be possible for people to be treated more or less as outdoor patients. We welcome that.
The Mental Health Act, 1959, repealed all previous Acts, but I think that the present Minister had some misgivings even about the 1959 Act, which did not go as far as he wanted to go. Because it did not go as far as he wanted to go, perhaps we shall see some advance even on that Act. Apart from getting more specialists to give this treatment, I submit that we have to do much more to provide more nurses, both female and male. We have to get them better salaries and better conditions of service or we shall not get the staff we need to give the special treatment which is required.
I think that the Minister, and any other person who has been to our institutions, will agree that our institutions are far too overcrowded. In the West Riding of Yorkshire the position is deplorable and abominable, and I dare say that the same situation obtains in many other cities where there are institutions. In the West Riding, of which I can speak in particular, it is appalling to see the numbers of patients in institutions, far beyond the Ministry of Health regulations. Nurses, both male and female, and attendants, carry out their duties and look after their patients in a way which one would not conceive to be humanly possible. They have an unparalleled task which they carry out remarkably well. Salaries and conditions must therefore be attended to at the earliest possible moment.
Again, we have many old hospitals. This, again, is a question of money. But if we are talking about money, is it not far better to spend money in this direction to help people back to health much more quickly, so that they may lead a normal life, return to industry and earn money, rather than maintain them at a very heavy cost to the country? I realise that much more money will be needed if we are to get patients back to a normal working life, but in the end we shall save money in this way, and we shall have a happier and healthier nation. I could go on at length in dealing with this vexed question. We must pay much more attention to treatment at an earlier stage rather than wait- 1648 ing until patients are in an institution for a life-time. If we do that we shall not only save money, but save lives and human suffering.
§ 11.14 a.m.
§ Mr. W. R. van Straubenzee (Wokingham)
May I start by congratulating the hon. Member for Rother Valley (Mr. David Griffiths) both on his good fortune in the Ballot and on the skill with which he has chosen his subject. Unfortunately, it is not a subject which we often have time to discuss in the House in the busy programme which jointly we have to get through, and I am certain that the House is in his debt for giving us at least a short period to give consideration to these important matters. We all know the hon Member's personal interest and sympathy in the subject, and I should like to congratulate him on the manner in which he moved the Motion.
It always seems to me that the difficulty in dealing with mental illness and mental handicap is that, by contrast with physical handicap, which always brings out in people the very finest and best of feelings, mental handicap brings out fear. There is nobody in the country who is not instantly moved, and hundreds of thousands of people very practically so, by the sight of someone, old or young, with a physical handicap. But, somehow, mental illness strikes a chill down the spine of many of those who otherwise would be only too disposed and anxious to help those affected in this way.
I do not know how we get over this fear. It requires, does it not, people of very strong character. The essence of dealing with someone mentally handicapped is not to sink with him but to be a rock to which he can cling, and for those who are merely on the fringe and are not very serious cases somebody of a strong character to whom the person can cling is a very material help in rehabilitation or bringing that person to a rather fuller life. I suppose that there is no more remarkable work being done in the country than in the training of mentally handicapped people, young and old.
Hon. Members have in their constituencies, as I have, examples which fill them with admiration. I sometimes wonder whether we do not take too much 1649 for granted, for example, the work of nurses in hospital who are looking after children with severe mental abnormality, many of whom, at least as far as our present medical knowledge goes, have no lasting chance of living at all, and yet upon whom is lavished all the care and affection which one would find in an ordinary children's hospital. They are afflicted in physical ways which make nursing difficult, troublesome and constantly demanding and yet I—and I am sure that this applies to every hon. Member who visits such places—never leave them without a feeling of awe at the sense of duty which drives on the nursing staff in such hospitals.
I should like to raise one point about the training of young people with mental handicaps, and that is the provision of those who teach them. Obviously, in this field as in so many others of our educational system, the provision of teachers is the kernel of the problem. Flesh and blood in this respect as in many others are much more important than buildings. I understand that a person who is being trained to teach a physically handicapped class or school does three years training as a normal teacher plus one year's special training in, broadly, the physical handicap on which they will be working. I understand—I hope that I have my facts right—that this is not so stringent in the case of those trained to teach mentally handicapped children and that the training period is shorter and, further, that there is a discrepancy in salary scales.
It is hardly surprising, if I am right, that in my area, and for all I know elsewhere, it is proving difficult to keep up to establishment in this important group of teachers. I do not propose to give names because inadvertently one might appear to be critical of those working in such schools or training centres, and I do not want to give the smallest impression of that, but I am factually conscious of some gaps in establishments in my area which mean that we are not able to give the training which we as a civilised nation want to give and should give to mentally handicapped children. I am wondering whether we should look again at the salary scales for these devoted people, for we have no right to trade on their sense of mission in financial terms.
In what I have just said I was concentrating on child training. Turning to 1650 adult training, some quite remarkable work is being done here. In one remarkable centre in my constituency, which again I do not propose to name, the problem is that some of the better trained inmates can earn larger sums than the senior nursing staff. This inevitably places sometimes a certain element of humorous pull on loyalties in the hospital. But it is still a remarkable and wonderful move forward that we are able to bring such people into the ordinary and everyday life of the country. It should be made clearer how desirable this is.
I have come up against the controversy and criticism at times that such people are being allowed to work outside and, in the view of the critic, are being exploited. I am sure that this criticism is honestly made, but it must surely be misplaced. The more we can bring forward such people to take their part in the everyday life of the country the better. The more they can be encouraged to do simple and, in some cases, more advanced tasks and to occupy their minds and bodies the better. As long as there is proper supervision there can be no question of exploitation of people with this unfortunate disability.
It is inevitable that one aspect of the Motion is of particular interest to me. The hon. Member for Rother Valley who proposed it commented—and I know what he meant—that when he went to Broadmoor he was more concerned with getting out than getting in. I hasten to add that no one who knows him would have any doubt about his ability to get out. I am particularly interested necessarily in the three special hospitals, Broadmoor, Rampton and Moss Side. I want to say a few words about them in principle, but to make one thing clear at the start. I will not make any mention in detail or at all of a recent escape from Broadmoor, for two reasons: first, I imagine that the Minister has not yet had an opportunity of completing the inquiries which he always makes; and, secondly, I know, and only just know, that I have another opportunity of doing so and it would be discourteous to the Chair, apart from anything else, if I touched on that detailed subject today.
I think that the House knows that Broadmoor was opened in 1863 as 1651 an asylum for criminal lunatics. In those days it was under the control of the Home Office. It was then located in what was deep country, the village of Crowthorne being a distant country village. So it continued until 1948, when the Criminal Justice Act of that year vested Broad-moor in the Ministry of Health and it was managed by a Board of Control. I have a certain amount to do with the Board, and, while not being critical in any way of individuals, I shared the view at that time that that command structure was not a very happy one.
On 1st November, 1960, under the Mental Health Act, 1959, a fundamental change was made. It was more fundamental in respect of these three hospitals than the country appreciated. Previous to that time, for a patient to be sent, for example, to Broadmoor—I will concentrate on that hospital because I know it best—he had to be either guilty but insane, or so found before a court, or removed insane from prison. In other words, there had to be an aspect of criminality and a patient had to be charged before a court or found unfit to plead. The hospital has accommodation for a total of 920 patients—705 men and 215 women. But under the 1959 Act a statutory duty was laid on the Minister by this House to provide for patients suffering from mental illness who needed to be detained under conditions of security, but who had not necessarily been before a court. It therefore follows—I do not think that the country as a whole has fully appreciated this—that there are now patients at Broadmoor who have not been before any court.
The question of principle that I put before the Minister is this. It is some time since that change was made. The change may or may not have been a good thing. It was very closely examined and argued in the Report of the Working Party into special hospitals under the chairmanship of Mr. D. Emery. There are two aspects of its working which cause me some anxiety. First, however much we may try to move with the times, Broadmoor at least—I imagine that the same applies, possibly to a slightly lesser degree, to the other two hospitals, has a stigma 1652 about it. If a member of one's family were so unfortunate as to be mentally affected and was therefore very violent and in need of special treatment and special security, and if he were sent to Broadmoor, I am afraid the fact is that, whatever we in the House may say, it has a taint, a stigma, about it, which we would find most undesirable. This may well be so with a number of families and, indeed, if they recover sufficiently, with the patients concerned.
Secondly, I should like to be more assured than I am that the introduction into the special hospitals of this non-criminal type of patient has not had a disruptive effect upon discipline. One does not need to have much knowledge of discipline to recognise that to handle a hospital which is comprised, to the greater extent it is true, of patients who either come from a prison or who have been sent there by a court, together also with patients who have no criminal background but are there for medical reasons, present problems of discipline which are not all easy to reconcile.
I therefore suggest to the Minister that, five years having passed since this very major change was made, which I repeat may be a right change and which I recognise flows logically from the changes made in the 1959 Act, it would now be appropriate for the Minister to inquire again into the workings of that provision of the Act, if necessary by the simple and practical expedient of a working party, which seemed to produce the answer last time.
At this point, it would be appropriate to mention an interesting development in the special hospitals which is indicative of the change in public attitude. Largely under the guidance of Lady Monckton of Brenchley, there is now in existence at Broadmoor, and actively so, a group of Friends of Broadmoor. Need-less to say, such a body has not been set up without some criticism. I, for my part, on being approached, was very willing and happy to be associated with it. It is indicative of the change of public opinion that in an institution which naturally raises many people's fears there can today be a body composed voluntarily of men and women who are anxious to provide fringe benefits, particularly for those visiting patients—this is a considerable problem at Broadmoor—in a 1653 way which I do not think was possible a few years ago.
As with the training of young people, so here at this special hospital, and indeed at all three of them, it is flesh and blood that are fundamentally important, not bricks and mortar. Can the Minister give the House some idea of the staffing position? I understand that the authorised staff is 351. If I am correctly informed, there is a shortfall from that authorised staff of between 40 and 50. That is a very high percentage shortfall. Among other things, it is small wonder that the staff are bound to do overtime in rather substantial quantities.
I mention this only because it has been the subject sometimes of criticism from outside, without the staff's position on the matter being appreciated. I realise that in recent years new steps have been taken, such as an increased allocation of housing, which is very important in that area. What I should like to be assured of is this. In view of this shortfall, if I am accurately informed, is the Minister satisfied that these special hospitals should have staffs with conditions tied to the National Health Service?
The Minister will know that they come to his Service by a very different inheritance from most of the others for whom he is responsible. They were for many years servants of the Home Office. Their professional body's name indicates that. Many of them, it must be said, perfectly honourably, much regretted the change when it took place and when they found themselves under the aegis of the Ministry of Health. If there be this shortage of staff in a place where I would claim that the general level of staff, certainly in former years, has probably been as consistently high as one could find in any institution of this kind, may we not be wise to look at the conditions imposed on them, with particular reference to the close way they are at present tied to conditions in the National Health Service as a whole? Is there not perhaps justification for arguing that they are a special case?
The last comment I want to make is one also of principle. I have made it quite clear—I repeat it—that I am now making no reference to very recent events, since I shall have the opportunity of raising them on another occasion. But 1654 it must be said very clearly that the primary responsibility of those in charge of Broadmoor is security. At any one time those in charge there are responsible to the nation for about 100 of the most dangerous men to be found in the country.
I hesitated for one moment to use the word "men", because even someone like myself, keenly interested in the subject, finds my faith in the divine spark questioned when I am taken into the maximum security block at Broadmoor. I appreciate that modern methods—modern drugs, in particular—not only may have in the future but have now a very great potential, even with those patients. But the fact is that at any one time any one of them can be as dangerous as any other man in the United Kingdom.
Broadmoor is in a growing area, with housing pressing in on all sides, by sharp contrast to what it was when it was first built. It is only a few years ago that in my constituency a child was murdered by an escaped patient, and these things are not forgotten. My consistent feeling has always been—and I am dealing with it in principle—that in an institution of this kind there is imposed upon a doctor a quite intolerable pull of loyalties if he is placed in charge. I make not the smallest criticism today of the present incumbent of the chief medical super intendentship of Broadmoor. I am tackling this problem exclusively from the point of view of principle.
When one talks to someone working in this field who is medically trained, of course one understands when a light of interest comes into his eyes. For such a person the primary interest is the advance of medical science—the remarkable work by which someone who, in that expressive medical phrase, was only recently a vegetable, is, by the onrush of medical science, able to do simple jobs, and that there flow from that situation certain interesting and sometimes physical problems. I respect this interest. I think we are extraordinarily fortunate in this country that there are many men who are prepared to devote their lives to forcing back the frontiers of knowledge, and I am not being critical of that interest and enthusiasm.
1655 What I say to the Minister, however, is this. The primary responsibility being one of security, at least at the special hospitals, it places upon a man with that interest and medical enthusiasm an intolerable pull of loyalty. Wearing his medical hat he may very well feel—and he may well be right medically—that a greater degree of freedom would be wise, that greater experimentation with certain types of implements would be in order, and that there would be advances and dividends to be obtained from a greater measure of trust to this person or to that.
I repeat, who am I medically to contradict? But this can and I suspect sometimes does impose dangerously upon the head man's responsibility to the nation for security. I believe we shall come to a time when we shall amend the 1959 Act and, without in any way putting the clock back, we shall have in charge of the special hospitals persons trained in security as their primary responsibility and responsible as such to the Minister, and, working under those persons, a strong advisory medical team such as we have at present. But the ultimate sanction will be vested in the man trained in security.
I realise that it is dangerous, particularly if one truncates the argument, to put forward a view like this. One can loosely be accused of wanting to return to the gibbering idiots of Dickensian days who were chained to the floor. I hope I have said enough to indicate my own passionate interest in this subject to make it clear that that is certainly not in my mind, but if we are to secure what I am so anxious to secure—a greater public understanding of these problems—we really have to restore the confidence that the public are entitled to feel that in these special hospitals, no matter how far medical science advances, security is and is seen to be the primary consideration of those in charge.
Those are the only comments I wanted to make about the special hospitals. I conclude by thanking the hon. Member for Rother Valley whose perspicacity in the choice of subject has enabled us to air something which is strongly felt on both sides of the House.
§ 11.45 a.m.
§ Dr. A. D. D. Broughton (Batley and Morley)
I wish to join with the hon. Member for Wokingham (Mr. van Straubenzee) in congratulating my hon. Friend the Member for Rother Valley (Mr. David Griffiths) on his good fortune in being able to raise this matter, and in complimenting him on his choice of subject. The two speeches to which we have listened, both thoughtful and interesting, have shown clearly the importance of this subject.
Before I go any further I must declare a personal interest in the matter under discussion, for I am employed in the National Health Service as a psychiatrist. Although I am privileged to work in that capacity, I want to make it quite clear that the opinions I am about to express are no other than my own. I have not been briefed by any hospital, nor do I speak on behalf of medical colleagues. Naturally, I would hope that my views are shared by many of my medical colleagues and, indeed, I hope they are shared by the Minister, but I put them forward strictly as my own personal opinions.
As a medical man and a Member of Parliament, I have felt very proud on many occasions when I have heard our National Health Service spoken of as being the best health service in the world. From what I have seen in other countries and from what I have read, I think that description of it is justified and I hope that this foremost position will be maintained. However, if it is to be maintained it is essential that there shall be no neglect of the mental health service. After all, we have to bear in mind that beds for the mentally ill form a large proportion of the hospital beds in this country.
In previous debates on this subject I have referred to our mental health service as being the Cinderella of the National Health Service. I still think that is true, although I am among the first to admit that there have been tremendous improvements in recent years. I understand that until recently less was being done in the way of providing staff and adequate facilities for the treatment of the mentally ill than was to be seen in other branches of the Health Service. It was this comparative neglect that led me to speak of the mental health service 1657 as the Cinderella of the National Health Service.
Nevertheless, and in spite of that, I think that our mental health service compares very favourably with those in other countries. I would not like people to have the impression that our mental health service is in any way a poor one. It is excellent. But that is no reason why greater efforts should not be made to improve it further. We shall be greatly interested to hear what my right hon. Friend the Minister of Health has in mind in this respect.
I understand that a few years ago there was a school of thought which believed that within a short space of time far fewer beds would be required in mental hospitals. I think I am correct in saying that many mental hospitals remain full to capacity. My hon. Friend the Member for Rother Valley spoke of overcrowding in some mental hospitals. If we are to have fewer beds in our mental hospitals—and we would all welcome that—it can only come about by there being less need and less pressure for them and I should like to draw attention to one or two aspects of the present position.
I will deal with certain types of cases. First, there are the aged. Nowadays people are living longer and there are many old people who live alone. With advancing years there is a gradual onset of senility. The chores of housework, especially cooking, become more and more a burden and trouble. Old people become absent-minded. Many are extremely lonely. They are apt to neglect themselves and their homes. When that happens they do not obtain the nourishing food needed for a balanced diet, and they then become physically weak and mentally muddled. For some, occasional assistance by home helps is not enough, and not all are fortunate in receiving the kind attention of the meals-on-wheels service. With further deterioration comes more severe mental confusion at which stage they become a danger to themselves and a worry to their neighbours, and so they are brought into a mental hospital.
Treatment is along simple lines. First, there is the devoted care and attention given by the nursing staff. Secondly, they are provided with warmth, comfort and good food. In most cases little more is needed and in many instances there is 1658 rapid improvement in both the physical and mental state. Within a matter of a few weeks these patients fall into one of three categories.
First, there are those who unfortunately are suffering from incurable dementia. For them there is no alternative but that they remain in a mental hospital. The second group are those who show some recovery in their mental state but are still slightly confused. I suggest that the ideal way of dealing with these patients would he to move them to psycho-geriatric units, preferably outside a mental hospital, but we appear to have very few, if any, of those units and therefore the patients have to be kept in mental hospitals.
The third category are those who have recovered sufficiently to be discharged from hospital, but here we have been faced with a problem. Many have outlived their relations, or their relatives cannot or will not take them. If they are discharged from hospital and sent home they are being returned to the environment and living conditions that brought about their illness and, therefore, it would be a matter of only a short time before they relapsed. It is extremely difficult to transfer these patients to geriatric hospitals or Part III accommodation because of the shortage of those beds. The result is that many of them have to remain in mental hospitals. There are quite a number of geriatric patients in our mental hospitals who are being kept there because there is nowhere else to send them. I suggest, therefore, to my right hon. Friend that more geriatric and more psycho-geriatric beds are needed.
Another group of patients is one which will decrease in numbers as the years go by. I refer to those admitted to mental hospitals some years ago before our modern methods of treatment came into use. Their ages range from the late fifties onwards. They have been in mental hospitals for many years and it is now impossible to discharge them. They give little, if any, trouble. They can look after themselves very well within their sheltered environment. They move freely about the hospital grounds and go into town but they could not cope with life in the outside world. Perhaps they can best be described as the inadequate type.
They could not obtain or hold down a job of work. They have no home to 1659 which they can go and therefore the mental hospital is a hostel for them. They are no longer psychotic but they cannot be discharged. I suggest that they could lead the same existence in hostels outside mental hospitals. But where are the hostels? I believe that I am correct in saying that the response of most local authorities to the provisions in the Mental Health Act is poor and very disappointing. Hostels are not being provided as was intended.
I should like to say a word about the policy of having psychiatric wards in general hospitals. There are some people who seem to think that psychiatric wards in general hospitals would be able to take and deal satisfactorily with all types of mental illness. I suggest to them that it will become necessary for them to revise their opinion. I believe that the psychiatric wards in general hospitals will play an extremely important part in the treatment of mental illness in the future, and I am sure that we have not enough of them at present.
I see cases admitted to mental hospitals in which the patient is suffering from acute mental illness which is secondary to organic disease, for example cases of severe mental confusion due to pneumonia or other toxic conditions. It is regrettable, but I am afraid that it is true that there is still a stigma attached to having been a patient in a mental hospital. It is a great pity that these people whose mental illness is acute and of brief duration and due to organic cause should have to be admitted into mental hospitals.
I should like to see all cases of toxic confusion treated in psychiatric wards in general hospitals, and those wards could well take other types such as the neurotics in need of hospital treatment, the less severe depressions, the alcoholics, and the early schizophrenics. If those cases were treated in psychiatric wards in general hospitals there would be less congestion in our mental hospitals. There will always be a need for mental hospitals. They would be required for the severely disturbed, the maniacal, the troublesome psychopaths, the severe depressions, the advanced schizophrenics, and the dementias.
To summarise, I hope that the Motion will be approved and that the Minister 1660 will do all in his power to provide better facilities in mental hospitals, including facilities for occupational and social therapy. I hope that he will give his careful attention to the need for adequate staffing. I understand that the medical staffing of mental hospitals is at present under review. I ask him to give his attention at the same time to the provision of more psychiatric wards in general hospitals and better outpatient facilities. Some of the psychiatric clinics held in general hospitals are far from suitable for their purpose, and I need hardly remind my right hon. Friend again of the value of day hospitals. Their value has been proved, and I hope there will be more of them in the future. I have already mentioned the need for hostels and the need for more accommodation for those who are aged and ill. This is a very tall order for the Minister, but I am sure that he will try.
There is much more that I might have said. I have not mentioned the mentally handicapped, the valuable work of psychiatric social workers and mental welfare officers. But other hon. Members wish to speak and I shall take no more of the time of the House. I conclude in this way. The present Minister of Health is known throughout the mental health service as one who has shown a deep interest in our branch of medicine. We all know that he has served as chairman of the mental health committee of a regional hospital board and has extensive knowledge of the needs of the service. He knows what we want. I am sure he will try to get it, and I believe that we shall not be disappointed. I wish him success in his efforts.
§ 12.2 p.m.
§ Mr. Henry Solomons (Kingston upon Hull, North)
; It has been said that we still have a long way to go in the treatment of psychiatric disorders. I was rather surprised to hear the remarks of the hon. Member for Wokingham (Mr. van Straubenzee), who seemed to cling to the old idea that patients in mental hospitals should have a rock to which they could cling. This is now rather out of date. I refer the hon. Gentleman and other hon. Members to an experiment discussed at some length in last week's issue of New Society, an experiment which has been carried out in a mental 1661 hospital in the north-west of London by Dr. David Cooper.
Dr. Cooper has conducted a daring experiment, since 1962, with adolescents and young adults two-thirds of whom are definitely schizophrenic. He and his colleagues have developed a technique for handling these patients which differs markedly from the traditional methods of the psychiatric hospital. The article is most interesting. The only quarrel I have with it is that the title is "Anti-Hospital". Of course, the experiment is not "anti" hospital but only "anti" old-fashioned mental hospital.
The rôle of the doctor in the special ward which has been set up by Dr. Cooper is minimised and the line dividing the patient from the doctor is deliberately blurred. The central aim has been to study a new method of treatment through a loosely organised regime, allowing patients not to get up if they do not want to, to stay in bed all day if they like, not to be compelled to engage in traditional hospital auxiliary work, and so on. This method of treatment, without strict adherence to the traditional methods and standards of orderliness, cleanliness and hygiene, is paying dividends. Patients call the doctors by their first names. Staff and patients have tea together. It has even been suggested that ex-patients should be employed as nurses.
When I speak of "ex-patients", I wish to draw attention to two significant figures. Dr. Cooper says that, although after only three years he cannot make a convincing estimate of the success or otherwise of his ideas, 43 per cent. of patients discharged from conventional psychiatric wards are readmitted to hospital within a year whereas the comparative figure for discharge from his unit is 17 per cent. This shows that there is a great deal in the methods with which he is experimenting.
The need for hon. Members to be here on a Friday morning somewhat earlier than usual may not have allowed them to see an article in The Guardian this morning, written by a consultant psychiatrist. This psychiatrist must, of course, remain anonymous—I do not think that he is my hon. Friend the Member for Batley and Morley (Dr. Broughton)—but it is a most interesting article, and I wish to draw attention to 1662 certain passages in it. The author discusses, among other things, the shocking buildings still in existence in which our mental patients are treated. One paragraph in particular shocked me:The wards are arranged in prison-like blocks with two long interconnecting corridors forbidding in the extreme. Some of the blocks are riddled with woodworm and the floors are unsafe. Most of the wards are huge barn-like constructions with high ceilings, drab green paint and peeling walls. There are no carpets on the floors and the walls are bare. The toilet facilities are primitive. Many of the wards lack baths. The window space is inadequate and, in winter, the ground floor wards are dark most of the day.I know that the Minister of Health has for some time, long before he came into office, campaigned for an improvement in the buildings and facilities in mental hospitals. I am aware of the great need for economy in these days. Nevertheless, as soon as he possibly can spend the money to improve our existing hospitals and to ensure that better mental hospitals are provided, the happier all of us concerned with the mental patient will be.
The hon. Member for Wokingham mentioned the problem of staffing. The author of the article in The Guardian has some scathing remarks to make about the standard of staff. He says that in the average mental hospital a quarter of the doctors may be expected themselves to be suffering from psychiatric disorder. Again, I am sure that this does not apply to my hon. Friend the Member for Batley and Morley; otherwise he would not be on this side of the House.
The author goes on to say:Another quarter will be foreign nationals who understand little of our language or culture. In the hospital where I work, two of the senior staff and one of the junior staff suffer from psychiatric illness themselves. The total medical complement is fifteen doctors for eighteen hundred patients".I have no wish to detain the House, but, having seen those two articles, I thought it my duty to draw attention to them. The House will be grateful to my hon. Friend the Member for Rother Valley (Mr. David Griffiths) for giving us an opportunity once again to refer to the shocking situation which exists. I am sure that my right hon. Friend will devote all his energies to improving the position as we find it today.
§ 12.10 p.m.
§ Mr. Arnold Gregory (Stockport, North)
I want to make a few remarks on this most important subject which has been so well introduced by my hon. Friend the Member for Rother Valley (Mr. David Griffiths). Like my hon Friend the Member for Batley and Morley (Dr. Broughton), I have a close link with the National Health Service, but, unlike him I do not follow a particular job within the profession. My main contact with mental hospitals and the mental health service has been by way of specialised supplies to the service, essentially in the provision of bedding and linen, produced specially for the service and made through the cotton industry, and in this capacity I have often visited the institutions and hospitals which are doing such a grand job of work.
The point with which I am most concerned is staffing and training. We all raise our hats to the great service which has been rendered by the specialised nursing service in the mental health service. When we take into account the task which they undertake and the jobs which they have to do, and the special training which they need, we are often disturbed by the way in which recruitment is made.
One of my first tasks when I came to the House in October arose from a consultation with one of my constituents on a most surprising matter which I discovered had a lot to do with the mental health service. This constituent wanted to arrange for his sister-in-law, who had arrived from Greece and was somewhat at loggerheads with the immigration officials, to stay in this country with a work permit. I felt that there was some difficulty with the person in the Home Office about the application, but I discovered that the main intention was that this person should remain in this country to serve as a ward maid in a mental hospital near my constituency.
I discussed this question with the person concerned and pointed out, "You must be serious in your undertaking to stay in this country and to carry out this job". To reinforce my own arguments with the officials and authorities concerned, I consulted both the hospital secretary and the matron of the hospital, the Mary Dendy Hospital, Mobberley, 1664 Cheshire. They were almost on their bended knees, both the matron and the hospital secretary, to get this person to remain in this country—with a Home Office permit and the permission of the Ministry of Labour—to assist them in their nursing tasks. They told me that for over 18 months this job as ward maid in this mental hospital had remained vacant and that there was no British national prepared to take on the job. They went on their bended knees to all the authorities concerned in order to fill this most important job.
In the mental health service we require very specialised service which, from my lay information, I believe differs largely from the kind of service rendered in general hospitals. I am sure that the Minister has this problem in hand and is considering almost daily how, in deploying the nursing staff in mental hospitals, we can use the techniques and the abilities of these people in such a way as to make sure that they stay in the service and to make sure that we continue to recruit, bearing in mind the circumstances which exist.
In Manchester, and in Stockport which is part of the Manchester Regional Board's area, we are aware of the special circumstances and difficulties which we have had in filling jobs inside the mental health service in nursing and in allied services. May I refer to the Goddard Report, initiated by Mr H. A. Goddard in 1955. It has remained on the record since then and it was reprinted in the 1964 issue of the Hospitals Year Book. I assume that it remains an authoritative statement on the conditions which prevail inside the National Health Service today—concerning itself primarily with mental hospital nursing.
This exercise carried out by Mr. Goddard was to conduct an analysis on similar lines to those he had already carried out previously for the National Provincial Hospital Trust, and to find out precisely what kind of role people played within the service on the nursing side, to find out how we can handle that kind of work within the service and how we can recruit more and more people to this very important aspect of the National Health Service dealing with mental patients.
1665 First of all, a pilot survey was conducted which enabled the investigating team to familiarise themselves with the atmosphere of a mental hospital, its working and its personnel. They also experimented with observation techniques and compiled a code list of 160 different tasks encountered in ward work, which gave some idea of the specialised undertakings of nurses within the mental health service. The report explains what kind of work they did in following this code through. A specially designed observation sheet was compiled, listing the activities performed with a code list relating itself to the 160 different tasks. The sheet also indicated how much of the nurses' time was spent in activities unconnected with the patient, how much time was spent in activities connected with the patients as a group and how much was occasioned by the specific behaviour of an individual patient. All this information was broken down.
The main points raised by this statistical analysis and by direct observation of the working of the wards are reviewed under headings which cover the division of tasks, the problem of supervision, the position of the nursing assistant, the use of part-time staff, the hours of work, the training of student nurses, the problem of incontinence and, finally, patients' category analysis.
I will not bore the House with the details of the report, which is easily available through the Hospitals Year Book and the body which promotes it. The point is that it was found that most nursing time was spent in satisfying the needs of the patient for comfort and general well-being and the maintenance of his physical health. It was also pointed out that patients in mental hospitals need almost constant supervision. This supervision can be given very adequately by nursing assistants who in many cases have long experience and know their patients very well.
But the main point which is made in the report, apart from breaking down what should be the role of the nurse responsible for mental nursing, is that it was made clear that many of the nurses who were specifically there to give patient comfort and patient care were absorbed in many tasks which were rather wide of the mark of what we would 1666 regard as the essential rôle of a specialised nurse in a hospital today.
We come back to this principle. In our task of recruiting nurses for the profession we must make sure that they are using the specialised training which they have received in the training hospital for the specific task of nursing. We must do all we can to ensure that we also raise the status of the people to whom I have referred, who are extremely difficult to recruit and who render valuable although relatively minor service within the hospital service. As the report points out, we are concerned not only with holding the staff but with making sure that, once they are trained, we can add to the staff and add to our techniques of giving the service, thus making sure that patients in mental hospitals are well cared for and that the right people do the right jobs.
§ 12.20 p.m.
§ Mr. Edwin Wainwright (Dearne Valley)
I should first like to congratulate my hon. Friend the Member for Rother Valley (Mr. David Griffiths) on his luck in the Ballot and on selecting this very important subject. Mental health facilities have been described as the Cinderella of the hospital service in this country and are probably the Cinderella of hospital services throughout the world. This is a great pity, because people who suffer from mental sickness require a great deal of sympathy from those who are mentally normal.
I got up a little early this morning and read the article in The Guardian. Much of my thunder has now been stolen, but this is an article which is greatly disturbing and I want later to refer to it. If the type of hospital which it describes is typical of our mental hospitals, it is a criticism of our society. It is no use making comparisons and concluding that our mental health service is far superior to those of other countries if this sort of thing is the criterion of the mental health service in this country. This is a shocking state of affairs and the article shook me tremendously.
There are varying degrees of mental sickness and I sometimes wonder whether we are spending enough on research. We ought to try to prevent mental sickness from occurring in people who are born with normal brains and minds. I have 1667 met people who have first suffered from a nervous breakdown which, by unfortunate progression, has led to mental sickness. I have spoken to some who have been fortunate enough to go to hospital and recover. They have described to me going into a dungeon, into the darkness, with their minds almost a complete blank, of being afraid to meet people and ignoring their friends and with their confidence entirely gone. Because of the treatment they have been able to receive, they have been able to resume normal life and are now living and working as ordinary citizens. It is not so long ago that people of this kind never came out of hospital, so that we have made some progress.
However, we ought not to give the impression that we are complacent about the progress which has been made in curing the mentally sick. Even in the year 1962–63, there was an increase in the number registered as mentally sick. Although the Ministry of Health Report for 1963 seems to be quite happy about the number of new places being provided in our hospitals, we are still not providing enough to meet the growing number of mentally sick. The Report says that just over 4,000 beds were provided in that year, but there was an increase of 6,000 new patients and there is a shocking waiting-list. It is also noticeable that there is a shortage of places for boys and girls up to the age of 16. If we cannot cater for young people suffering from mental sickness, we must do more than we have been doing, for these figures are a terrible criticism of what we have done so far.
The article in The Guardian is by a consultant who is unnamed but who could easily be traced if necessary, so that what he says is obviously the truth. The article talks about barnlike and Victorian buildings housing patients, the lack of toilet facilities and the lack of washing facilities. It says that the patient may see his doctor only once a year, that the junior doctor may see 20 patients in his 2½ hours at the hospital and the senior doctor only 10. If the senior doctor has to examine ten patients in 2½ hours, he does not have enough time to give each case the individual attention which it should have.
1668 The writer of the article says that those who suffer from mental sickness have no power to state their opinions about their lack of treatment. He says:In fact, who is there to complain? The patients who know are often too incapacitated to talk. Articles on community care, the therapeutic community, wonder drugs and the supposed advances of the recent Mental Health Act have little meaning to the wretched individual, suffering from chronic schizophrenia, and abandoned in a cheerless Victorian mausoleum with ninety fellow sufferers and one nurse to keep an eye on them all. Once a year, of course, he may see a junior doctor.People in the well-off section of the community make certain that their sufferers get the best kind of attention. I hope that the Government will reverse this trend of the increasing number of patients who are unable to provide for themselves and will make certain that anyone suffering mental sickness, regardless of his capacity to pay, shall have suitable accommodation and the best of treatment. If we cannot do more than we have been doing, we do not deserve the confidence of the nation. Although we have had 13½ years of Tory rule following six years of a Labour Government and before that many years of rule by Toryism, none of us, regardless of party, can be satisfied with the progress which has been made.
§ Sir David Renton (Huntingdonshire)
Surely the hon. Gentleman must acknowledge that the Mental Health Act, 1959—I think it was—which was a Conservative Government's Measure, was one of the greatest departures that this country has made in achieving a new approach to the problem of mental ill health.
§ Mr. Wainwright
I am grateful to the right hon. and learned Gentleman for making that intervention. Keir Hardie once said that the Tory Party had introduced more social reforms than any other political party in the country. That is quite true, but the Tory Party, of course, has been in power in the country far longer than any other party. However, the Tory Party only introduced social reforms because of the pressure exercised by other political parties on behalf of the people of this country. If anyone wishes to dispute that he has only to check what is the present condition of a good many sections of the community today and the kind of treatment which 1669 we keep arguing in this Chamber that they ought to have,
I do not want to give the impression that this matter ought to be the subject of a battle betwen the parties in the House in order to obtain further progress on behalf of mentally sick people. We in the House ought to be united on this issue and in saying that these people deserve all the attention we can give them because they are so unfortunate as to be mentally sick. Therefore, we as a House of Commons ought not to be debating differencies between the parties on the subject but should be working on the issue as one unit in order to make quite certain that these people receive the best possible treatment.
On the subject of elderly people, I believe that this is something where the community as a whole fail their neighbours on many occasions. Nothing is more harmful to the mental stability of a person than reaching old age and suffering from loneliness. Loneliness brings in its wake mental sickness and, therefore, more ought to be done by the community and by the Government to correct this state of affairs. It is a terrible indictment of many neighbours of elderly people that they should allow so much loneliness to exist among them. We can do more, of course, by way of providing hostels where necessary, and this should be done. Many elderly people, however, prefer to stay in, perhaps, their little cottage or flat instead of going to a hostel where they would have companionship. These people ought to have the due consideration of members of the community.
A lot of voluntary work is being done, and I think that my right hon. Friend ought to consider helping any section of society which is catering for the needs of the elderly. This question of mental health has got to have more and more attention paid to it by the Government. Before I sit down, I wish to say a few things about the salaries paid to the staffs in mental hospitals. It is quite obvious that we are not attracting into those hospitals a sufficient number of people who are qualified to do that type of work.
I understand that a person can be accepted for training for a mental health post without having the G.C.E. standard. This is the only section in the nursing 1670 profession, so I am informed, which can be so accepted for training. It is quite obvious, therefore, that the salaries paid to such people will be lower than those paid to ordinary nurses. Something should be done to ensure that these salaries are increased. [Interruption.] The hon. Member for Hertford (Lord Balniel), who is sitting on the Opposition Front Bench, mentions salaries. They are higher than they were, but they are still not attracting the right people. That being so, some criticism can be levelled at both the previous Government and the present Government for not making certain that the numbers of those applying for training in mental health work are increased.
§ Lord Balniel (Hertford)
I am sorry to interrupt the hon. Gentleman, but I am not quite sure that he rightly interpreted my aside. It was, in fact, an inquiry as to what are the salaries of nurses in mental hospitals. I think that there are special inducements for those who want to nurse in mental hospitals.
§ Mr. Wainwright
I should hope that that is so, because, it requires more training to be successful either as a nurse or a member of other staffs in mental hospitals. These people must have the temperament essential to deal with mentally ill people, and it is quite obvious that longer training in this branch of nursing is necessary. I hope that we shall look more and more into the problem of trying to increase the number of psychiatrists, doctors and nurses in our mental hospitals.
In conclusion, let me say that this is a very kind Motion. There is no criticism in it at all. It praises what has been done in the past and looks forward to what is going to be done, we hope, in. the future. I hope that the whole tone of the Motion is accepted by the Government and that we shall see a great improvement in the quality of the buildings and of the staff in our mental hospitals.
§ 12.38 p.m.
§ Mr. George Wallace (Norwich, North)
This is a most important debate and I personally greatly regret that it has to take place on a Friday, when the attendance in the House is not so high as on other days. This is a subject that has been brought home to every hon. Member at some time or another during the course of their constituency work. 1671 We have all at times had in our "surgeries" a difficult case to handle concerning, frequently, the vain appeal for the release of some mental patient or another. It does not need any words of mine to underline the pathetic anxiety of parents of a child who has been in a mental hospital for some time.
I have not had any professional or expert experience in this subject or in a hospital, but as in the course of one's duties one comes across these cases one has to find out for oneself. I have visited a number of mental hospitals to see for myself, and I must say that the standard varies from hospital to hospital. Where there is a large proportion of voluntary patients the standard is far higher than in the general mental hospital taking all types of patients and a higher proportion of certified cases.
I agree with the hon. Member for Kingston upon Hull, North (Mr. Solomons), who has left the Chamber, and others that some of our older mental hospitals can only be dealt with properly by being pulled down and completely rebuilt on modern lines.
When visiting one of the larger hospitals, the first thing that is drawn to one's attention is the overcrowding and the aimless wandering of patients along corridors which one hon. Member has described as being akin to a prison. I have never visited a prison, but if a prison is like that it must be a fairly desperate sort of place.
In many areas, the lack of accommodation and overcrowding is an extremely serious matter. It is serious from the viewpoint that it is desirable to segregate various types of patient. I can say from experience that, due to overcrowding, that segregation is not taking place. Only recently, I have been trying to deal with a case in which an allegation of sexual assault was made by a patient's parents. The patient is mixed up with other types, and that kind of danger is always evident when overcrowding exists.
We have talked about staff shortages, but we certainly have not paid our tribute to the staffs of our mental hospitals. I have seen scenes that would almost bring a lump to one's throat, of the pathetic devotion that patients have to their nurses. I have in mind the matron of one large hospital who would walk 1672 through the wards and the women patients would come to her and be satisfied at the touch of their hand on her cloak. That is no exaggeration. Many of these nurses and doctors are giving devoted service under conditions of extreme difficulty. Many of them are devoting their lives completely to this service.
I should like to pay my tribute also to another section of the staff who never hit the headlines, and that is those members of mental hospital staff who are engaged in the training of patients in some kind of craft. To anybody who cares to visit one of these large hospitals and sees the results achieved in training what, to some, would appear to be impossible types to train, it is incredible what can be done in assisting these people to some extent to become useful members of society by reason of the fact that they are producing something. I have in mind some difficult cases who produce envelopes, doing little jobs which they have been taught with great patience and time, which at least helps to make them to some extent useful members of society.
When I saw that my hon. Friend the Member for Rother Valley (Mr. David Griffiths) was moving this Motion today, the main point to which I felt that I should like to draw attention was the need for the extension of out-patient facilities in our general hospitals for those who, for various reasons, are in need of treatment for mental illness of some type but who are not sufficiently seriously ill to warrant their admission to a recognised mental hospital. It is true that in recent years considerable advance has been made, but it is not enough. In some general hospitals there are facilities in the out-patient department for out-patient treatment and there is no visible indication of the type of treatment that is given or that it is treatment for mental cases. That, of course, is desirable and essential, because even in these enlightened days there is still a certain amount of stigma attached to this type of illness.
A further reason that prompted me to bring in this point was an experience which I had some years ago, when I was formerly a Member of the House before my absence of 15 years. Things have changed in the treatment of mental illness even in 15 years. On the occasion which 1673 I recall, I was approached by a worried justice of the peace who, during the course of his duties, had been called in to certify a young girl for admission to a mental hospital. He had the good fortune to be married to a very determined woman of great perception, as, indeed, most women are. When he reported to his wife what he had done, she called him several names and said to him, "Go and get that young girl. Bring her to this house and I will look after her." Flaying signed the order, the justice of the peace was in great difficulty. However, he did as his wife told him and then he realised that he was really in trouble. That was why he came to me.
The young girl was taken to his home. The wife of the justice of the peace said that there was nothing wrong with the girl except that she had been crossed in love. That, unfortunately, frequently happens and introduces a mental state. But for the intuition of that woman, the girl might have been admitted as a certified patient of a mental hospital, where, because of overcrowding, she would have mixed with other patients and might even have been there now. That is a case which came to me during the course of my duties as a Member of Parliament.
I often wonder whether people are admitted to our mental hospitals who should not be admitted at all and who should not he there today. It is said, more in jest than anything else, that some of the devoted medical staff often get like the patients themselves, but I agree that a lot of medical staff in our mental homes are good characters. One of them whom I know used to "run a book" on the General Election, but, unfortunately, I let him down and he gave it up.
We live in enlightened days, but although the stigma of mental illness has to some extent gone it still exists in many quarters. Our effort must be to try to remove that stigma by complete reorganisation of our hospital system and by the provision of greater out-patient facilities.
On the subject of recruitment, it is not every nurse who wishes to go into a mental hospital. Indeed, not every nurse wants to nurse the geriatric sick. It is often a fairly tough job. It is, however, obvious that recruitment will never be improved until we have improved the 1674 conditions, both conditions of working and conditions of service.
In my non-expert way, having seen some of the service in operation, having met the relatives of many patients, having met and talked to many patients and having seen something of the whole setup, I have come to the definite conclusion that there has got to be a complete rethinking of our approach to this problem and to this service. There has got to be a complete reorganisation of the whole set-up so that we save quite a large number of people from being in hospital far too long, often not getting out at all, and so that we turn people who are temporarily mentally sick into useful members of society. It is said that genius is akin to madness, and it may be said that there are some in prominent positions who, in certain circumstances, might have been in mental hospitals. That, however, is a point which I do not wish to pursue.
This is a most important debate. It is only too true that this service has been the Cinderella of the National Health Service for far too long, and that the time has come to pay more attention to it. We must provide greater facilities for the treatment, on modern lines, of this form of illness, from which, in many cases, people can recover and be restored to society fit and in a proper state of mind.
§ 12.50 p.m.
§ Mr. Julius Silverman (Birmingham, Aston)
I want to raise an aspect of the mental health service which has hardly been touched upon so far but which is extremely important, namely, the question of community care. It has already been said that radical changes have taken place in the treatment of mental patients in hospital. People who some years ago would still have been in hospital are able to be discharged, and the number of beds in mental hospitals has drastically declined. It is hoped that by 1975 there will have been a reduction of about 50 per cent. in the number of such beds.
This development involves certain consequences for the community, outside the hospitals. It must be borne in mind that in many of these cases there is not a radical alteration in the patient. Notwithstanding the advances in psychiatric medicine, modern drugs and modern 1675 methods of treatment, only in comparatively few cases do we get the sort of dramatic cures of other types of illness that are obtained with modern surgery or medicine, as a result of which people emerge from hospital completely cured. In mental health more often the job is to abate the illness and to assist the person concerned to take his place in the community, functioning as nearly as possible as an ordinary member of the community. In this sense the psychiatrists in hospitals are performing not merely a medical but also a social function.
What we have to ask ourselves is what happens when the patient leaves hospital. It is in this respect that existing provisions are in many senses inadequate. It is not surprising that we have the number of relapses which have already been mentioned by my hon. Friend the Member for Kingston upon Hull, North (Mr. Solomons). He referred to a figure of 43 per cent. At the moment there is not sufficient support, assistance and contact to enable the person concerned to keep out of hospital and function as a member of society.
Paragraph 709 of the Royal Commission on the Law Relating to Mental I11-ness, 1954–57, says:We consider it essential that the central direction of the community services for mentally disordered patients should be in the hands of the medical officer of health"—that is, the local authority—He and his staff (medical and administrative staff and social workers) hold a key position. As well as providing general help and advice to individual patients and their relatives, and helping to arrange for them to obtain whatever specific forms of care seem appropriate to their needs, they should take a comprehensive view of all the services which may contribute to the promotion of mental health and the relief of mental disorder. The medical officer of health should stimulate the development of any services which serve this end and are the local authority's responsibility, even if such services are not directly administered by his own department. He and his staff should also work in close co-operation with the general practitioners and the hospitals and be in touch with the staff of other local authority and government departments which provide other general social services, such as the youth employment officers, disablement resettlement officers, children's officers, probation officers, and the staff of the education services, National Assistance Board, etc. They should also be in close touch with voluntary associations and societies. In our view it is 1676 essential that this central organising and individual social work should be recognised as part of the responsibility of the medical officer of health. Its vitality and efficacy will depend to a large extent on whether or not he takes an active personal interest in it … it does not seem to us to be so important to decide whether the more specific forms of care, such as social centres, workshops, occupation centres, training centres and hostels, should be provided under health or welfare powers.That is in accordance with what I have said, namely, that this is both a medical and a social problem, and nobody can say exactly where the boundary lies between the two ways of dealing with the problem.
This is largely an aspiration which is still not achieved. We do not have a sufficient number of social workers outside the hospitals to help these patients. We do not have a sufficient number of psychiatrists who are doing domiciliary work and keeping in contact with these patients. We do not have a sufficient number of home helps to assist them in coping with their problems, and we do not have a sufficient number of home nurses to keep them out of hospital. These services must be drastically extended.
One of the suggestions made by the Royal Commission—and some local authorities are probing towards this—is that those people who are discharged from hospital and who receive substandard wages but are not entitled to National Assistance should receive a financial grant to enable them to take their proper place in the community. All sorts of other possibilities are open if that primary facility is given. I hope that the Minister can tell us what is being done in this connection, and what consultation he is having with his right hon. Friend the Minister for Housing and Local Government on the matter, in so far as it comes within his responsibilities, because this is an integral part of the National Health Service.
It may be said that local authorities are not likely to go too far in this direction too quickly, because of the pressure upon the rates. This provision should be the subject of adequate Government assistance. If it is said that in these times of economic pressure we do not have sufficient resources to enable us to devote money to this end, I entirely disagree. In my view such assistance would 1677 prove to be an economic way of dealing with the problem. A cash grant given to a person to enable him to keep out of hospital saves a large sum of money—perhaps £16 or £20 a week—which would otherwise have to be spent upon him in hospital.
In the long run what I have suggested would mean not the spending of more money but the saving of more money, quite apart from the valuable social function which we would be able to fulfil. I hope that the Minister will deal with this very important part of the mental health service—the question of community care and its extension, and the need for providing adequate facilities by local authorities and other bodies to perform their proper function in this respect.
§ 12.59 p m.
§ Dr. David Kerr (Wandsworth, Central)
I am grateful to my hon. Friend the Member for Rother Valley (Mr. David Griffiths) for bringing this matter before the House. It is a matter of some regret to me that the necessity to do the field work in respect of the subject that he is raising deprived me of the opportunity of hearing his introductory remarks.
If I may digress for a moment, perhaps it would help the mental health of those who sit in this Chamber—assuming that we are not beyond all redemption—if somebody could devise some sort of instant official record, so that no one was deprived of the opportunity of hearing remarks such as those that were made in my hon. Friend's introduction. We should then have an opportunity of garnering the harvest of a Member's thoughts before we came into the Chamber, perhaps boring our friends even more into the ground by reporting what had been said.
Fridays present a curious contrast in the sort of attendance which they attract. It seems that my idea for an instant HANSARD would be so useful when, as is bound to happen on future Wednesdays, we discuss, in a sense, an extension of the Motion before the House today. How very useful it would he for all those hon. Members of the Opposition who will find it an occasion to come in late and whose mental health will suffer from anxiety about the care of their affairs outside the House.
1678 Be that as it may, we must disabuse ourselves of the idea that the drama of mental health lies somewhere between this House and mental hospitals. It is quite true that the state of the mental hospitals is a matter worthy of articles in The Guardian and even, perhaps, in The Times. It is also true that the great bulk of mental illness of the really florid and dramatic sort, which is expressed by cases of people who think that they are a fried egg, or King Canute, or Napoleon, continues to demand treatment in mental hospitals.
With great respect to my hon. Friend the Member for Birmingham, Aston (Mr. Julius Silverman), it is not true any longer to say that mental hospitals do not produce these dramatic cures. They do. One of the most important aspects of progress towards mental health is precisely the extraordinary change which has come over the whole therapeutic field.
§ Mr. Julius Silverman
I was not suggesting that there are not dramatic cures. I was saying that over the largest fields of mental illness, this is still not the case.
§ Dr. Kerr
Alas, I must acknowledge that this is perfectly valid.
I want to continue this argument by reference to a much broader consideration of the question of mental health. The Motion is expressed in broad terms, but in so far as I have been able to hear the debate today I think that we have confined ourselves rather narrowly. I am grateful to my hon. Friend for extending it a little further into the subject of community care. How right he was when he emphasised this. An hon. Member opposite rose in defence of the Conservative record by referring to the 1959 Mental Health Act.
I am in no way behind him in applauding the aims of that Act. It was, without doubt, one of the most praiseworthy Measures of social reform which we have seen introduced. I would remind hon. Members of the Opposition—such of them as are represented in this important debate—that that Mental Health Act had the greatest support from this side of the House. But once it was on the Statute Book, what a different story there was to tell. What a story of "passing 1679 the buck" from the State supported hospital services and trying always to force these people, with the excuse that they needed community care, on to the rate-aided services provided by the local authority. Is it any wonder that those who welcomed the provisions of the Mental Health Act began to regard it as a piece of political window dressing? The potentialities remain, but the actualities are no longer there.
In 1948, the local health authorities, which were then the great municipal hospital authorities, handed over, without more than a sigh of regret, their buildings, staff, records and good will to the National Health Service. This, of course, included the vast majority of mental hospital beds. Before 1948, it was the municipal health authorities which were responsible for providing mental hospital beds. There were very few provided by voluntary services, by the so-called voluntary hospitals. Yet, in 1959, when a new burden of provision was placed on those local health authorities, what help did they receive in terms of capital, in terms of return of unused buildings, from the then Conservative Government? What possibility lay open, particularly to those local health authorities responsible for large urban areas where sites were scarce and land values high, to enable them to provide establishments such as hostels for the mentally sick discharged into the community, sheltered workshops, and new offices for mental health services? This was the challenge put before before the local health authorities.
When we come now, as a new Government, to look at this problem we should look particularly sympathetically at the community care services. Of course, in very close collaboration with the community care services provided by the local health authorities must be found the general practitioner. It seems to be a fashion to quote from documents, so I make no apology for referring the attention of the House to the report of the Annis Gillie Committee on the Field Work of the Family Doctor. In a particular section dealing with the rôle of the family doctor in the mental health services, a paragraph says:The present trend towards community care for the mentally disordered usually means care in their homes. This puts a heavy and increasing 1680 load on the family doctor, who must be in charge of the patient. All the services at present often inadequate) provided by clinics, hospitals, local authorities, employment officers and voluntary workers exist to support the family doctor and should be co-ordinated through him.At the same time, I am reminded of the Sherlock Holmes story about the dog which did not bark. This has been the operative factor throughout all our discussions this morning, and, indeed, throughout so much consideration of the problems of the mentally sick. When we talk about community care services, when we talk about mental patients, the dogs which do not bark in all these considerations are the very people who, in so many ways, are most adversely affected by mental illness—not the patient himself or herself but the relatives, the family, who have the responsibility, who have to suffer the embarrassment, the anguish, the anxiety and, often, the physical burden of caring for the mentally sick patient.
We should do well to bear this in mind when talking about community services. Certainly, the Royal Commission on the Law Relating to Mental Illness and Mental Deficiency produced such a magnificent Report based on the evidence provided by many Socialists and Socialist supporters who work very hard in this field. I do not want in any way to decry the magnificent record of service, thought and idealism which went to the compilation and construction of that Report. It swung the pendulum most vigorously away from mental hospitals, which, over many years, had acquired a well-justified reputation for dinginess, often for lack of light and with untrained staff. Even so, that swing of the pendulum has already found a genteel kick-back towards the importance of mental hospital care. We have a very grave responsibility in this House for the determination of national policy. At some moment, having regard to what advice and technical assistance is offered to us from so many valid sources, we have to make up our minds what is the appropriate policy to pursue.
In the last few years, this constant seeking for more and better aspects of community care has led in many cases to increased burdens placed upon the families, and, inevitably and as a consequence, on the patients whose care we are trying to bring outside the hospital service. In a recent municipal health association 1681 conference on the theme, "The Distant Goal"—held about two years ago when we had begun to feel the effect of the working of the Mental Health Act of 1959—we detected the first clearly-expressed and well-documented doubts about this uncritical discharge of mental patients from the hospitals to the community care service.
It has been said that we must be very careful that when we unlock the doors of the mental hospitals we do not turn them into revolving doors. Already, we are beginning to discern that this is one of the potentially wrong consequences of the Mental Health Act, 1959. We have to take another look at this, and I hope that when the Minister replies to the debate he will find an opportunity to indicate whether, and if so, how, he is shifting the centre of gravity a little way from this constant chase after better community care service.
Having said that, I should not like anybody to interprete my remarks as being in any way critical of the importance and value of community care service. In the topicality of today's extraordinary news about how one can turn a somersault in space, attached by an artificial umbilical cord to the uterus of a space ship, I am prompted to reflect on the importance in the generation of mental illness of isolation.
Certainly, the demand for mental health services are increasing. It is not only that, by dealing so effectively, as we do today, with the great field of physical illness we are allowing the occurrence of metal illness to expose itself above the social line. There is more to it than that. The stresses of today are giving rise to an increased burden of mental illness which is manifesting itself in many different ways.
When we talk comprehensively, as we do in the House, about a subject such as mental health, we must be very careful not to overlook that it does not mean one particular thing. We are talking generically. When we are talking about mental health and mental illness we are talking about a whole range of disorders. At the one end we are talking about the chronic schizophrenic paranoid, the man or woman who, as I suggested, thinks of himself or herself as a fried egg or King Canute. There are the psychotics, at one end of the scale 1682 —or perhaps I should not call it a scale; perhaps it is best described as the interconnecting circle of mental illness.
At the other end is the enormous burden of neurotic illness which is born almost entirely by the general practitioners of this country, who are untrained, who deal with the problem empirically and whose opportunities for postgraduate study in this matter are severely restricted. There is no doubt that the greatest number of cases of mental disturbance of any sort are those which find their way into the surgery, and out again partially or wholly healed.
This is a matter which has caused many of us the gravest concern, and I hope that the Minister will reflect on the needs which have been clearly shown time and again to revise the curriculum of the medical students. I am well aware that that is beyond his powers, but no doubt he will consult his right hon. Friend the Secretary of State for Education and Science to see how we can encourage the General Medical Council and the medical schools to provide a medical education which is more closely applicable to the type of mental practice which so many newly qualified doctors will be embarking on one day.
That is the first thing. More important, however, is to ensure that the British Medical Post-Graduate Federation and the peripheral medical schools and hospitals are encouraged to provide new post-graduate opportunities for general practitioners to seek an opportunity to acquire knowledge which is changing daily. Of all the dramatic changes in treatment which we have witnessed in the last 20 years, and which have been such a source of confusion for the poor family doctor like myself, there have been no more dramatic improvements than those which we have witnessed in the drug treatment of mental illnesses.
Much of the research has been done in this country and we can be very proud of it. I want to be honest about this, for I am as critical of the pharmaceutical industry as is anybody else. But we must acknowledge that the industry's contribution to the advance in drug treatment for mental illness cannot be dismissed. At the same time, the vast amount of research in this topic which is done in our universities, our hospitals 1683 and our own academic laborataries is a matter not of satisfaction but of mitigated pride in the British contribution to this field.
As the same time, this sort of research is going on all over the world, and this daily increase in knowledge, in new techniques and in new approaches bears very hardly on the overworked practitioner. Unless we can increase the amount of time which is devoted, in the series of post-graduate courses available to him, to mental health post-graduate re-education, we shall overlook a most important sector of his work.
I have referred to two aspects, and two aspects only, of mental health—psychosis and neurosis. On the fringe of mental health problems at one end lie the long arm of the law, Rampton and Broadmoor, and the sort of fringe no-man's land between the criminal, the psychopath and the mentally disordered person, perhaps the mentally subnormal. This leads me to another very important aspect of mental health which has not even been mentioned today—the problem of the mentally subnormal. Here we face an enormous dilemma. Here we face the dilemma of trying to apply some financial judgment, some sort of monetary value, to the social work which we on this side of the House, and I believe many hon. Members opposite, want to undertake.
What is the social value of assisting the mentally handicapped child? I think that many hon. Members could spend a very useful morning visiting some of the all-too-scarce hospitals which take these children within their portals. Many of them are children only in terms of mental capacity. Many of them are adults in terms of their birth certificates. But these are some of the greatest human tragedies.
I referred a few moments ago to the problem of families which have within the family circle the mentally sick. There is perhaps an even greater tragedy, and that is of the family which discovers that it is producing a mentally subnormal child. Here there is no hope of a cure. One cannot cure a deformed being, a deformed creature, whether that deformity is of headline character, such as the thalidomide babies born wïthout 1684 limbs—and what a tragedy that is—or whether the deformity is not apparent anatomically but manifests itself in the slow progress of the child and its failure to achieve the normal intellectual milestones which the average among us achieve. The gradual awareness—sometimes it is not so gradual but sudden—which afflicts a family is a very great tragedy indeed.
There are very few opportunities to deal with the problem available to families who find themselves in this position. There are mental welfare officers and almoners, but the services are scarce indeed. As time goes by and new demands for social services call for greater numbers into these services, it seems that there can never be enough social workers, trained and experienced in this field, to deal with all the problems which we know exist. As society becomes more sophisticated and as it studies itself more closely and discerns its own problems, it throws up new problems which it finds itself quite unable to answer. We have now the problem of the mentally subnormal child. Some of the most magnificent and unannounced research in this problem is done in this country.
May I refer particularly to the work done at the Fountain Hospital, by Dr. Hilliard, Dr. Kirman and others and the work being done at Queen Mary's Hospital, Carshalton, to which the Fountain Hospital was, in my view, mistakenly removed some years ago. There is dramatic work going on in educating the very subnormal children not very far from this House.
One of the most impressive and encouraging things which I have witnessed in recent years was at the Junior Training Centre at Fulham. There, children whose mental capacity had hitherto put them beyond any hope of formal education showed themselves able to read and to calculate. Of course, they will never be programmers for computers; they will never be journalists. But they have taken a step towards independence and a step away from social and family burden which we must take into account.
This brings me back to the point which I was making a short time ago. This imposes on us a new financial judgment, a new monetary difficulty. Education such as this cannot be done with oversized classes of 30, 40 or 50 children. 1685 It must be done by one devoted, patient teacher with four or five children under her care. Can we afford the manpower, or womanpower, to devote to this project? Do not we have to establish a priority which gives such devoted teachers to primary schools and such skills to secondary schools and such abilities to universities?
Do we have the right to recruit and train people to deal with this social problem? Some means must be found for this society for which we make our-serves so arrogantly responsible to be able to take that decision. We cannot opt out of it, because the dividing line between neglecting the mentally subnormal and putting them in a gas chamber is very fine.
Am I expressing myself too strongly? I think not. Either the community so organises itself that it can provide the care and, more than the care, the opportunity for this range of mental sickness and mental subnormality or there will be a stain on the community because it is devoting its financial and manpower resources to the wrong ends. This is perhaps a simplification. But we are all entitled to simplify. We do it all the time. We would not understand one another if we did not simplify our arguments from time to time.
None the less, there is no greater gap between what is needed and what is provided than in this field of the mentally handicapped child and adult. It is no use talking about community care for many of them. Some of them are incapable of being left to care for themselves, even to the point of feeding themselves. Society must accept this. But we must never take the view that they are rejects which must be allowed to fester away and die.
In a curious way, we are back to the very simple attitude of some of the most primitive communities. The most primitive communities accept as part of their responsibility the mentally subnormal and mentally sick. In some of them they are worshipped as being possessed by gods. I am not suggesting that we should go as far as that, but certainly we need have no regrets in accepting responsibility for these people who are explicitly unable to demand for themselves the services which they need and can do it only through people like us. If it means that 1686 others must have something pared off their needs and provision, then I think that this must always be the touchstone of our approach to community needs.
It is not only in this rather florid field of the mentally subnormal child that there are many degrees of mental sub-normality. There are many children who are more than educationally subnormal who grow up and can find some sort of occupation provided that they are given adequate training. In Clapham, the London County Council's Industrial Centre is busy producing goods on a simple production line system and making use of the services of boys who are not educable in a school sense but are sufficiently possessed of mental ability to be able to learn these tasks.
The interesting thing from the social point of view is that their general behaviour and general attitudes have improved vastly since they have been engaged in some creative activity together. This has a lesson for all of us. None of us is so happy as when we are together in the House indulging in creative activity. In this respect, we have a certain similarity to these unfortunate people. But we need much more of this. In Bristol, York and, I believe, Oldham and a number of other places this problem has been, not dealt with, but approached; somebody has dipped his toe into the cold water. But we are nowhere near satisfying the needs.
I do not think that we should be seduced by the idea that the mentally subnormal can be justified in the care which we provide for him only if he returns something to the community. We must accept the idea that there are people who are mentally ill, such as the bad schizophrenic who is in hospital all the time, who will never make any contribution to society. They will live on society as parasites, and as parasites we must accept them and cater for them.
Lastly, I wish to say a few words about the staff who are responsible for these people. My hon. Friend the Member for Stockport, North (Mr. Gregory) drew attention to the administrative difficulties of mental nursing. I regretted that he made no reference to the particular problems of nursing severely subnormal children. Of course, they are finding their way into the 1687 community, but largely because of pressure on beds, hospitals cannot always take even severely subnormal children. Remarkable work is being done in day nurseries in the London area and elsewhere in trying to make very young severely subnormal children part of the complement of the nursery. This is a way of helping the parents.
The work of the staff—and let us not overlook the parents—should not go without some measure of consideration from the House. We should be very wrong not to pay tribute to the devotion and self-sacrificing attitude of many of the nurses and doctors who work in this apparently hopeless and endless field of endeavour. They should receive a very warm and hearty vote of thanks from this House. It is with people of this calibre in mind that we should take some hope when we look at this rather dismal and undernourished problem of mental health. Above all, let us remember that we have made dramatic and encouraging progress along a very long and dusty road.
We on this side of the House are confident that the leadership of the Minister will carry us very much further in the next few years.
§ 1.29 p.m.
§ Lord Balniel (Hertford)
It will probably be for the convenience of the House if I intervene at this stage. I do not wish in any way to curtail the debate, but I understand that the Minister has a pressing engagement later in the afternoon which might necessitate his leaving the Chamber.
I want to begin by warmly congratulating the hon. Member for Rother Valley (Mr. David Griffiths) on having taken such good opportunity of his winning the Ballot to bring to the attention of the House our mental health services. It is now some time since we have had a debate in the House on the mental health services. The House appreciated, not only the fact that the hon. Gentleman spoke from his experience of mental hospitals in the West Riding, but also the sincere and moving way in which he opened the debate.
The Minister has for many years been a forceful critic of the mental health services. Although we have sometimes been 1688 at the receiving end of the criticism, we have always appreciated the consistently constructive approach that he adopted. Whatever might be the political differences which lie between us, I think that I can speak on behalf of the whole House, as this is the first debate we have had on the mental health services since the right hon. Gentleman assumed the office of Minister of Health, when I say that we have a great personal pleasure in that, after such a long interest, the right hon. Gentleman has now assumed responsibility for these services.
I cannot conceive that this is a subject on which any political differences can arise between us. The scale of effort which is required to meet the challenge this problem presents is one which can more than absorb the united energies of the Opposition and the Government.
The debate has inevitably covered a very wide field. It has covered the special custodial hospitals such as Broad-moor, Rampton and Moss Side, which were referred to by my hon. Friend the Member for Wokingham (Mr. van Straubenzee). It has covered the building programme of hospitals, training centres and hostels. It has covered the staffing problems which exist in the mental health service. As in a short debate one cannot cover the whole range of services, one is bound to confine one's remarks and highlight just one or two specific matters of importance.
The first matter to which I should like to draw the attention of the House is a matter in which the Minister has taken a deep personal interest. This is the provision of in-patient accommodation for mentally ill and seriously maladjusted children and adolescents. The House will remember that on 8th January, 1964, the Ministry issue a circular about the provision of in-patient accommodation for seriously maladjusted children and adolescents.
The circular suggested that the initial aim should be to provide beds for assessment and relatively short-term treatment of seriously maladjusted children at the level of about 20 or 25 per million of the population. The circular also suggested that there should be a provision of 25 beds per region for long-term treatment of seriously maladjusted children. It further suggested that the provision 1689 for adolescents should be increased to 20 or 25 beds per million of the population.
These suggested figures may seem to the House to be a very small provision, but, none the less, it is a marked improvement on the existing provision. The existing provision is that over the country as a whole there is a total of 370 beds for seriously maladjusted children—that is, approximately 8 per million of the population. There are at present only about 7 units for adolescents, providing a total of 157 beds.
The Ministry circular has been very warmly welcomed by those interested in the problems of seriously maladjusted children, because, although the numbers suggested might seem very limited, the needs of these particularly unfortunate children are very urgent indeed.
I have the honour of being Chairman of the National Association of Mental Health. One of the activities which the Association has followed in recent months has been to undertake a survey of what is in fact the planned programme of the different regional hospital boards in attempting to meet the request put forward in that Ministry circular. Clearly, our resources for undertaking a survey, as we are no more than a voluntary organisation, are limited. None the less it would be less than frank if I did not tell the Minister that we have been very disturbed, indeed almost appalled, at the low priority which is being given by regional hospital boards to the provision of in-patient accommodation for seriously maladjusted children.
I will give an example of this by calling to the attention of the House something which affects my own constituents and something in which I happen to know the Minister has himself taken a deep personal interest in the past. At High Wick, there is a unit for seriously disturbed children. If my memory is right, it takes children up to about the age of 10 or 12. When these children leave the High Wick unit they will either return to the community and, one would hope, receive training in junior training centres, or alternatively, if they are not fit by that time to return to the community, they will have to receive in-patient treatment and care in the adult wards of a mental hospital. I do not think that it is necessary for me to emphasise how unsatis- 1690 factory is the position when seriously maladjusted children or adolescents have to receive in-patient treatment in the adult wards of mental hospitals.
It had been planned that a special unit for psychotic children and adolescents should be established close to St. Albans, which would provide the children from the High Wick unit with special treatment. The building of this special unit, which was originally planned for 1966, has unfortunately had to be deferred by the North-West Metropolitan Regional Hospital Board. Recently, my hon. Friend the Member for St. Albans Mr. Goodhew) asked the right hon. Gentleman why this special unit had been deferred. The right hon. Gentleman said that the reason was as follows:Because in the view of the regional hospital board other schemes had higher priority within the resources likely to be available."—[OFFICIAL REPORT, 8th February, 1965; Vol. 706, c. 3.]Having served on that regional hospital board, I fully understand the extreme difficulties which face regional hospital boards. The demands for expenditure in the Health Service are almost unlimited and the election of priorities is difficult. But it seems to me that there is a grave danger that these specialised units, which can cater for only a very limited number of persons, however urgent their need, almost invariably will remain at the bottom of the priorities given by the different regional hospital boards. This particular specialised unit to which I am referring is only one of quite a number which had been planned. Also, there are other types of specialised units which are of equal importance but which equally are being given too low a priority.
I think that the House will agree that it would probably be desirable that there should be special units for the treatment of alcoholics, for the treatment of those who suffer from drug addiction and for those with suicidal tendencies. Certainly special units ought to be provided for the treatment of psychopaths. Whilst I fully recognise the difficulty facing the regional hospital boards of providing priority for these specialised units, I should like to make a suggestion which the right hon. Gentleman may be prepared to consider. Perhaps by expecting each regional hospital board to provide such a specialised unit we are reaching for something which is too optimistic. 1691 By reaching too high, perhaps we shall achieve too little. Perhaps, instead of asking each regional hospital board to provide a special unit for seriously maladjusted children, he should insist that a group of regional hospital boards should provide such a unit for their combined areas.
I should like to raise another point on the circular which was issued last January. It refers to the fact that the Standing Mental Health Advisory Committee advised the Minister to explore ways of initiating as a research project a survey of the total need for in-patient care of seriously maladjusted children. This was produced over a year ago and I should like to know whether the right hon. Gentleman can now indicate whether that research is being undertaken.
I now wish to turn to another part of the mental health service, to the services which are available for those at the other end of the age scale. I refer to the care of the mentally-confused elderly, to whom a number of hon. Members have referred. The Ministry is at the moment undertaking a review of the Hospital Plan, and I presume that it is the Minister's intention to undertake a similar review of the health and welfare plans produced by the local health authorities. If it is his intention to review those health and welfare plans, I suggest that he should give special attention to ensure that in those plans there is adequate emphasis on the provision of psycho-geriatric hostels for the elderly mentally confused.
We fully appreciate the efforts which are being made by the local housing authorities to Provide accommodation for the elderly—preferably grouped housing schemes, where individual houses or flatlets, are provided for the elderly, but where there is a warden in the midst, with communal recreational and eating facilities. Such grouped housing schemes seem to me to contain the two essential ingredients of success in that they place emphasis upon the independence of elderly persons and, at the same time, they provide the background of security which is of much value.
We also fully appreciate the way in which the local health authorities are 1692 spending much more than in the past on mental health. It is worth recalling that in 1949 less than £1 million was spent by the local health authorities on mental health. By 1959 expenditure had increased to £4 million, and then with the passing of the Mental Health Act in 1959 expenditure by the local authorities on mental health soared upwards so that during the present year at least £10 million is being spent by the local authorities. With this increased expenditure about 130 hostels have been built for the mentally ill or subnormal, and a number of adult and junior training centres have also been provided. Indeed, tomorrow I shall have the pleasure of opening yet another junior training centre close to my own constituency.
Whilst efforts are being made by the housing authorities and the health authorities for the provision of accommodation for elderly people, there seems to me to be a danger that since the passing of the Mental Health Act the responsibility for the care of mentally confused elderly persons, for whom basically no really effective medical treatment can be provided, might fall between the hospital service, the housing authority and the local health authority. In the past, although these persons were not treatable by medicine or psychiatric care, they would have been accepted in a hospital.
The speeches that we have heard today, and in particular the speech of the hon. Member for Rother Valley, emphasising the crowded conditions of our mental hospitals, are a reflection of the fact that many of these mentally-confused elderly persons were in the past being cared for in the hospitals. Indeed, every hon. Member has the most vivid knowledge of walking around the psychiatric wards of mental hospitals and seeing the beds filled with elderly senile persons. We have all seen wards where the beds are so crowded together that often there is not even room to place lockers between the beds, or where the beds overflow into the corridors of the hospital. In passing, I should like to take this opportunity of paying my own tribute to the dedicated work which is done by the staffs of these hospitals in really incredibly difficult circumstances. [HON. MEMBERS: "Hear hear."]
Although these mentally-confused elderly persons in the past have been cared for in the hospitals, they are not now being accepted by the mental hospitals. 1693 In saying this, I am making no criticism at all of the hospitals. On the other hand the care of a mentally-confused or seriously disordered elderly person is a burden which simply cannot be allowed to fall entirely on the families. Too often the burden of caring for such a person is quite insupportable for a son or daughter who is caring for his or her own children. Such persons are not only in need of the care and assistance which all elderly persons need; they are also in need of medical attention. I should like the right hon. Gentleman to say whether he will look into this matter and make clear which authority is responsible for the care of these mentally-confused elderly persons.
I believe that perhaps the responsibility has been blurred since the passing of the Mental Health Act. Will the Minister take this opportunity of making it quite dear that although little medical treatment can be given to such persons the responsibility for caring for them rests firmly on the shoulders of the local health authority. Does not the Minister think that the time has now come for some guidance to be given to the local health authorities on how such people should be cared for? A study of the health and welfare plans shows that many of the authorities are proposing to build a number of homes for such persons, but so far too little thought has been given to what is the best kind of home.
How should the local authorities select the residents? How large should the home be? Should elderly persons with a mild disorder be housed with other elderly people who are not mentally confused at all, and if so in what proportion? Should the elderly mentally confused be housed separately with others who are suffering from the same affliction? The time has probably come when it would be of value to local health authorities if the Minister could give some guidance to them on the best type of home to provide.
The purpose of providing psycho-geriatric hostels and the other hostels for the mentally handicapped is so that such persons should be properly cared for not in hospital but in the midst of the community. This shift of emphasis away from the hospital towards the community is being undertaken not for administrative convenience or for economic convenience 1694 but because it is of therapeutic value to the mentally handicapped. But it should certainly not be a shift away from skilled care to unskilled care.
The care of the mentally handicapped in a hostel is a very skilled job indeed. It is not something which can be left entirely to a person with a strong sense of dedication, vital though a sense of dedication is. If the wardens of these hostels are to have a proper relationship with their residents who are mentally handicapped, and if they are to take full advantage of the various social agencies which can be brought in to help doctors, psychiatrists and psychiatric social workers, the wardens must be provided with skill and knowledge. I recognise, of course, that most wardens are persons who have received training of a psychiatric nature, but this is not necessarily the case and indeed such training, for instance, as a nurse receives in a psychiatric hospital is not of itself necessarily enough qualification to become a warden.
The National Association for Mental Health, which in the past pioneered the training of teachers for the mentally handicapped, has run the first course consisting of 20 persons for the training of wardens of hostels. Even this week it is running the second of these courses. The first course has shown that there is an urgent need for similar courses to be run by either the local health authorities or the Government. A voluntary organisation, such as the National Association, can indeed pioneer and run the first of the courses but the main burden must be undertaken by the Government. The scale of the task is something which is far beyond the limited means of a voluntary organisation.
I know that the Minister will reply that the National Council for Social Services is undertaking a study of residential accommodation and that we should await the report of that study. I would say with the greatest respect to him that were he to give that reply it would be no more than mere procrastination. I think that I can say to him that beyond peradventure it is proved certain that there is a need for the running of courses for wardens of hostels. I hope that he will interest himself in this matter and give serious consideration to the possibility of the Government initiating similar courses in the immediate future.
1695 My hon. Friend the Member for Wokingham, in a most interesting and well-informed speech, spoke of our responsibilities towards the community. We who are interested in the mental health services have as deep and as serious a responsibility to the community as we have towards the mentally ill and the subnormal The reorientation of this service away from excessively custodial care towards treatment in hospital and towards care in the community is a tremendous advance.
It is a tremendous step which has been taken in the last few years to move away from the care of of the mentally handicapped in those old, cold custodial institutions where, removed as far as possible from the community, the inhabitants were treated almost like medieval lepers and were excluded from view and from contact with the outside world. It is a tremendous step forward that we now treat them in psychiatric wards attached to general hospitals and we assist their return to the community by caring for them in hostels actually in the heart of the community.
On the whole, I think that there is a remarkable and outstanding understanding among the general public of the need for this. The attitude has been transformed in the last 10 or 20 years but it needs only one tragedy, such as occurred in the constituency of my hon. Friend the Member for Wokingham, or a lesser but nevertheless deplorable event—a girl being frightened by someone who is suffering from mental disorder or a child being abducted by a mentally demented person—for the whole community to swing against the policies which are being pursued at the moment and turn away from the trends of advance which we all know is necessary. In the negative sense this must be guarded against by the courts realising that the hospitals can no longer be custodians as they used to be in the past.
I should like to echo the remarks of my hon. Friend the Member for Woking-ham and say that it would be interesting to hear from the Minister what study his Ministry has undertaken in the recent years into the legal aspects of the Mental Health Act. Before the passing of the Act one of the gravest wrongs was that 1696 persons were detained against their wishes when they could well have been voluntary patients. But today, if anything, the problem is probably the exact opposite. It is possible that people for whom treatment is necessary are not necessarily getting it. I have already mentioned the mentally confused elderly. This is infinitely the largest group of persons who are in need of care and protection but who might not be receiving it. But perhaps there are other groups—with rather more specialised problems and I ask the right hon. Gentleman whether his impression is that the doctors and the mental welfare officers are satisfied with the ways in which Sections 26, 29 and 30 of the Mental Health Act are working. These are the Sections concerned with the admission for treatment, admission for observation or the detention of informal patients.
The most important safeguard against a reversal of the advance in mental health is that the community should be rid of unnecessary fear. I believe that the best way the community can be rid of such fear is by itself participating in the after-care of mental patients. I like to hope that the Minister, during his tenure of office, will give his attention to the after-care services. Their development is a matter of great urgency.
We have frequently heard in the House of the inadequacy of the prison aftercare services. If they are inadequate, the after-care services for mental patients are virtually non-existent. Patients are sometimes discharged when they are homeless. A large proportion of patients leaving hospital are without a job. Many are destitute, and many live on National Assistance. However much the attitude of the community may have changed in the past few years, it remains unfortunately true that it is too often extremely difficult for a patient returning from a mental hospital to rebuild his life in the community. It is no wonder that the rate of readmission is so high. The hon. Member for Wandsworth, Central (Dr. David Kerr) referred to the general practitioner service. One good link would be created between the community and the hospital if the general practitioners who serve the community could also, if interested, be given a proper place in psychiatric hospitals.
1697 The after-care services will inevitably depend on the efforts of voluntary organisations. Their success in turn will depend on the inspiration and energy of a few dedicated persons in each community. I ask the right hon. Gentleman not only to rely on their sense of dedication, but, during his tenure of office, go out of his way positively to encourage the establishment of an after-care service for patients leaving the mental hospitals. Here, indeed, is a great field for reform.
§ 2.3 p.m.
§ The Minister of Health (Mr. Kenneth Robinson)
First, I add my congratulations to those of other hon. Members to my hon. Friend the Member for Rother Valley (Mr. David Griffiths) on his luck in the Ballot, on selecting such an important topic for debate and on introducing his Motion in so sympathetic a way.
Perhaps I may remind my hon. Friend that it was about 11 years ago that I, too, for the first time since coming to the House, was lucky in the Ballot, and that I, like him, selected this very topic for discussion. I gather that that occasion was the first in roughly a quarter of a century that the subject of mental health as a whole was discussed by the House of Commons. I am happy to say that there have been many occasions since. That was not the beginning of my interest in mental health, but it was, perhaps, its first Parliamentary manifestation, and at this point I thank the noble Lord the Member for Hertford (Lord Balniel) for the warm personal tribute which he paid to my long-standing interest in the whole subject of mental health.
Lest there be any mistake about it, I say at the outset that Her Majesty's Government find the Motion entirely acceptable. We welcome the opportunity which it has given for a very wide-ranging debate, particularly at this time when we have, so to speak, both to take stock of our inheritance and to look to the needs of the future. There has been a good deal of stimulating discussion today. I agree with very much of what has been said about the directions in which we should make progress. It is only disappointing that, apart from the noble Lord, only one hon. Member opposite has spoken and, at this moment, four of them constitute the maximum number of hon. Members 1698 opposite who have had an opportunity throughout the debate to listen to the points made by my hon. Friends.
§ Lord Balniel
I am sorry to intervene, but I must point out that I intervened when I did to enable the right hon. Gentleman to leave to meet a pressing engagement outside the House, and that it is within my knowledge that there is at least one other of my hon. Friends who is most anxious to take part in the debate.
§ Mr. Robinson
I am glad to confirm that I have no intention of trying to bring the debate to an end, and I am glad, also, that there is the possibility of a 50 per cent. increase in the number of contributions from the Opposition benches, from two to three.
Before dealing with some of the main points raised by my hon. Friends, I remind the House briefly of our basic aims and objectives in this important sector of the social services. I entirely agree with the noble Lord that there is a large measure of agreement between both sides of the House on this matter. Broadly, our aim is to provide and to provide as raipdly as is compatible with the balance of priorities—something which we have always to consider—a full range of services which will enable the mentally disordered to live their lives as near to the normal as they can.
As many hon. Members have said, the emphasis has shifted and is, I think, still shifting from institutional to community care. Most of us would agree now, perhaps with differences of stress and interpretation, that this is right. I enter just one caveat here, and in doing so I am really echoing something said by my hon. Friend the Member for Wandsworth, Central (Dr. David Kerr). In deciding whether a patient should be treated in the community or admitted to hospital or in deciding whether a patient should be discharged from hospital into the community, we must always consider the whole family situation, not only the needs of the patient himself but also the needs of his family, before coming to a conclusion.
Many factors have played their part in the shift of emphasis towards community care. There have been the great therapeutic advances of the past 20 years, both in the physical treatment of mental illness and in the opening out and liberalisation of the régime inside 1699 hospitals. As the noble Lord said, public attitudes have matured. There is a greater tolerance of mental disorder and more confidence in psychiatry. I agree that these trends need to go further. Equally, I agree that they could be set back. We must all hope and pray that they are not.
Out-patient facilities and various kinds of day-hospital care have been developed and expanded, and for the mentally subnormal, too, the aim of the hospitals is, wherever possible, to give those forms of training and care which will allow a greater number than in the past to return to a reasonably happy and useful life in the community. I remind the House that the general movement towards care in the community has not been brought about by any administrative decisions, but it is to this that we must set our sights for the future. If it is to become a reality everywhere rather than merely a concept, we shall have to look, in the first instance, to a good deal of further progress in the local authority services.
I listened with much interest to what my hon. Friend the Member for Birmingham, Aston (Mr. Julius Silverman) said about this. He was suggesting that there needed to be much more help in Exchequer funds to local authorities to provide these services. I am sure that he recalls what was said from the then Opposition benches at the time of the passing of the Mental Health Bill through the House about the unfortunate concurrence of the introduction of the general grant order, which we felt would act as some kind of brake on the development of these services by local authorities.
I cannot try to cover the whole field of local authority provisions even in the mental health field during the course of this afternoon. I want to concentrate on a few of the most important parts of the service where we can see clearly the path that we ought to take.
First, there is undoubtedly a need for many more training centres for the mentally subnormal, centres which are purpose-built and properly staffed. There are a number of local authorities in the country which have shown that, given thorough, careful and expert training and brought along at their own speed, the 1700 subnormal are able to perform tasks which only a few years ago would certainly have been considered far beyond their competence. Such things as basket weaving and the knitting of floor cloths have given way, and are giving way, to much more complex industrial processes and to workshop operations involving powered equipment of many kinds.
Incidentally, there is no evidence that the subnormal are more accident prone than ordinary workers in this kind of work. Indeed, there is some evidence to suggest that they are more adaptable to a strict routine than most people are. We have yet, I think, a great deal to learn about the capabilities of the subnormal and about the best ways of training them both in social habits and in work habits, and there is plenty of scope for imagination and experiment and for individual authorities to learn not only from their own experience but from the experience of each other.
There is also an opportunity here for industrial organisation, to lend a hand. Though it is the local authority's job to take the initiative in seeking out suitable work for trainees, it is not always easy in these days of growing technical complexity to be aware of all the kinds of work which it might be possible to undertake on a subcontracting basis. I am sure that it would be a great help on occasion if industry could come forward with its own offers of work. Many firms, we know, have been agreeably surprised by the standards of workmanship achieved by the subnormal working under proper supervision.
Then there is the pressing need for more residential accommodation both for the subnormal and for the mentally ill. Apart from the elderly mentally infirm who are cared for in the homes provided under the National Assistance Act, the number of mentally disordered people accommodated in local authority hostels increased from 441 at the end of 1960 to 1,523 at the end of 1963. But local authority development plans provide for a vast increase in this number—an increase from 1,523 in 1963 to 15,000 places by 1974. This is a measure not only of progress but of how far we still have to go.
1701 Perhaps I can now turn to the hospital service, where we have a challenge of a different kind but no less of an opportunity. We have a legacy, as many hon. Members have mentioned in the debate, of old buildings, often remote, usually designed for a custodial function. In the course of time they will be abandoned, remodelled, or replaced. But this will inevitably be a long process. Meanwhile, the hospitals face the formidable task of adapting their resources to provide area services, which in the short term will have to be largely exercises in organisation and management.
We can, I think, now identify some of the best lines of attack—increasing outpatient and domiciliary work, increasing the number of day patients using both the old hospitals and converted homes in urban areas, perhaps hostels run by the hospital, and so on. The division of the staffs of the large hospital into teams, to give defined area services and better liaison with the local health authority and general practitioner services, is another possibility; this is one of the things commended last year in the very detailed advice given by my Department to hospital authorities in a circular entitled "Improving the Effectiveness of Hospitals for the Mentally Ill." This advice was based on practice and experience in many hospitals with high standards, and we are now working on similar lines to deal with other parts of the psychiatric hospital services.
The need for more psychiatric units in general hospitals is, of course, now widely accepted. Facilities of this kind have existed in one shape or another for very many years, and there are already some 5,000 beds available in general hospitals for the treatment of psychiatric patients. This is one of the subjects which were touched on by my hon. Friend the Member for Batley and Morley (Dr. Broughton). I agree very much that we must press on with the provision of these psychiatric units in general hospitals.
There are, of course, many claimants for the money allocated to the hospital building programme, and it is not an easy task to get one's priorities right. But I am very anxious that the psychiatric services should receive not only their 1702 proper share of these resources but an early share—their proper share at the right time. I referred in my statement to the House on 8th February to the need for hospital boards to examine and, where necessary, adjust their priorities, and I particularly mentioned psychiatric provision. I would most certainly deprecate any tendency to select psychiatric hospital provision as the conventional first victim wherever any trimming is necessary, and perhaps the noble Lord will regard that observation as my answer to the point he made about provision for severely disturbed children and adolescents.
Of course, it is no good building or adapting hospitals without making proper provision for staffing, and I should like to touch briefly on some aspects of the staffing problem. As far as medical staff are concerned, I am glad to say that the number of senior officer medical staff specialising in mental health has been rising steadily—from 1,002 in 1959 to 1,134 four years later. Within these totals the number of consultants rose from 539 to 671 and of senior registrars from 122 to 162. I think that there is probably a need for faster growth in future. Last year, regional hospital boards forecast an increase in consultant posts to over 1,000 in the ensuing five years—that is from 671. I believe that the numbers who are qualified, or likely to qualify, for consultant rank in psychiatry is unlikely to be as high as that, but, at any rate, my Department approved the figure of 1,000 as a desirable target.
Of course, where there is a shortage, as there is here, it is very necessary to try to secure a distribution of the available specialist manpower which fairly meets the needs of the service as a whole. My Department consults regularly with representatives of the profession about any applications for increases in senior staff, and it approves those where the need is judged to be the greatest. I am glad to say that since 1959 the number of consultant appointments approved in psychiatry has exceeded that for any other specialty.
My hon. Friend the Member for Stockport, North (Mr. Gregory) talked about certain difficulties in recruitment and admission of nursing staff. Here, too, there has been a steady overall rise in recruitment. The latest number for all 1703 grades in post in psychiatric hospitals is 47,000 and that is the highest so far.
§ Dr. David Kerr
What proportion of this satisfactory increase in numbers is fully trained nursling staff and what State enrolled and State assistant nurses?
§ Mr. Robinson
Besides being a doctor, my hon. Friend must be a clairvoyant, because I was about to say that within that total the proportion of nursing assistants has certainly increased, but I do not have the precise figures.
I do not want him to think that these nursing assistants are completely untrained, or anything like that. I am sure that he knows that some of them are trained under a scheme recommended by my Ministry. Others receive training on the job and many of them by now have a great deal of nursing experience and have been giving for many years valuable support for the qualified staff.
The General Nursing Council's new rules, which I recently approved, provide for the admission of experienced nursing assistants to the Roll of Nurses, and I am glad to say that many thousands have already applied for enrolment. Other measures have also been taken which ought to help the nursing service in psychiatric hospitals, for example, the decision to apply the General Nursing Council's educational standard to psychiatric student nurses who enter training after January next.
Having mentioned increased staffing in the hospitals, it is only fair to acknowledge that, parallel with this, there has been a heavier burden placed on the staff, for example, through the increase in short-term admissions to hospitals for the subnormal.
So our general objective is clear enough—better provision and better quality provision in a comprehensive range of mental health services largely reorientated towards community care. It is worth remembering that a good many of the details can be filled in only as we go along. All experience shows that only the provision of a particular service brings fully to light the need for that service. We must not be frightened of experiment and of setting up working models, for example, psychiatric units in general hospitals with a variety of local authority supporting services.
1704 Nor must we neglect other kinds of research. Although there is still room for expansion, at this moment more research is going on in Britain into mental health than ever before. The Medical Research Council now has ten units wholly engaged on such research. Five of these units were set up in the last four years to conduct research into the epidemiology, genetics, chemical pathology and sociology of psychiatric illness and also into the metabolism of the brain. This last is likely to make a very important contribution to our understanding of those forms of mental disorder which are thought to result from chemical changes within the brain itself.
In addition, related investigations are being undertaken in other units working in the field of applied psychology, social medicine and genetics. The Council also supports a research group studying the relationship between organic and functional mental disorders and provides further assistance for psychiatric research through its schemes of temporary research grants and training awards. The Council's expenditure on research in mental disorder and work closely related to it rose from £260,000 in 1959–60 to £510,000 in 1963–64 and in the present financial year it is likely to be about £709,000.
There is also my own Ministry's scheme for locally organised clinical research which is run in parallel with the Medical Research Council's arrangements.
§ Lord Balniel
It is quite possible that the right hon. Gentleman does not have the figures with him, but can he say what proportion of the Medical Research Council's total expenditure on research is spent on research into mental health?
§ Mr. Robinson
I remember doing some research into these figures myself very many years ago, and that when I first asked it was 1d. in the £. I think that we have now got it up to 1s. in the £, but I would not like to quote the current figure without notice. I will certainly write to the noble Lord and let him know. In my own Ministry's scheme for clinical research we hope to contribute £70,000 to £90,000 in the coming year.
A number of points have been made in the course of the debate. I do not 1705 think that I can answer them all, but it is not the function of the Government spokesman on a private Member's Motion to try to answer everything, as he would do if winding up a Government debate. There are, however, one or two issues which I will gladly take up.
The hon. Member for Wokingham (Mr. van Straubenzee) raised a number of issues, as he rightly said, of principle connected with Broadmoor Hospital, which is in his constituency and the noble Lord echoed his views about whether non-criminals ought to be in Broadmoor Hospital and whether this was one of the legal aspects of the Mental Health Act which we have considered.
As the hon. Gentleman rightly said, this was considered by the working party and I do not have evidence to dissent from the view of the working party, which was that patients should be classified according to their mental condition and treatment requirements and admitted to special hospitals if treatment in conditions of special security were necessary. I am sure that that is right, because it means that the medical requirements defined in that way coincide with the statutory position.
It is worth remembering that in the special hospitals there are patients who have committed various offences, some of them serious, but who have not come into conflict with the law because arrangements were made for medical treatment. Equally, in psychiatric hospitals there are a number of patients from the penal system, so to speak. I am afraid that at the moment I see no no reason to depart from the existing arrangements in this respect.
§ Mr. van Straubenzee
Would the right hon. Gentleman direct his mind to this rather more limited point? I was not pleading necessarily that as the result of one representation to him, or more than one, he should change the practice. I was making the more limited point that he should merely inquire into the working of the practice.
§ Mr. Robinson
While it would be wrong to suggest that any formal inquiry is going on—and this answers what the noble Lord was saying—of course my Ministry always keeps in mind the work- 1706 ing of the Mental Health Act which after all, made the most radical change in the law of this country which has ever been made, perhaps more radical than have ever been made in any country. It would be miraculous if we had every detail right, but at the moment I do not see any evidence to suggest that we need amending legislation yet. However, I certainly take the point and I will keep it in mind.
The hon. Member for Wokingham mentioned the Friends of Broadmoor and I should like very much to echo the tribute which he paid to Lady Monckton of Brenchley and to thank him for his interest in this Association, because it is extremely important that people from the local community around Broadmoor should take an interest. I believe that the hon. Gentleman has given a very valuable lead, as the local Member, in associating himself with it.
The hon. Gentleman made a point about the staff there. I would like to say that I really feel it is right that the staff of Broadmoor, which, after all, is a hospital, should come within the National Health Servico and its staff are, in consequence, on National Health Service pay and conditions. They receive an additional rate in salary of £160 a year—it has recently been increased—over what are equivalent grades in a National Health Service psychiatric hospital which is not a special hospital, and this is intended to reflect the difference in their working conditions. It is negotiated through the Whitley Council.
The hon. Gentleman also mentioned what he regarded, I think perhaps rightly, as a conflict of principle which must face the medical staff of Broadmoor, the conflict between their interest in the clinical condition of the patient and their concern for the security of the public. The hon. Gentleman used the words that "this must set up an intolerable strain". I can assure him that this is not an intolerable strain. I have discussed it with the medical staff. After all, all psychiatrists in any medical hospital have to balance their medical responsibility for the patient with the interests and safety of the community as a whole.
I agree that this is in slightly sharper focus in a hospital like Broadmoor, or in one of the special hospitals where high security is an essential consideration. 1707 But I beg the hon. Gentleman to remember at all times that Broadmoor is a hospital—I think that it is increasingly being so recognised—and that the stigma of which the hon. Gentleman spoke is beginning to fade at last.
My hon. Friend the Member for Wandsworth, Central, in a very interesting speech, based largely on his own personal knowledge, used the phrase, which I have heard a number of times before, about the danger of the open door of the mental hospital becoming a revolving door, relating this to the readmission rate. I would like to say a word about it because I think there is a great deal of misunderstanding about the readmission rate. One hon. Member quoted a figure, which certainly coincides with my information, that 26 per cent. of readmissions take place in the first year after discharge. This is a figure based on the 1955 cohort of admissions, but we have no reason to believe that it is substantially different today.
This is 26 per cent. within a year. But the figure most frequently quoted for readmission rate represents the readmission of a patient who at some time in his life has previously been in a mental hospital—may be, as a child—and who is readmitted perhaps when he is a psycho-geriatric case. Nevertheless, this is a readmission, and this figure may well be around 50 per cent.
I want the House to appreciate, as I said a day or two ago in a Written Answer, that the increase in this total of readmissions is very largely a reflection of therapeutic advances which have been made resulting in long unbroken spells as an in-patient being far less necessary than they were in the past.
One or two hon. Members mentioned an article in The Guardian of today, by an unnamed consultant psychiatrist. I have read that article, but I really do not think that the conditions described in it—and, I think, described with a touch of exaggeration—are typical, although, quite clearly, the grim prison-like Victorian buildings which he describes are all too typical of the type of mental hospital buildings of the mid-nineteenth century and which are so difficult to modernise, although admirable work of this kind has been done in some of them.
1708 We all know that there are bad patches in the Mental Health Service, but I think it a remarkable achievement that in the face of the kind of difficulties that have been described the devoted staffs of these hospitals are able to maintain standards as impressively high as they are in so many cases. Our aim, certainly, is to raise the standards, particularly those of the less good to the level of the best. I would have thought that the writer of this article might have made representations to his management committee or to his regional board. Of course, he may have done so, but I have no evidence of that.
There is one other point with which I would like to deal and this was raised in the noble Lord's speech. He spoke about the circular which my Department sent round a year ago about the units for children and adolescents. I am told that at the time the circular went out there were 25 such units. Since then the number has increased to around 30 and there are plans for additional units, although it is difficult to say at the moment how many. The noble Lord asked about the possibility of establishing total needs for these groups. We are considering carrying this out by means of research projects, but in the meantime we are seeking the advice of the Medical Research Council's subcommittee on epidemiology. It may need a thorough research to establish all we want to know.
Another point was raised by the noble Lord, to which he forecast the answer that he thought I was going to give. Actually, it was a rather good forecast. It was about the wardens of local authority hostels. The noble Lord suggested that everyone knew that training courses for these wardens were necessary and that it was simply a matter of employing delaying tactics to await the report of the National Council for Social Service, which, in any case, we hope to have before the end of the year.
I am advised that the reason why it is desirable to await this report is that the Council is looking at training over a much wider field than this, and it may well be—we do not know what its recommendations are going to be—that in this field, as in the field of social workers, it will find a common contact in the work of running homes for the elderly, the handicapped and other 1709 groups which may call for general rather than specific training. It is in that context that we really must await the Report of the Council and then decide how best to proceed in the light of its advice.
I should like to say, in conclusion, that I have tried to give some outline of the tasks that we face and the way in which they are being tackled. There are a lot of problems on which I have not been able to touch, I readily admit. I mentioned at the outset the need to provide a full range of services and it has become increasingly clear in recent years that the full range is indeed vast.
I should like to have paid tribute to many people whose work in the prevention, treatment and after-care of the mentally disordered is of vital importance—the family doctor, the social worker, the voluntary bodies and many others. But if the range is vast, the moral is, I think, unmistakable. All who play a part must play in concert, and community care must be made to mean continuity of care. The need for the closest working links between all parts of the service grows as the concept of mental health widens, and it is widening all the time, and in concluding my remarks I would put this need to work closely together very near the top of the list. We can meet it with good will and good management, but without it much else that we strive after will prove unattainable.
§ 2.40 p.m.
§ Sir Anthony Meyer (Eton and Slough)
The hon. Member for Wandsworth, Central (Dr. David Kerr) said something about the need for a running HANSARD. I very much feel the need for this, because I was unable to be present for the early part of the debate. Therefore, I do not propose to range widely and I shall not detain the House for more than a few moments. What has emerged from such of the debate as I have been able to hear is that if the mental health service is still the Cinderella of the Health Service, she is at least within visible distance of the ball. Let us hope that she gets there before too long.
I was struck by something that my hon. Friend the Member for Hertford (Lord Balniel) said about the plight of families 1710 who have dependants with mental handicaps. I am sure that all of us, when visiting our constituents, have been impressed by the sad plight of these families, particularly when they have children who are mentally defective. We have in my constituency an excellent club, where these children are able to meet together and where devoted helpers come in from outside to bring joy to their lives on a few occasions during the week. One cannot help thinking, however, of the rest of the week and of the very great difficulties which these families must encounter at home.
I am always struck with immense admiration for the mothers who manage to make a tolerable life for these children of theirs, who are not sufficiently incapacitated to be admitted to institutions but who, nevertheless, require this special care and attention. It is, obviously, one of the compensations of nature that these children seem to draw a special affection from their parents. It is something which touches me greatly when I see it.
There is really only one point which I want to make and it does not strictly concern the Minister, but perhaps I may take this opportunity of expressing the hope that he will urge his noble Friend the Lord Chancellor to consider it. I refer to the way in which the Court of Protection looks after the interests of mental patients and their estates. My hon. Friend the Member for Bebington (Mr. Howe) raised this point in the debate on the Administration of Justice Bill. The fact is that the Court of Protection makes a fixed percentage charge for administering the estates of people who are in institutions under care. I understand that a fixed percentage is imposed irrespective of income, although in case of hardship the charge can be remitted.
The line where hardship is drawn seems to me to be such that on smallish estates, although the money taken out is not sufficient in quantity to impose what by statutory definition would be called hardship upon the relatives, it nevertheless imposes a real sacrifice on people who are trying to maintain a reasonable standdard of living.
There is in my constituency a good lady who has been fighting a one-woman war on this matter with the Lord Chancellor's Department for many years. She has a son at grammar school and the 1711 £20-odd a year that is taken out of the £400 a year that the estate yields represents a real sacrifice for her. This lady points out particularly that for the £20, the Court of Protection seems to do almost nothing. She stated to me in a letter:The Courts did not have any accounts to pass as they did not require these to be sent to them. I was sent a very short inquiry form to complete and shortly afterwards the demand was sent for the annual fee of £20.This may not be a major scandal, but it none the less seems to me to be wrong that a standard charge of this kind should be imposed by the Court for doing almost nothing.
It was suggested by my hon. Friend the Member for Bebington that in this way the large estates to some extent sub-sidise the small estates. That argument is not valid. Apart from those which, on strict hardship grounds, are excluded from the charge, all these estates seem to me to be subsidising the Court. This is not the usual practice, because normally the courts are subsidised from public funds and any income that they derive might be regarded as a windfall for the court. The time has, perhaps, come when this tax on lunacy should be looked at again. I very much hope that the Minister may find an opportunity to speak to his noble Friend the Lord Chancellor about it.
§ 2.45 p.m.
§ Mr. Raphael Tuck (Watford)
I should like to call the attention of my right hon. Friend the Minister to a hospital which my wife and I visited a short while ago, and that is Leavesden Hospital, which is near my constituency of Watford. In that hospital for mentally subnormal people there are about 2,300 patients, of both sexes and of all ages. There is a large waiting list of almost 300 but there is little hope that any of these people will be accommodated in the near future because of various inadequacies.
In the first place, the staff is very inadequate. There are shortages of sisters, ward staff nurses and student nurses. The hospital is about 20 short in assistant staff nurses. The male staff is also inadequate, and the position will be accentuated in the near future because many of the nurses are approaching re- 1712 tirement age. The result is that a number of wards have had to be closed altogether. Consequently, there is extra pressure on the time and the work of those who are supervising and working in the remaining wards.
The wards themselves are very crowded. More staff recruitment is necessary although the hospital has an excellent industrial training unit. The buildings, which are 90 years old and unattractive, have been vastly improved by decoration and by the display of imagination by those responsible, but they are still very old and the wards are very overcrowded. In one small ward into which we went, there were 56 beds. One almost had to climb over one bed to get to another. Even though these people are mentally subnormal, one can imagine the effect upon them of being herded together almost like a lot of animals.
The workshop accommodation is also inadequate. I must, however, pay tribute to what has been done to make the best of existing conditions and also to the doctors and nurses in the hospital. There seems to be no sense of institutionalisation. These doctors and nurses have a sense of dedication. They really love these poor unfortunate beings and they do everything in their power to make them happy and comfortable. I must particularly pay tribute to the work of Dr. Shepherd, the physician superintendent, and Dr. Bevin.
Not only is there inadequacy of staff, but the diet of the patients is very bad Patients get butter only twice a week. I understand that the allowance per patient in this kind of hospital is only 70 per cent. of the allowance for other kinds of hospitals. If dietetically it is justifiable for these patients to exist on margarine and the National Health Service cannot afford to give butter, one might ask why the Service should spend additional money on patients in general hospitals.
It seems that there is an inequitable distribution of national resources between the National Health Service and other calls upon the Exchequer, and, in particular, within the National Health Service itself and it is indefensible that more money and better conditions should be enjoyed by hospitals for normal patients while hospitals for the mentally 1713 subnormal have to be satisfied with the dregs. We saw a meal that had been given to patients one evening. It looked like pigswill. It consisted of spaghetti and some tomato sauce, with perhaps a little meat thrown in, all sodden and most unappetising.
The male staff of these hospitals is retired at 55. Why should this be? These men have many useful years of service before them, and the community needs their services. The retired nursing staff is bound by the earnings rule. This means that if such a person works for a private employer he keeps his pension, but if he returns to part-time nursing and works for the State his pension is correspondingly reduced. Why is this? Is there any justification for it?
This inevitably means that people who have retired are not continuing to do the job for which they were trained and to which they have devoted their lives. Again, they cannot work overtime—at least, they can, but only in a curious way. They cannot work overtime at the hospital at which they normally work. They have to go to a different hospital. The adverse effect that this arrangement must have on patients cannot be overstated. It must be very great, for the nurses that they are used to are changed, simply because those who work in the day time cannot work overtime in the same place at night. This chopping and changing around is thoroughly unjustifiable.
These people are members of our community. It is true that they are of a subnormal standard, but if we have a dog which becomes a little stupid or a little old or infirm, as an act of mercy we may put it to sleep, or, if we keep it, we treat it with increased affection and see that it has more than it had when it had its proper faculties. We do not allow the mentally subnormal to be put to sleep. Yet, when we keep them alive, we seem to feel that we can treat them rather as untouchables or subhumans, or even almost animals. Surely we should treat these people as well as we treat those in normal hospitals. They have the same feelings. In fact, they may have even more acute and sensitive feelings, although they cannot express them. If we treat them as untouchables we are committing a sin, in keeping them alive 1714 in this way. If we keep them alive, let us treat them with care, as members of our community, and accept full responsibity for them.
§ 2.52 p.m.
§ Mr. Christopher Norwood (Norwich, South)
I commend this Motion, calling attention to the mentally disordered and to the need for making progress in their treatment. Even in my short time as a Member I have had a number of cases of mental illness brought to my notice. I suppose that is true of most hon. Members. We learn things about the lives of other people which in many cases we would rather not know about. My hon. Friend the Member for Wandsworth, Central (Dr. David Kerr) spoke a great deal about the work done by the general practitioner for the neurotic patient, as I believe he described him. He went on to discuss the question of mentally subnormal people—not those who are disordered but those who are subnormal. I have found a tremendous inadequacy in the provision for these people. This is an indictment of the empty benches opposite. This may be regarded as a matter of no importance for them. Over the last 15 years, in a rich and prosperous society, they failed to provide an adequacy of places.
In my constituency there is a boy of about 11 years of age. He is one of two children. He has an elder sister. His father is a competent, decent man. The boy is mentally subnormal, and is also blind. Although I have written many letters on the subject, it has been found impossible to place him in permanent accommodation in an institution so as to relieve the pressure on his mother. His mother has suffered one mental breakdown, and there is another impending. The best that the current services can provide is to take this boy away from the family when disaster is impending for the mother. The father goes to work. Although he basically runs the home, he cannot be there all the time. The best that can be done is to take this boy away occasionally. This has happened on occasions, for periods of two or three weeks.
This is an indictment of the empty benches opposite, but it is also an indictment of the community. It is an indictment of our attitude. I very much 1715 agree with my hon. Friend the Member for Watford (Mr. Raphael Tuck) about this, although I do not accept his comparison with the treatment of animals, because to me human life is inviolable. Nevertheless, I understand what he means and have great sympathy with him. Our attitude in respect of this matter is an indictment of us, because although we may be capable of looking after ourselves people like the boy I have mentioned are incapable ever of looking after themselves. Is it possible to imagine a greater combination of unfortunate circumstances than to be blind and mentally subnormal? Yet our community is unable to put this boy into permanent institutional treatment under the hands of dedicated specialists.
In time, no doubt—if pressure is maintained—the powers that be will move his case up the list and be forced to accommodate him. Yet I am informed that even in the city one-half of which I have the honour to represent he would not be at the top of the list of people for admission to local institutions. I shudder to think what the plight of the others must be. Each of the disabilities from which this boy suffers would require great character to overcome. Taken together, the task is impossible. If this community cannot provide institutional care for a growing boy of 11 or 12 years of age—a boy who is severely mentally subnormal and so big physically that his mother now has a problem in handling him—I do not wonder that hon. Members opposite stay away from this debate. Well they might. They can stay away for ever, because they stayed away from this problem throughout the period during which they were preaching prosperity. It would be wrong to say that they have done absolutely nothing, but they have done very little.
If I have spoken too forcefully I hope that the House will forgive me. I feel very strongly about this case—the more so because I find it so difficult to make any progress with it. My hon. Friend the Parliamentary Secretary has done me the courtesy of saying that he will meet me to discuss this case. I greatly appreciate that, and I hope that it will lead to results. I do not wish him to commit himself to anything, but I thank him for his sympathy. This situation has existed for several years—long before 1716 this party took office. I believe that the boy has been committed into the temporary care of an institution on eight occasions. I think that this is a situation which therefore persists over several years. I am grateful to the Parliamentary Secretary for saying that he will once again look into this case.
I have only limited experience of visiting institutions for the mentally handicapped. I have had, I will not say the misfortune, but the by no means pleasant experience of going to Rampton in order to appear at an appeals tribunal for the child of another of my constituents, a young man. It would be improper for me to say, and I am not in any fit position to judge without being an expert, whether he ought to be in that place. I am sorry that I did not give notice of this point beforehand, so it might not be possible to give a full Departmental reply, but I would refer to one difficulty which appears to me to exist in the review tribunal procedure. The tribunal can only either discharge a man or woman concerned or not discharge them. In other words, in this case I think there is an argument perhaps for further care, but not necessarily in a place like Rampton.
I would add that I met a number of the officials and people who work in Rampton and I would echo the words of my very good friend the hon. Member for Norwich, North (Mr. Wallace) when he said that he knows people in the mental service of great dedication and great purpose, performing tasks of the greatest possible social service. The officials and doctors whom I met at Rampton impressed me as being people who were dedicated—this is an easy word to use—but at least very sympathetic people. I criticise the administration of the hospital. It has an awful air about it—unavoidable in the circumstances perhaps—of iron bars, closed corridors and locked doors. The male nurse who walks round with a visitor has in his pocket the only thing which really matters, the keys: for each door, a new key.
That is a terrible situation, maybe an inevitable one. I do not know. But it strikes me that when considering the release of people like this young man—who is about my age, perhaps 28—the review tribunal does not have the power to put them in the care of another 1717 authority or another hospital. It must decide either that they shall be wholly released, or that they shall remain there. I think that this would require legislation, though it may be a matter which could be done by direction of the Minister. This strikes me as an unfortunate flaw in the arrangements. I think that it would be very much better and greatly to be approved, if the review tribunals had power to release a man or woman, subject to conditions. I understand from the chairmen of tribunals and from what I have been able to look up in the Act, that they do not have that power; they either have to discharge, yea or nay. This creates an element of inadequacy.
One of my hon. Friends talked of the social stigma connected with mental illness. As I said, I am not speaking only about those people who are mentally disordered, but about those who are mentally inadequate, who could be said to be part members of our society—part of us and yet not quite like us in some ways. This must, of course, include 2 vast number of people in our society for whom there is totally inadequate provision at the moment. The terms of this Motion are quietly and generously drawn. They do not impose an impossible task on the Government. I think that, in the nature of things, our Government are the Government who are likely to be sympathetic to this problem. There are, I do not know the number, but it must run into many hundreds of thousands, of people who, through no fault of their own, and, more to the point, no fault of the families into which they are born—because that is a matter of God's chance how it comes and how it goes—are left with a tremendous burden.
There are many people in this increasingly competitive world who find it harder and harder to compete and who, in some cases, will not be able to do so at all. On the whole, as a community in this respect we perform very badly. One of my main reasons for speaking on the subject is that the Motion urges us to make further progress. I do not suggest that if it is accepted the stars will come out tomorrow night and all will be perfect, but if the Government are prepared to make a little progress, I shall be happy.
May I refer to one matter which arises from a case in my constituency and which seems a little odd? First, it must 1718 be taken for granted, after the case which I have already mentioned, that there is an inadequacy of places for the mentally subnormal in Norfolk. This is not a situation for which the Government can in any way be blamed. If the blame lies, then it lies on the empty benches opposite. I have no doubt about this. Protestation is no substitute for action. There they sit, gilded, beautiful but unkind—and unseen; not a party dedicated to any social purpose of any kind whatever, as far as I can see. Does the right hon. Member for Monmouth (Mr. Thorneycroft) wish to intervene? No? Naturally, he does not wish to rise. My right hon. Friend, or enemy, opposite does not wish to rise. Why should he? He has neither the record nor the opportunity to rise to make any point on this matter.
I return to what I was saying, and I am sorry if I have been led astray. We are short of mental health nurses, particularly, I believe, men. A man came to see me a month or two ago who is rather a late student nurse. He is perhaps in his forties or fifties—a man of mature years. Although he is paid rather more than the ordinary student nurse of 19 or 20 years of age, nevertheless he has to forgo a substantial deduction from his wages, because, as he is over 21, he does not benefit from the cheap luncheon arrangements or the cheap travel arrangements.
I earnestly suggest to the Minister that when we are considering recruitment to the mental health service we should consider making it particularly attractive for older people who, I think, ought to be the best possible mental nurses. Someone of the age of 40 or 50 has the confidence and the maturity to handle difficult people. It ought to be made attractive to these older people to take up the profession of mental nursing, a profession which we all recognise as vital.
If, in raising these specific matters, I have brought them to the attention of the Department, I am gratified. I commend my hon. Friend the Member for Rother Valley (Mr. David Griffiths) on having put the Motion on the Order Paper dealing with a subject about which most of us would know very little if we were not Members of Parliament or performing some social service. It is, nevertheless, a subject of great interest to the 1719 health of the community. It does not just affect the people concerned or their families. Looking after the inadequate is a task which commands the attention of the strong and the able, because if a man is strong and able he ought to look after his weaker brothers. That is the simple proposition.
§ Question put and agreed to.
That this House welcomes the progress made in the provision of services for the mentally disordered and urges Her Majesty's Govern-men to take steps to encourage further Development.