§ 4.13 p.m.
§ The Secretary of State for Social Services (Mr. David Ennals)
I beg to move,That this House takes note of the White Paper on the Review of the Mental Health Act 1959 (Comand Paper No. 7320).I welcome this opportunity to open the debate today on our recent White Paper, the "Review of the Mental Health Act 1959". One yardstick by which the compassion of any community can be measured is the facilities and legal framework which it provides for the mentally disordered. In few areas of social policy have attitudes changed so dramatically as in the field of mental health. Gone are the chains, whips and fetters of previous centuries. Gone are the ignorance, superstition and inhumanity which could leave a patient in Bethlem chained to a wall for years. Gone, too, are some of the fears and ridicule which produced labels such as "imbecile" and "lunatic".
Public attitudes and prejudices, inevitably, have changed more slowly than professional attitudes. Future generations will no doubt be as contemptuous with us—for our prejudices, for example, towards discharged mental patients—as we are with earlier generations. But not only have public attitudes been changing; the pace of change has been quickening too. The landmark which led to this change was the Mental Health Act 1959. The bedrock upon which this Act rested was the principle that people suffering from mental disorder should, as far as possible, be treated in the same way as those suffering from physical sickness.
Certain inalienable policy implications followed from that principle: first, that compulsion was to be used as little as possible; secondly, that care rightly became more important than custody; and, thirdly, that treatment must not be confined to hospital—indeed, that the emphasis should be on community provision rather than institutional care. After all, nine out of 10 people who are treated for a physical ailment never go into hospital at all.
The 1959 Act was rightly seen to be as far reaching as the County Asylum Act 643 of a century and half before. The mishmash of legal amendments, alterations and afterthoughts which had grown up over the years was replaced by a single Act. But it is now 25 years since the Royal Commission which led to the 1959 Act first began its study and two decades since the proposals were enacted. With the increase in the pace of change, many developments have occurred in this last 20 years. Let me point to three.
The first is public perceptions. We have at last come to accept that there is no clear and unambiguous boundary between mental illness and mental well-being. People have woken up to the fact that as many as one in nine of us must expect to spend some part of our lives as in-patients of psychiatric hospitals.
The second is professional developments. The opportunities which new drugs created for open door policies are now well known. But new developments have not been confined just to drugs. In an earlier era, for example, medical professionals were totally preoccupied with the individual. Today the relationship of the patient with his family and society is seen to be equally as important. Everyone needs emotional warmth and support. Where patients fail to receive this from their families, the service has to try to provide this through other means—such as foster care or a more domestic scale of hospital care.
As regards patients' rights, a growing concern for civil rights in society as a whole, not surprisingly, brought into its ambit the rights of patients in mental hospitals. Yet this is not as new a phenomenon as some might think. It was concern for the rights of the individual which led to the mental health reforms of the last century, and, indeed, to the Mental Health Act itself in 1959. The issue is not very simple. I intend to look at some of the most crucial of these questions in detail in a moment.
First, however, I want to comment on the philosophy with which we have approached this proposed reform. There are three separate strands to the Government's strategy for the mentally ill. As a first priority we concentrated on the two strands which inevitably are linked together—services and resources. As hon. Members are aware, the broad lines of strategy on services and resources have 644 been laid down at national level. There were the two "better services" White Papers. There was a consultative document on priorities and there was the follow-up report "The Way Forward".
Today's debate is on a White Paper with a more narrow focus—the law on compulsory powers—which makes up the important third strand of our strategy. But, before I look more closely at this strand, let me briefly bring hon. Members up to date on services and resources—of course, the White Paper is not about those. However, we ought to look at the law in relation to the broader picture, so, first, I mention the shortcomings—and there are many.
It gives me no satisfaction to have to report to the House that the latest published statistics show that there are still 11 local authorities with no direct residential provision for the mentally ill, 36 which have no day centres, and 44 which have no direct residential provision for mentally handicapped children. Only 31 authorities have met the minimum standards for residential care for the mentally ill and only three have met the minimum standards for day care.
§ Mr. Robert Kilroy-Silk (Ormskirk)
Instead of mentioning the round figures, why does not my right hon. Friend actually now name all those local authorities which have not met the minimum standards?
§ Mr. Ennals
I have quite a lot of material to deal with in the White Paper. I shall not do what my hon. Friend asks now, but he will know that league figures are published. If he writes to me, I shall let him have the figures which indicate the records of individual authorities.
All right—there have been some bad things.
§ Mr. Ennals
Perhaps my hon. Friend will allow me to proceed.
Let me list, on the other hand, some of the achievements. The number of mentally handicapped children in hospital is now lower than the White Paper target for 1991. About half the 204 health districts in the country are now served by a general hospital psychiatric unit. Nearly one-third of all psychiatric admissions are 645 now received through general hospital psychiatric units. The number of available day hospital places for the mentally ill has been rising rapidly—from about 7,500 in 1972 to 11,700 at the end of 1977. Out-patient attendances for the mentally handicapped are up by 8,650 since 1970.
Further, the number of community psychiatric nurses has increased tenfold in recent years. The number of WTE psychiatric nurses has gone up 7,000 in the last four years at a time when the number of long-stay hospital patients has been steadily falling. We have now reached the target of one nurse to three patients. There have been considerable improvements also in the nursing staff of mental handicap hospitals. Joint funding has helped to improve community services, inadequate though many of them still are. For example, residential provision, which has been increasing by 350 places a year, has kept pace with the White Paper's targets. There are now over 5,500 places.
In addition, NHS capital and revenue expenditure on the mentally ill has been increased by 2 per cent. a year since 1976. Taking account of the drop in the number of beds, that means a 5.5 per cent. increase per patient.
We should, therefore, take some pride in this progress. But what about the law? The White Paper which we are debating today was designed to complement our new strategies for services and resources. We went out of our way to consult all parties—most of whom were demanding changes. No package can satisfy them all—doctors, mental nurses, social workers, patients' rights campaigners, Members of Parliament and Butler committee members concerned about mentally abnormal offenders.
But I believe that we have achieved the right balance between what were sometimes conflicting claims. We have, for example, accepted the need to provide more protection for individual patients' civil rights. But in strengthening these rights we have sought to ensure that the needs of hard-pressed staff have not been overlooked.
The mental health law must, as the 1959 Act does, cover several areas. It must provide for the care of the patient who cannot appreciate his need for care and treatment. It must also protect the 646 public against those whose illness or handicap may cause them to endanger others. It must strive to safeguard the liberty of the individual; and it must pay proper regard to the interests of the staff involved in caring for the mentally ill and the mentally handicapped. In the White Paper we have tried to balance the various interests and, where necessary, to reconcile them. In doing this, we had 300 comments in all as part of our consultation.
We are now receiving comments on the White Paper itself, and initial reactions suggest that we have perhaps managed to strike a fair balance. In some of these issues, the interests and views of various groups are genuinely and fundamentally at odds. It has been the Government's task to weigh the arguments and then to determine their own point of view. We have not merely compromised for the sake of it. Where we have had to, we have made a firm proposal based on our assessment of what was the right thing to do.
I am encouraged in the belief that we have been able to strike a just and fair balance by the welcome given by the House to the Private Member's Bill introduced two weeks ago by the hon. Member for Chertsey and Walton (Mr. Pattie).
At the heart of this Bill are four proposals which are set out in the White Paper. The Government hope that the Bill will bring about the early implementation of these four reforms, which will benefit the majority of patients, both the informal and the detained.
In undertaking the review of the Act—a major task—we have comprehensively scrutinised all the issues surrounding the nature and use of compulsory powers. We have come up with more than 100 proposals for change—most of which will need changes in legislation, but there are some on which we can take action independently of legislation. Some of the proposals are marginal changes in the detail of the law. Individually, none of them represents a startling departure from what I believe to be the fundamentally sound framework of the 1959 Act. But, taking all 100 proposals together, we have what amounts to a substantial reform which will, if enacted, carry us forward into the years ahead with a soundly based legal framework for mental health.
647 I now turn to a more detailed description of six of the important issues where the various and complex factors involved do not lend themselves easily to a consensus. Those six issues are: the criteria on the use of the powers; mental handicap; the rights of patients, including consent to treatment; the protection of staff; mentally disordered offenders, and, finally, guardianship.
First, then, I shall deal with the criteria governing the use of compulsory powers. In what circumstances should society exercise control over a person on the grounds that he or she is mentally disordered? We should always be sure to remind ourselves of the nature of a compulsory power. It means that an individual is to be deprived of his liberty, often in circumstances where the very condition which triggers society's use of powers so clouds the judgment of the individual that he cannot see that it is for his own benefit and safety. He may, therefore, view the action of society as, at best, a gross imposition, an infringement of his liberty, and, at worst, a malevolent action of aggression. He may view the action of society in this critical way. The ultimate purpose of the law is to protect and enhance the liberty of the individual, yet mental health law expressly addresses itself to the restriction of liberty for some individuals. I think that it is this paradox which causes mental health law to become so complex and detailed.
Compulsory powers are designed for those exceptional circumstances where a patient's mental disorder warrants detention in hospital for treatment or reception into guardianship and the patient is unwilling to agree to that. The White Paper adopts the principle that compulsory powers should be available only as a last resort. But if all alternatives have been exhausted, compulsion is on occasions clearly necessary. I am thinking, for example, of patients with a mental disorder which is likely to benefit from treatment, or of someone undergoing an episodic crisis. Only five out of every 100 patients in mental hospitals are under a compulsory order. People often forget that the percentage is so small.
We must beware of the use of such powers to provide for what would be, in effect, the preventive detention of those 648 people whom some elements in our society would want us to ignore. The changes proposed in the White Paper, whilst they acknowledge that certain mentally disordered people may need asylum and protection from harm, are designed to promote a pattern of care in which the function of the hospital, in the broadest sense, is treatment and rehabilitation of the patient with the aim that, whenever possible, he can return to employment and his home.
§ Mr. Patrick Jenkin (Wanstead and Woodford)
Is not the burden of what the right hon. Gentleman is saying that there is no equivalence between a compulsory admission to hospital and the maintenance of emergency services? Has the Secretary of State's attention been drawn to those hospitals where, in the present disputes, the unions involved are allowing the admission only of patients under compulsory powers, while excluding the admission of patients under the voluntary procedures? Will he say something about that?
§ Mr. Ennals
I say only that I greatly deprecate this action and that I am well aware of it. It is happening on the outskirts of my constituency, and it causes me a lot of alarm.
This leads me directly to the second issue that I wish to discuss—that of mental handicap. I know that there will be some who will object to the view that this approach is suitable for mental illness but not for mental handicap. They will argue that the factors which warrant the detention of some mentally handicapped people in hospital are more usually due to additional psychiatric or behaviour disorders than to intellectual retardation or diminished social competence.
I know that this is the view of the National Society for Mentally Handicapped Children and of other bodies which work on behalf of mentally handicapped people. They argue also that including mental handicap in the measure has the unfortunate effect of equating it in some people's minds with other forms of psychiatric disorder. The society and others pressed strongly for separate legislation for the mentally handicapped. This advice came from organisations which 649 are highly respected for their contributions to policy-making. They are organisations with which I have had much contact over many years. Our rejection of the advice was not taken lightly.
After thoroughly exploring the various arguments, we decided to retain mental handicap within the Act chiefly because we believe that there is a group, although it is small, of mentally handicapped people whose mental handicap is uncomplicated by mental illness or personality disorder but who nevertheless need to be compulsorily detained in hospital to ensure that they get the care and training that they need, or who need to have a guardian to take decisions that they cannot take for themselves.
Statistics show that only three out of every 100 patients admitted under a compulsory order are there on the ground of mental handicap. I know that in the vast majority of cases care can be provided without recourse to compulsory admission or guardianship in the community. The burden of the professional advice available to me is that there will be some, although a small group, of mentally handicapped people for whom compulsory powers are needed and for whom the only realistic course is hospital care.
In theory, the Government could maintain their established view on the need for compulsory powers but could differentiate between mental handicap and mental illness by introducing separate legislation for mental handicap. Two different pieces of legislation setting up similar arrangements for two different, but sometimes overlapping, groups would cause confusion and difficulty—not least for relatives and friends. The Government have, therefore, rejected the idea of separate legislation for its own sake.
I cannot emphasise too strongly that, although we believe that there is a need for compulsory powers for a small minority, we agree wholeheartedly that the mere fact that a person is mentally handicapped is no justification in itself for the use of compulsory powers. For the vast majority of the mentally handicapped they are irrelevant.
§ Mr. Moonman
My right hon. Friend mentioned that the White Paper was just about right in terms of needs and so on. He has rejected the idea of separate legis- 650 lation for the handicapped. Is that in line with representations made to him by the various organisations concerned?
§ Mr. Ennals
I said that I had received representations from the National Society for Mentally Handicapped Children and other organisations which deal with the mentally handicapped. It is interesting that a report just published by the Royal College of Psychiatrists took the opposite view and welcomed our decision. On every controversial issue I have received representations from diametrically opposed opinions. The task of the Minister sitting in the middle is to weigh up those opinions and reach conclusions.
A further issue involves the rights of individuals which must be protected as far as is compatible with ensuring that the care and treatment which they require is made available. It is a tribute to the dedicated work of medical, nursing and other staff, and to the therapeutic advances that have been made, that the vast majority of patients accept voluntarily the need for treatment and the need to attend hospital either as an out-patient or an in-patient. This is because people are less frightened than they used to be and because the issues are more openly discussed. This is accepted as part of general treatment.
There are cases—although they are in the minority—when the patient does not accept that he needs treatment or refuses to agree to the treatment that is proposed. Staff have great professional skill in explaining sympathetically to the patient the need for and the nature of the treatment. Sometimes that skill does not prevail. What should happen then?
In 1959, the power to impose treatment was left implicit in the long-term detention powers of the Act. Nowadays we are aware that it is much better if the legal position on these complex and difficult areas is as clear as the ability of the legislator will allow. It is vital to the essential function of a hospital for mentally disordered people that the staff are not left uncertain of their legal position when they seek to provide treatment and care for their patients.
The detailed proposals which we have made are admittedly somewhat complex. But the circumstances of patients and the nature of treatment vary and account must be taken of these variations. First, any patient—detained or not—must 651 accept the normal pattern of in-patient care. That is unavoidable. Secondly, if the patient is wholly incapable of comprehending what treatment is being offered staff must be able, within certain limits, to treat the mental disorder so as to ameliorate—or, if possible, cure—the condition. Without this power the purpose of the detention would be frustrated.
We suggest that a relative or friend who takes a close interest in the patient should have the proposed treatment explained to him and should be given the chance to discuss the patient's needs.
Many detained patients are capable of understanding the purpose and effects of a treatment if it is explained to them in simple terms. A detained patient who is capable of this will have the right to refuse to accept proposed treatment—that is, if he is unconvinced by the efforts of staff to persuade him of the advantages. At the same time, the Government feel that there are some circumstances in which staff should be able to override his wishes. But it will be clearly subject to two safeguards for the patient.
First, we have accepted the Butler committee's recommendation that treatment should be imposed against the patient's wishes only if it is necessary to save life, to prevent violence or to prevent deterioration in the patient's condition. Secondly, we propose that except in an emergency the patient's wishes should be overridden only where a concurring second opinion has been obtained. I believe that thus far our proposals meet with general approval. Indeed, they are generally in line with existing good practice. It is when we come to the form that the second opinion should take that we enter more controversial waters.
Hon. Members will know that the White Paper proposes the establishment of a multi-disciplinary panel for the purpose of giving second opinions. We envisage that this panel will have substantial medical membership, but we suggest that it should also include a lay member. Most medical opinion is opposed to this suggestion on the ground that the panel would be interfering with professional, clinical judgment. I appreciate the strength of this view and I recognise that the doctrine of clinical freedom is pursued in the interests of the patient for whom the doctor takes responsibility. 652 What I find—and I think the House may find—difficult to accept is that the decision to override the wishes of a patient who, though mentally disordered, is capable of a valid consent should be left entirely in medical hands.
After all, other professions may be involved in the case and have important contributions to make on these difficult issues. More importantly, the rights of the patient to accept or refuse treatment require a full and careful consideration of the expected benefits. This is not solely a medical matter.
The White Paper therefore proposes a multi-disciplinary panel to give second opinions. We do not suggest that the panel should usurp the psychiatrist's role. There is no question of the panel expressing an opinion on the clinical quality of the proposed treatment. The panel will not suggest alternative forms of treatment, nor will it seek to influence the future management of the patient in any other way. The panel will try to reconcile the duty and aim of the doctor and the staff—which is to treat the patient—with the fundamental requirements that the patient's rights and liberties should be respected. As part of our further consultation on the White Paper, we intend to discuss with the professional and staff bodies concerned the membership and working methods of the proposed panels.
With uncertainty about the law on treatment having been clarified, I hope that members of the medical profession will recognise that the proposed panels will enable them, as a profession, to participate in a fair and balanced approach to what are very difficult questions.
§ Mr. Christopher Price (Lewisham, West)
My right hon. Friend has set out the position very fairly. He said that the medical evidence would be substantial, but does he see the medical profession having, as it were, a majority holding on a panel—with a lay minority holding—or does he see the medical profession on the panel having a minority holding? That is at the root of those difficult cases where the composition of the panel might be important. That is one of the matters in which the medical and other professions are interested.
§ Mr. Ennals
I understand the point behind my hon. Friend's question. He tempts me to commit myself, but I will 653 not be tempted. [HON. MEMBERS: "Be tempted."] No, I resist all temptations. It is important that we should now proceed to proper consultation. I have already said that that is what we intend to do. We intend to discuss with the profession and other bodies the membership and the working members of the proposed panels. I think that if we were to reach hard conclusions before that consultation took place we would close some options, and that would not improve the possibility of getting agreement, which is what we want to do.
We recognise that there are some sorts of treatments where special safeguards—over and above the safeguards that will ordinarily operate—are needed. These fall into three categories—that is to say, "irreversible" treatments; "hazardous" treatments or "not fully established" treatments. The special safeguard would be that both the agreement of the patient concerned and a concurring second opinion should be obtained. This would apply to "irreversible" procedures such as psychosurgery.
When I launched the White Paper I was asked questions which I could not answer, and I promised that we would soon have better statistical information on psychosurgery. We now have that information. In 1977, 44 operations were carried out in England and Wales. When one looks at these figures in the context of the number of people who receive a form of treatment for mental disorder, one finds that they are very small indeed.
In a typical year, an estimated 5 million people with a psychiatric problem visit their general practitioners and 3,300,000 visits are made to day hospitals or outpatient clinics. However, even though the figure is small, in no area of mental health are the safeguards that we propose more important than in psychosurgery.
The protection of patients does not relate solely to this difficult issue of consent to treatment. Unnecessarily prolonged detention is another serious breach of a patient's rights. On this front we have set out important reforms. The patient's right to apply to a mental health review tribunal will be virtually doubled by halving the period after which detention must be renewed. In addition, we have several detailed proposals which are designed to extend and develop the functions of mental health review tribunals.
§ Dr. Gerard Vaughan (Reading, South)
The Minister has just given some very interesting figures on psychosurgery. Will he confirm that those figures represent the total number of patients, including informal and detained patients, or is he referring to detained patients only?
§ Mr. Ennals
That is the total number, including both detained patients and non-detained voluntary patients. That shows what a very small figure we are talking about, but that is not a reason why we should say that we need not worry.
In proposing to make clear what the rights of patients are, I recognise that we must make sure that the legal position of staff, which is the fourth issue I wish to raise, is also quite clear. The two are closely interrelated. We must reduce as far as we can any uncertainty about the legal position of staff so that they are not distracted from the task of managing and caring for their patients. There is no doubt that staff who care for mentally disordered patients have an arduous and demanding job which requires great skill and humanity. I know from my long experience of mental health work how true this is. We must be satisfied that they can approach this task conscientiously without always feeling that they must look over their shoulders.
The amendment and clarification of the law, and the clear central guidance which we propose, will, I believe, enable staff to concentrate on the job of caring for patients and will strengthen their confidence in tackling the difficult situations that can arise on a ward. The new "holding power" which we propose for registered mental nurses and registered mental nurses for the subnormal is designed to cater for the situation where an informal patient either becomes extremely disturbed on the ward or wishes to take his discharge and where a doctor is not immediately available. Nursing staff may well feel that they have reasonable grounds for preventing the patient from leaving hospital because he could be a danger to himself or others, even though he is a voluntary patient. But if there is no clear emergency they may be uncertain as to how far they can go because the patient is informal and is not subject to compulsory powers. The new power that we propose will last for six hours, long enough to enable a doctor to be called to deal with the case, and its 655 existence should reassure staff of their position.
Section 141 of the Act provides protection for staff in the event of civil or criminal proceedings being brought against them in relation to their actions under the Act. In its present form, however, it represents a very considerable obstacle for patients who are seeking access to the law. It is here that the question of achieving a proper balance arises. It seems to the Government that we can maintain a full and adequate protection for staff against mischievous or frivolous prosecutions, while at the same time strengthening the access which patients have to the law.
The central proposal is to remove criminal actions from section 141 and transfer them to the same section—section 126—which covers the ill treatment of patients. This will mean that the Director of Public Prosecutions, rather than the High Court, would have to give leave before criminal proceedings could be taken against staff.
The fifth issue which I wish to touch upon concerns the mentally disordered offender. Three-quarters of mentally disordered offenders admitted to hospital—some 770 out of 980 in 1976—are under section 60 of the Act without restrictions, and their position is virtually the same as that of a person admitted under one of the civil powers.
There is, though, a small group of mentally disordered offenders who would, in the opinion of the court, based on expert medical opinion, be likely to commit further and serious offences if released too soon. To guard against this risk of premature discharge, section 65 of the Act empowers a court to impose restrictions on the discharge of the offender. The effect of the restrictions is to require the approval of the Home Secretary should it be desired to discharge, grant leave to or transfer the patient. The duty of the Home Secretary is to have particular regard to the need to protect the public.
Offender patients, to whom the provisions of section 65 are applied by the court, are usually referred to as restricted patients, and the White Paper devotes a lengthy section to their position. Several detailed changes are proposed, the most important of which draws upon a sugges- 656 tion of the Butler committee that the wording of section 65 be amended so as to indicate clearly its essential purpose—which is to protect the public from serious harm.
I realise that there are strongly held views about other aspects of section 65 where we have decided, after the most careful consideration, that the Government cannot recommend changes. The first concerns the power that courts have to impose restrictions on an offender for an indefinite period. It has been argued strongly, by MIND, BASW and others, that the court should be empowered to make an unlimited restriction order only where the defendant was convicted of a serious offence, for instance, involving serious violence against the person. They point out that criminals who it is known are dangerous are released from prison when they have completed their sentences, whereas some restricted patients may have been convicted of relatively minor offences but may be faced with an indefinite period of detention. In my view, this argument pushes the analogy with criminals too far. The length of a prison sentence is meant to be directly related to the gravity of the prisoner's offence.
However, section 65 is not concerned with the nature of the offence in this way; rather, it is concerned with the future needs to guard against premature discharge. I want to point out that although restrictions may be imposed for an unlimited period their duration does not bear any relationship whatever to the length of a notional prison sentence. The Government have, therefore, come to the conclusion that the balance of advantage lies with leaving the law as it is.
§ Sir Derek Walker-Smith (Hertfordshire, East)
The right hon. Gentleman says that the Government would leave the law as it is, but a moment ago he said that section 65 was not concerned with the nature of the offence. Of course, that is a requisite of section 65(1), which states thathaving regard to the nature of the offence, the antecedents of the offender and the risk of his committing further offences if set at large ".All those things must statutorily be taken into account, and then it must be necessary for the protection of the public. Those are the criteria that are spelt out by the Act, and I apprehend that the 657 right hon. Gentleman proposes to maintain them in this form.
§ Mr. Ennals
I am grateful to the right hon. and learned Gentleman, who knows a great deal about this subject. I appreciate his intervention. I was saying that the provisions that he quoted are ones that will not be changed when we bring the legislation before the House.
§ Mr. Graham Page (Crosby)
Surely that will go hand in hand with annual reports on the patient. I think that the White Paper says that the Government accept the idea of annual reports with statutory backing.
§ Mr. Ennals
I would want to check that before I gave the right hon. Gentletleman an answer. With permission, perhaps I can ask my right hon. Friend to confirm whether or not that is exactly so.
Much attention has been focused on the ability of the NHS to accept and provide care for those patients who are difficult to manage or who are likely to be violent or disruptive. A patient is not necessarily difficult to manage or violent simply because he is an offender, or simply because he is the subject of a restriction order.
The White Paper acknowledges that there has been an increasing reluctance on the part of some hospitals to accept patients whom they feel would be particularly difficult to manage. This has been highlighted by the publicity given to cases involving offenders whose mental disorder warranted detention in hospital for treatment but who have to be sent to prison, or kept in prison, for want of a suitable hospital place. It has been argued that the solution to this problem is simple—that the courts should be empowered to require a hospital to admit an offender where there is the appropriate medical evidence that he is mentally disordered and that his condition warrants hospital admission.
Let me explain the reasons for the reluctance of some hospitals to accept these patients. In brief, it is an inevitable consequence of the beneficial changes made in the care of psychiatric patients over the last two decades and of the resulting change of attitudes of staff. The last 20 years have seen a move to a much more open therapeutic environment in 658 psychiatric hospitals. This change, which is still developing and which permeates every facet of hospital life, has brought immense benefit for patients, staff and the public. Inevitably, a freer and more open approach makes it more difficult to manage patients who are extremely violent or disruptive, or who need secure accommodation of some sort.
In particular, staff sometimes feel that they might jeopardise the hard-won advances made for the benefit of the patient if they have to cater for a small but difficult group. They do not want to go back to the days of the locked wards. They may also feel that the security needs of a few will absorb too much of the staff time needed for the treatment and care of patients as a whole. Moreover, where the patient concerned is restricted, doctors may sometimes feel that their hands are too much tied by the restrictions that require them to seek the Home Secretary's consent before allowing a patient out of hospital on leave, or discharging or transferring him.
I believe that it would be quite wrong for Government to invite Parliament to give the courts the power to oblige hospitals to accept patients for whom they did not feel they could offer appropriate care and treatment. I am glad that the hon. Member for Reading, South (Dr. Vaughan) agrees, because it is a controversial matter.
§ Mr. Kilroy-Silk
My right hon. Friend may welcome the support of the Opposition, but I do not agree with him. He talked a great deal about the right to give treatment to patients who refuse that treatment. Will he now spend a little time telling us whether those patients who are disgracefully put into prison because NHS hospitals will not accept them also have a right to treatment? How will my right hon. Friend ensure that mentally disordered offenders are not kept in inhuman conditions in hospitals, and that they receive, as of right, proper medical care and treatment under hospital conditions?
§ Mr. Ennals
I presume that my hon. Friend got his argument twisted and that he was really talking about "conditions in prison". I recognise that this is a problem. In fact, I have had discussions with my right hon. Friend the Home Secretary about ways in which there can be an improvement in the psychiatric 659 treatment of those who are in prison and who need such treatment. That is a real problem, and I do not want to duck it.
§ Mr. Michael Spicer (Worcestershire, South)
I merely seek a point of information. Of the 200 restricted patients whom the right hon. Gentleman mentioned earlier, how many does he estimate are in the two special hospitals and how many are in the hospitals about which he is now talking?
§ Mr. Ennals
I cannot give that breakdown without notice. My right hon. Friend will deal with it when replying to the debate, or in answer to a parliamentary question or in some other way I shall ensure that the hon. Gentleman gets an answer. The point that I was on prior to the interventions—
§ Mr. Ennals
I tried to answer it. I am coming to part of it, because I want to deal with the question of regional secure units, which is an important issue about which my hon. Friend is extremely interested. The other part of his question was whether we could improve the psychiatric care of those who are at present in prison. We must look at both sides of this problem. We must see how we can provide better circumstances in which people who are in prison, but ought to be in hospital, can get treatment in hospital, and how people in prison can get psychiatric treatment. I believe that we must deal with both points.
I can assure hon. Members that the NHS has an obligation to provide a range of facilities to meet the variety of different needs of the community it serves, and patients who are difficult to manage are no less a part of that community than those who are co-operative and amenable.
I mentioned regional secure units, but I am not suggesting that they will be the answer to all our problems; far from it. However, they will provide secure accommodation for those patients who require a degree of security less than that of special hospitals but greater than that in local psychiatric hospitals. Our programme for their development, as hon. Members will be aware, has had considerable difficulties. But over the last three years we have made great efforts, and 660 progress has been made with regard to interim secure units.
There are now about 100 places in designated interim units, and we plan to double this number by the end of the year. However, I cannot pretend that progress has been uniform by any means. The process of influencing attitudes is a slow and gradual one, but I believe that the efforts we are making are beginning to produce practical results. This is something in which my right hon. Friend the Minister of State has himself been actively involved. There are attitudes of staff, attitudes of unions and attitudes of local residents to the establishment of secure units. There are many obstacles that we must try to overcome.
We have now decided that because of the very high priority that we attach to these schemes, further funds should be made available to those regions where the Department feels that they are needed. The extra allocations will be made available to regional health authorities as the units are established, so long as we are satisfied that the money we are already allocating is being fully spent on secure units and that an additional contribution is required for a particular unit.
§ Mrs. Lynda Chalker (Wallasey)
Will the Secretary of State outline how many of the regions that have the money for the interim secure units are not fully utilising them at present? From visits and talking to people about this, we feel that hardly any of them are using fully their present allocation.
§ Mr. Ennals
The position is not nearly as bad as the hon. Lady suggests. My right hon. Friend has devoted a good deal of time to this issue and intends to deal with it in winding up.
The sixth and final issue that I wish to raise is guardianship. This chapter in the White Paper is "green-edged", and we have put forward our thoughts as the basis for consultation. Guardianship takes us away from hospital services to the personal social services provided by local authorities. I opened my speech today by saying that the White Paper on the review was written to complement our strategy on resources. The options that we have put forward for the refinement of existing powers of guardianship are a good example. We want to see a shift in the balance of care from hospital 661 to community, and this has been and remains a central factor in our overall strategy. We have therefore sought comments on various ways of adapting compulsory powers so that they can provide a flexible means of making services available to clients in the least restrictive setting possible, whilst still providing any necessary guidance and control.
Before looking more closely at these options, I want to mention the fundamental suggestion that has been put to me that the Government should enforce their strategy of shifting resources from hospital to community by means of legislation, that mandatory duties should be placed on local authorities and that health authorities should be obliged to transfer their resources into the personal social services.
I fully understand the case that is made, but, frankly, creating new legislation does not create new resources; nor can legislation of itself bring about the transfer from one sector to another of trained manpower or of physical facilities such as buildings and equipment. It is a relatively simple matter to direct finance. However, any fundamental structural change of this kind can only take place gradually. There are powers that exist without further legislation, and I have turned down proposals to introduce new powers into the Act.
It is against this background that we hope to see the use of guardianship powers on the mentally ill or mentally handicapped living in the community adapted to new purposes. Guardianship has not been used nearly as much as the Percy Royal Commission hoped. The White Paper argues that this may be due in part to the all-embracing nature of the power that stems from guardianship and that is not viewed by authorities and their social work staff as being appropriate to the community. Our aim is to adapt the powers more closely to the need in the community to provide alternatives to compulsory hospitalisation.
We have also suggested that a guardian might have a useful function in relation to informal patients. We are thinking here of the informal patient who is so disordered that he cannot be held to agree or refuse to enter hospital or to accept or decline treatment. That category of non-protesting patient may be particularly vulnerable and needs someone to take 662 decisions on his behalf. We have suggested that the appointment of a guardian might help. The guardian would look after the patient's interests in matters of consent to treatment. He would also be alert to the need to ensure that a stay in hospital is not unnecessarily prolonged. Once the patient left hospital, the guardian would represent a ready-made link, guide and mentor when the patient was ready to return to the community.
I have picked out six issues which I felt merited some close attention this afternoon. I selected these six not only because each of them is important but because, as a group, they exemplify the thinking and philosophy that have formed the basis of our review. Of course, there are many other issues which are discussed in the White Paper. In every case we have made the fullest use of the many comments and suggestions that we received.
As the House knows, our intention is to embody in a Bill the proposals contained in the White Paper. The essential exercise of consultation and discussion on these proposals is not yet complete. The task of analysing the comments and preparing legislation is already in hand and we would hope to put a Bill before the House towards the end of this year.
§ Mr. Robert J. Bradford (Belfast, South)
Would any subsequent amending Act apply to Northern Ireland? Northern Ireland operates under the 1961 Act passed in the former Stormont. Therefore, would any subsequent Act apply directly to the Province or would an Order in Council have to be applied?
§ Mr. Ennals
No decision has been taken, nor would it be taken without consultation with the Secretary of State, who would also wish to consult others.
The reforms proposed in the White Paper will, when enacted, mean that all remaining legislative distinctions between informal patients and patients who are in hospital for some physical illness will be removed. We want to ensure that all patients—formal and informal—receive full and clear information on their legal position and rights. We intend that this should be in a form that they can readily understand. But because we know how difficult this may be we also intend to set up and evaluate some schemes of patients' 663 advisers. The aim will be to provide further support for staff in protecting the interests of those patients who have most difficulty in understanding their position. However, we can best help informal patients, and also detained patients, by continuing to improve the quality and quantity of our services.
If we are to continue the process of improving mental health services, we must provide a clear and balanced legal framework to support it. That is the aim of the White Paper, and I believe that it will have the support of hon. Members on both sides.
§ 5.7 p.m.
§ Dr. Gerard Vaughan (Reading, South)
The House listened with great interest to what the Secretary of State said and particularly the way in which he opened the debate. He was right to begin by saying that this was a subject for great compassion. Although often the numbers are small, the implications of the law and the changes of the law proposed are of immense importance to individuals.
It is not an easy White Paper to debate. It makes over 100 different proposals. Some are small but almost all are of great importance. I shall not cover the whole of the White Paper but will concentrate first on a few general issues and then on other points that we think are especially important, because I know that many hon. Members wish to raise points based on their experience about which they feel strongly.
Looking at the White Paper, the comments on it and the general articles, no one could fail to realise how much work has been carried out by MIND. It is due largely to its repeated pointing out of the shortcomings of the 1959 Act that we are today debating the White Paper. I also recognise the important contribution of the British Association of Social Workers, Dr. Bluglass and the Royal College of Psychiatrists.
The 1959 Act followed the excellent report of the Percy Commission. But, more than that, it followed several major breakthroughs in psychiatric treatment. In the early 1950s I worked for a time in a psychiatric hospital. I remember vividly the locked wards and the bunches of keys—an appalling situation. I remember also the aimless, futureless mass of pat- 664 ients herded together. Nobody really knew what to do with them and they did not know what to do with themselves.
Then there was the advent of electro-convulsive therapy. It is important to remember when ECT is criticised today that it transformed the situation. Then there were drugs such as largactil which transformed the situation even more and made it possible for the first time seriously to consider unlocking the wards and returning people to the general community.
The 1959 Act crystallised all this by putting in a legal framework the principle that psychiatric patients should have the same rights and be under the same conditions as patients with physical illnesses. I think that the White Paper is a little complacent when it says that so much has been done. Even today the informal psychiatric patient is not really on quite the same footing as the non-psychiatric patient. He has hanging over him the possibility that he could become a formal patient if his illness became worse or if other problems arose.
The 1959 Act provided that psychiatric hospitals should be for treatment only. Although we have moved some way, we have not yet achieved that objective. These hospitals are still used for care and custody and not just for treatment. However, we are moving in the right direction.
Since the 1959 Act, treatment has progressed. We now have the long-acting drugs which have helped so much in cases of schizophrenia. We also have anti-depressants which have largely replaced the queues for ECT. Now the law can be changed towards liberalisation of the care of patients. I am sure that every hon. Member welcomes this possibility.
It is that possibility which makes the White Paper so important today. The other day the Bill of my hon. Friend the Member for Chertsey and Walton (Mr. Pattie) was universally welcomed. That is a sign of how various people working in this field are prepared for some quite major changes in mental health legislation. The Government are right to consider amending the Bill. The most important question is what compulsory powers, if any, are needed outside hospital in the community.
665 This White Paper is supremely important because it deals with the dignity of man, when his capacity to control his own destiny has gone or has been reduced because his mind is disordered. It deals with the extent to which his freedom can be removed by society in order to help him, and it deals with the protection which society exerts for its own sake against him. We must recognise that there are times when society puts its own protection before the interests of the individual.
Despite the fear we all have about mental illness, these are great personal issues. We should have expected that a White Paper dealing with them would have been universally welcomed. In fact, the Secretary of State, in his opening speech, spoke as if this was a great triumph. Perhaps it is from his point of view. But, sadly, that is not the general view. It seems that nobody is particularly pleased with the White Paper—everyone seems to have reservations and criticisms of one kind or another. The British Association of Social Workers says:This timid paper with its myopic vision…rarely lifts its head to see which way we are going…It fails to promote new initiatives,…fails to lead and inspire in the manner of the great Act which fathered it.Rather harsh words, but that is what was said. Wherever one looks there is criticism. Tony Smythe, the director of MIND, says:The DHSS has thrown down a woolly glove. There in the slush it will lie until after the general election ".The Guardian started with praise under the titleActive Ennals Stout of Heart ";but sadly a few days later, after closer examination, it said that the White Paper was "woolly…pusillanimous".
These criticisms result from the Government's failure to follow up "Better Services for the Mentally Ill" which was published by the right hon. Member for Blackburn (Mrs. Castle) when she was Secretary of State. The 1959 Act also failed in many ways because it was not given the resources to back it up. Sadly, we in this House have had to face the implications of a number of Acts—the Children and Young Persons Act, the Chronically Sick and Disabled Persons Act, the Mental Health Act 1959 and the 666 Children Act—all of which have raised hopes and then resulted in a great deal of disillusionment. Although Parliament has passed the legislation, it has not always provided the resources to carry it out. That is our main criticism of the White Paper.
We believe that the Government have grossly underestimated the resources needed in terms of buildings and staff. The proposals for violent patients, for example, are absolute nonsense unless more special units are provided. The hon. Member for Ormskirk (Mr. Kilroy-Silk) clearly recognises this. There are also the anxieties of the unions, particularly COHSE, about the facilities. Already some hospitals think it necessary to send out a union representative with a doctor to examine a patient and see whether the hospital is prepared to accept him.
We should have liked in the White Paper a much more realistic and up-to-date review of the mental health services. The Secretary of State has gone some way in giving us some figures, but he has not gone far enough. He sounded far too complacent in talking about the increase in the number of nurses. He knows, as we all do, that many mentally ill patients, and particularly mentally handicapped patients, are housed and treated today in the most appalling conditions. Many wards have inadequate staff. I know of wards where beds are closed because there are insufficient nurses to look after the beds, even at a low level of nursing care.
For the mentally handicapped we must depend very largely on the services of overseas-trained doctors. There are now some posts which it is impossible to fill suitably. This is the context in which we should look at any changes in the law.
§ Mr. Ennals
I do not know why the hon. Gentleman is making these points, because the whole purpose of this substantial and complicated White Paper is entirely to review the Mental Health Act. White Papers have been produced dealing with the provisions within the community and within hospitals. It would have been confusing for the House and for the public had we included that in the White Paper. I should have thought it right to concentrate entirely on the legislative provisions.
§ Dr. Vaughan
I was just coming to that point. We are afraid that by narrowing the vision only to the 1959 Act the Government will shelter behind the proposals in the White Paper and avoid facing the real and urgent issues for mentally sick people in our community. If the Secretary of State can reassure us about that, one of our major criticisms of this White Paper will disappear.
§ Mr. Stephen Ross (Isle of Wight)
I entirely agree with what the hon. Gentleman is saying. We listen with interest to the view of the official Opposition. Is there to be considerable public expenditure in that direction if the Conservative Party comes to power at the next general election?
§ Dr. Vaughan
The Opposition can promise that they will not brush on one side an appreciation of what is going on. We shall not take the complacent approach of the Secretary of State—that only improvement is needed—when we know from various inquiries that many places are an absolute and total disgrace.
It seems that much of the White Paper is cast the wrong way round. We have a campaign for the mentally handicapped to which the right hon. Gentleman referred, and we also have Exodus, which is aming to get all mentally subnormal children out of hospital. However, the exodus out of Egypt meant 40 years spent in the wilderness. We do not believe that the approach of Exodus is completely right, nor do we think that the right hon. Gentleman's approach is realistic. We need a campaign of entrance into the community. That is the approach that we want him to take. We hope that he will take a much closer interest in community barriers that prevent patients from returning into the community. I am sure that that is a philosophy that the right hon. Gentleman shares.
We are disappointed that the Government have not seized the opportunity to face the problems in the community for the mentally sick. One small step in that direction would be to remove mental subnormality from future legislation. I refer to "mental subnormality", the old name for the condition, because to change its name is merely a euphemism. To make that change does not alter the situation. There is surely no need for mental sub-normality to be a special category within 668 an Act dealing with mental illness. Surely low intelligence on its own does not make a person a danger to the community. To put mental illness and low intelligence together is an insult, and a cause of confusion, to the mentally subnormal. It is interesting that it is mainly the junior doctors working in psychiatry who seem to take that view. They feel that mental subnormality should be removed from the psychiatric sector and treated as a condition of low intelligence.
When we consider the reasons for detaining a mentally sick person who may also be mentally subnormal, we should also consider, as MIND has said, the behaviour that leads to detention. It is not mental illness that leads to detention but the behaviour that follows certain types of mental illness. As the right hon. Gentleman will realise, a person may be mentally ill and suffering from a certain condition but be a perfectly acceptable informal patient. That is why the level of detainees has been reduced to 7 per cent. There is a strong argument that it is the disorder that goes with certain types of mental illness that should be recognised in the Act rather than specific sorts of mental illness and disability.
I turn to some of the specific proposals. We welcome the proposal that a written statement should be given to patients setting out their rights of admission and their rights to leave, provided that it is made clear that it must be safe for them to do so. That needs to be specifically stated in any written document. We welcome the proposal that if a patient's status is changed he should be properly informed of that change within 24 hours.
The most relevant feature is that whatever information is given to the patient must be in a form that he can understand. If he is mentally ill or of low intelligence, the wording, or the explanation from the hospital staff that goes with it, must be of a character that enables him to be properly informed. The Royal College of Psychiatry has observed that the new definition of treatment, which includes behaviour techniques, habilitative techniques and training techniques, may all lead to problems if they are not properly supervised. No doubt the Government will want carefully to consider that point of view.
The suggestion that certain nurses should have the right to detain a patient 669 compulsorily for a short period is extremely important and a good advance. It will remove much of the confusion about whether a patient may be restrained for a short time while other measures are considered. I do not understand why the period needs to be six hours. That seems to be an extraordinarily long period. Surely in any hospital it should be possible to obtain an experienced doctor within two to three hours and the necessary social work back-up to get the patient on a proper detained basis. Six hours would be unnecessarily hard on certain patients.
Significant in the White Paper is the recognition that social workers, if they are to oversee the compulsory arrangements—most of us want that to continue—must have special experience. The generic social worker has been a total disaster. We have all come across instances where a young generic social worker, changing her job every week, confused, bewildered and often frightened by what has been asked of her, is totally out of her depth when it comes to judging whether people should be put on a compulsory order and where they should go. It will be a great advance to have a specially trained social worker who knows what he or she is doing to the same degree as the old mental welfare officer.
It is surprising how little reference is made in the White Paper—it is a serious fault—to the standards required of doctors who will operate under section 28. There is an urgent need for criteria to be set out for selected doctors. There is a great shortage of suitably qualified general practitioners.
I have not gone into the proposals for the tribunal reviews. My hon. Friend the Member for Wallasey (Mrs. Chalker) will deal with that matter and others when she addresses the House. It seems that the White Paper proposals would be an advance and an improvement on the present procedure. We are worried about the resource implications in terms of staff in the hospitals and the members of the tribunals. We do not think that the Government have faced the implication of their proposals.
There are the curious features of consents to treatment, to which the right hon. Gentleman referred, and the treatment of detained patients. One of the most important steps in the 1959 Act was to make 670 psychiatric treatment available in the same way as any other medical treatment. The White Paper appears to be moving in the opposite direction. It is strange to have to raise the issue, but surely where informal consent is available there is no basis to erect a barrier around the administration of treatment. There must be consent between the informal patient and the medical staff. If there is not, it will be impossible to carry out treatment.
I cannot understand the provisions in the White Paper in this respect. For detained patients, it seems to many of us that the question of consent has already been dealt with legally by arranging for compulsory detention. The proposal of a second opinion for irreversible or hazardous treatments makes great sense. This has been the general practice of good doctors in this field for many years. It is not a new proposal. It is not only in the psychiatric field where this occurs. If one is presented with a complicated decision over an operation, most surgeons will turn to another surgeon for a second opinion.
What seems strange is that the Secretary of State appears to be suggesting that if an experienced psychiatrist has decided that a particular kind of treatment is necessary, he should turn not to another experienced psychiatrist but to a panel of people, some of whom will have had no experience in that field. It makes absolute nonsense of a lot of medical training. Why spend up to 10 years training to become a psychiatric consultant and then have one's view of what is best for a patient reversed by someone working in a different speciality who may have spent only two or three years in training?
§ Mr. Christopher Price
The hon. Gentleman is making a comparison between an experienced consultant and a less experienced professional of some kind. Would he not agree that many professional nurses in psychiatric hospitals have had about 100 times more experience of the needs of psychiatric patients than the doctor who has regular but very much less intensive contact with the hospital?
§ Dr. Vaughan
The hon. Gentleman has made a good point. It is a matter that we shall have to debate before legislating.
There was an interesting article in The Guardian recently on this subject. 671 Sadly, it confused the multi-disciplinary team with a multi-disciplinary panel. I can understand that some of the medical profession have become upset. No experienced psychiatrist, to my knowledge, would embark on a doubtful form of treatment without discussing it first with his multi-disciplinary team—not only the nurse and the ward sister but also the social worker and the psychologist. The psychiatrist will have formed his view from the report of this team as well as from his own experience. This is a matter which many hon. Members will want to consider further.
The White Paper seems to us to have raised many excellent issues. We query whether the Government have faced up to the question of the resources which will be required. We think that they have underestimated them. We should have liked to hear much greater emphasis put on the needs of the community. I hope that the Secretary of State will not use the White Paper and any future legislation on it as a substitute for facing up to the urgent needs of the mentally ill and the mentally handicapped.
I started with a comment by MIND. I end with a comment from MIND:Even disappointing White Papers can serve a purpose: in this case they give us time to debate these issues and to come up with better and more relevant solutions to some of these very large problems.I hope that the Government will face the challenge realistically.
§ 5.35 p.m.
§ Mr. Eric Moonman (Basildon)
It is regrettable that over the past 20 years since the 1959 Act was passed, and increasingly within the past 10 years, when we have discussed mental health it has always been because a report has suggested ill treatment of patients, that there has been abuse or something has happened that has demanded the attention of the Secretary of State. This occasion is therefore to be welcomed. It gives hon. Members a chance to examine not only what needs to be put right under the Act but also what sort of Act we should like. We can also give thought to the services that have been operating.
Reference has been made to the fact that this is the first real opportunity we have had to put another Bill on the 672 statute book. I wonder whether the proposals are courageous enough. I make this as a general comment and will return to specific issues later. Many of the items in the White Paper are most creditable, but they reflect issues which we have faced for the last 20 years.
A Bill, if it involves taking decisions for the next 20 years, must also anticipate the future. In addition to matters that will need to be put right, based on our hard experience over the last 20 years and information and evidence given to the Secretary of State, a new Act should also anticipate as intelligently as possible what will be needed in the mental health service over the next five to 10 years.
The White Paper does not give any encouragement to those who have argued the need to avoid the discrimination between the mental health service and the general hospital service. This happens in the most extraordinary ways. It affects the number of nurses made available to psychiatric hospitals and to mental health and mentally handicapped hospitals compared with general hospitals. It reaches even the cost of feeding patients. There has never been any justification for the fact that it costs £8.18p a week to feed a patient in a general hospital and almost half that amount to feed a patient in a mental handicap hospital.
The Secretary of State was right in stating that his aim was to put right many matters. But we have the opportunity to bring together the two parts of the National Health Service in the course of implementing this White Paper. We need to deal with the element of discrimination in the mental health service. We can then have an Act on the statute book which not only serves us for some time ahead but which also tries to remove some of the unjustifiable anomalies that have been part of the burden of the mentally handicapped and the mentally sick.
The hon. Member for Reading, South (Dr. Vaughan) was right to mention the enormous help given by outside bodies, such as MIND, the hospitals and the Royal College of Psychiatrists, which have provided us with background material. I hope he will agree that the all-party committee in the House has played an important part. In 1966, when I first became a Member of the House, we tried to raise 673 some interest in this subject. We did not try to do so in the Chamber because we knew it would not attract great interest here. It is a subject which interests hon. Members when a problem has been raised by constituents or because they see an issue that needs to be put right. We can discuss it upstairs in Committee Rooms with outside experts to brief us on the needs to improve the service.
The all-party committee has helped enormously in bringing to the attention of hon. Members what needs to be done. It has done much good educational work. In 1966, it was not possible to get more than two or three hon. Members to attend a meeting on this subject, but many more hon. Members are now interested. It is not a party issue. The great success of the committee is that it is not in the pocket of any party or Government.
I wish to deal with a number of specific points. The troubling feature about emerging attitudes towards the treatment of the mentally ill is the obvious conflict that has been created between local authority services and the medical profession. We have seen, in the name of "clinical judgment", patients who may be troublesome because of their illness refused admission or patients with marked residual symptoms discharged when they are unable to cope within the community. In some quarters, it is assumed that the distress of those patients will force the local authority to take action. The patient becomes a pawn in promoting new resources, mostly without success.
We have seen increasing doubt and distress about the reliability of the social services and a reciprocal response to hospital services. Health care planning teams, joint planning and other devices have not solved the problem. It is likely, is it not, that the best solution is for rehabilitation and day care to be a continuous process from the hospital?
That aspect was touched on by the Secretary of State and I wish to amplify it only a little further. We must ensure that conflicts of initiative do not promote avoidable anxieties and avoidance of responsibility. After all, the treatment of a broken limb and the subsequent rehabilitation to a restoration of functions are not seen as divided functions. Why should a broken mind be so treated?
Obviously it is not as simple as that, but fragmented responsibility means that 674 those who wish to do so can more easily avoid their fragment of responsibility when the demands are too great for them rather than expose their inadequacy or demand help. We are talking about the crisis of leadership. We must not pretend, as many do, that all our medical and nursing care is superb. Psychiatric care in its many aspects demands much of the personalities involved, and from time to time their judgment is faulty and unsavoury incidents occur. I am not necessarily referring to Normansfield or Ely.
The Act seeks to offer the best possible protection for patients and staff alike, but let us not forget the protection of the relatives and the public and their need for support. The attitude of some groups towards, for example, medium secure units is disgraceful. Although money is available, the setting up of such units is resisted by fairly powerful forces. The relatives and the public carry the burden, particularly in the poorer areas whence most of the problems emerge.
My right hon. Friend mentioned medium secure units, and no doubt we shall hear more about them from the Minister of State. Something more than resources is required here because the resources have already been allocated. What is required is the will to ensure that in every part of the country there is such a facility and a common understanding that great courage is needed by the Department and the areas concerned.
One or two hon. Members have had the opportunity to visit the Prestwich hospital in Manchester. We found to our dismay that, although there is a great deal of good will and much work has been done in trying to establish a medium secure unit, there are problems that will not be easily overccome unless courageous and bold decisions are taken. I hope that the Minister of State will refer to that problem when he replies to the debate. There is a feeling on both sides of the House that we need action to take us from the stage of the blueprints to the stage of haying the units in operation.
I am not concerned with apportioning blame, but I hope that those who have resisted the establishment of such units, at Prestwich and elsewhere, will think again. I have listened to some of the objections of my trade union colleagues in NUPE and I am not impressed. They 675 must come up with a better argument if we are to believe that their case is about the patient.
My own region of East Anglia has no firm plans for a regional secure unit. It has identified a possible site, but there are all sorts of difficulties that should have been overcome by now. A run around the regions gives the same impression, although in the Northern region planning is advanced on a 30-bed unit at St. Luke's hospital in Middlesbrough and in Yorkshire planning is advanced on a 40-bed unit at Wakefield. Other hon. Members may wish to indicate the problems in their parts of the country. The good will exists, but it seems that we are not translating that into action and that is the great test of this part of the debate.
§ Mr. Kilroy-Silk
While my hon. Friend is dishing out gold medals to the regional health authorities that have made at least some limited progress, why does he not also point out that some have made no progress? The Oxford regional health authority has received almost £1 million and has not spent a penny of it on establishing a regional secure psychiatric unit or improving mental illness or psychiatric services in the region, but has retained the money in its regional reserves and has not submitted even a plan to the DHSS for the establishment of such a unit.
§ Mr. Moonman
I am not suggesting that medals are in order at the moment. It is better to look at medium secure units in a realistic light. We have had more than one discussion in the House on the importance and value of such units, not only for their own sake but because they would enhance and strengthen other elements of the mental health services. My hon. Friend's remarks are justified because some regions wish to have no part in taking on this important work.
§ Mr. Michael Spicer (Worcestershire, South)
Is not the true scandal that about £700,000 has been allocated by Parliament in the past three years to the region with which the hon. Gentleman is concerned and that only about £50,000 has been spent?
§ Mr. Moonman
That is a scandal, but I ask the hon. Gentleman to bear in mind 676 that the hon. Member for Chertsey and Walton (Mr. Pattie) and I felt when we visited Prestwich recently that the troubles there are affecting the willingness and initiative of other authorities to go ahead. If there were a willingness in areas such as Oxford, I would concede that they should take account of some of the problems, but the ripple effect of what is happening at Prestwich is extraordinary. People are being obdurate and cannot reach a compromise, and that is giving excuses to other regions for not making progress.
That is the most terrifying aspect of what is happening at Prestwich. It cannot be seen in isolation. The view has been expressed to me from Oxford that the ripple effect of what is happening at Prestwich is the underlying difficulty behind the problems at Oxford. We cannot dismiss Prestwich lightly as the consequence of a group of people preferring to delay or to have greater security outside the hospital grounds. It is causing considerable difficulties, and I appreciate the dilemma faced by the Government, but I hope that the Minister of State will comment on this matter when he replies to the debate.
§ Mrs. Chalker
Does the hon. Gentleman agree that one of the sad spin-offs of this situation, whether at Prestwich or anywhere else, is that it excites in the community a fear of secure units which makes it so much more difficult for other regions to overcome the difficulties? It behoves us to try to put right what is done in the units in order to allay the fears of the regions that are attempting to make progress but are facing enormous community objections.
§ Mr. Moonman
The hon. Lady is absolutely right, and I am glad that she has put those facts on the record. There is no party difference on this matter; we all speak feelingly about it. When the hon. Member for Chertsey and Walton and I went to Prestwich, we met representatives of local residents. Although they had some disbelief in the value of the scheme, after discussion and explanation they were totally impressed with it. It would be wrong to say that they now believe in the concept of the secure unit, but some of their fears were allayed by the discussion. There are important characteristics arising from a case study 677 in Prestwich which should encourage other authorities if it were not for the obdurate attitude of certain individuals. However, I am glad that the matter has been raised, and I am sure that my right hon. Friend will take it into account in replying.
I should like to make three points about the White Paper. First, it appears that the White Paper is arguing that there should be no changes in the procedure for the admission of informal patients. MIND puts forward the argument:Nearly 90 per cent. of those admitted to mental illness and mental handicap hospitals and units and 95 per cent. of those resident there at any one time are informal patients.I accept that argument. The Government seem to offer no protection against inappropriate admission for informal patients. They consider that the actions taken by these patients are purely voluntary, assuming that the patients have consented to loss of liberty, therefore waiving the right to review. It is only fair to ask how accurate that assumption is.
The voluntary nature of admission is particularly suspect where members of staff impede the discharge of a patient without recourse to lawful procedure. The all-party committee visited Friern hospital following the famous secret report of the regional monitoring unit which indicated the dilemma. That report demonstrated that staff sometimes prevented informal patients from leaving hospital by removing their clothing, locking them inside rooms and restraining them with the use of drugs. It is important to hold professionals accountable for the care of informal patients. There should be a thorough review of the need for hospital care for non-protesting patients, particularly children, mentally handicapped and long-stay patients. The requirement should be that the reviewing body explores every community thoroughly.
I asked my right hon. Friend to indicate the amount of support for the Bill he had received from voluntary organisations on the matter of the mentally handicapped. However, my hon. Friends and I believe that he did not fully state the position. I understand that all the major voluntary organisations concerned with the care of the mentally handicapped recommend the removal of the mentally handicapped from the ambit of the Act. COHSE has 678 carefuly examined the definitions and recommends that the mentally handicapped should be removed from the jurisdiction of the Act. Therefore, I ask my right hon. Friend to re-examine the matter.
Failure of the White Paper to make special legislative provision for the mentally handicapped is a disappointing feature. I am not entirely clear about the arguments that have been put forward to justify that omission. The Act was formulated to meet the needs of psychiatrically ill people, but its terms suggest that it is wholly applicable to the mentally handicapped. The premise of the Act is that psychiatric illness may cause anti-social behaviour, that illness can be "cured" and that the behaviour can be corrected through compulsory hospitalisation. That does not square with the experience of the mentally handicapped that some of us have had.
Another fundamental point is that the Act should specifically outline the facilities that should, rather than may, be provided. The hon. Member for Reading, South pointed out the difficulties that he would have in justifying some of the services being put into the Act. It is a matter for discussion. I hope that we shall be able to explore that aspect before a Bill is introduced.
Crisis intervention should be encouraged, if only to resist the growing assumption that psychiatric hospitals are available only where imminent tragedy is to be avoided. Similarly, compulsory powers to divert disturbed people at risk within the community may play a valuable role in future. However, compulsion implies sanctions. What can those sanctions possibly be? I hope that the Minister will provide an answer.
The recent MIND conference laid down a series of proposals which, no doubt, my right hon. Friend has had the opportunity to consider. The crisis intervention service was recommended. The final statement upon that was that there should be a crisis intervention serviceto bring primary mental health care to a level commensurate with its importance,(c) to recognise the importance of care, support and guidance for the mentally ill living at home and for their caring relatives.We should use this occasion not only to produce an Act to support and strengthen hospital services, for all those who take 679 part in running those services, but to strengthen community care services. That is an example of what I mean by anticipating the future trend. There are many trends and fashions in the mental health services. Facilities that we argued about 10 years ago as being wholly applicable are no longer applicable. However, the need for the provision of back-up to community care will remain with us for the next 10 years or so.
I believe that it is not misleading to point out that there is minor reference only in the White Paper to resource implications. In a fine aide-mémoire to members of the all-party committee, the Royal College of Psychiatrists said that it believed that the resource implications resulting from the proposed amendments to the Act had been seriously underestimated. It said:The amendments will, if they are all enacted, result in a considerable amount of extra work particularly in relation to Mental Health Review Tribuanls, automatic reviews and related matters.I believe that we should get right not only our sums but the legislation. Many of us who have examined the legislation of the past 20 years that affects the social services are not impressed by the way in which it has worked in practice.
Part of the problem is that we did not consider the resource implications and what, in practice, they were likely to mean. If a mental health Bill is presented this year, we shall have an enormous responsibility to ensure that it takes full account of the costings—both updated and future costings and inflationary effects—and the points raised by the Royal College of Psychiatrists.
Earlier in the debate reference was made to problems regarding the generic social worker. Earlier debates seemed to imagine that the service would work itself out. I do not believe that the proposals will work themselves out unless we understand the resource implications. However anxious I may be to develop a Bill to take full account of the need for future improvement, I should prefer to take it in two parts. I would give priority to matters at the top of the list and delay and defer other matters rather than fool people. If we go ahead on everything, the problems that we have failed to consider will come back here.
680 The small number of hon. Members present today gives us the chance to have a calm debate. Whenever the general election takes place, there will be time to think the problem through. We have waited long enough for the White Paper. I urge that we now start to do our sums in the most realistic way. I assure my right hon. Friend that, if he takes Members into his confidence, he will get the greatest possible support. There would be no political advantage for either side in trying to do otherwise.
What is being suggested is an attempt to take account of good practices at all levels in the psychiatric profession to ensure that we remove some of the ambiguities in the law. We have been helped enormously by organisations and people who have given a great deal of time to ensure that the Bill, when it is produced, will contain a great deal of realism. I am aware of the organisations which have been mentioned. I am impressed by the way that my right hon. Friend has taken the trouble to explain some of his dilemmas—for example, the problem of the medium secure units.
At the end of the day, it will be for the House to recognise that the mental health service can take account of the improvements which have been made, not only in other EEC countries but in the United States. Nevertheless, the task of implementing them will be according to the cloth that we produce in this country. The debate on the White Paper today is only the beginning of a series of discussions which I hope will enable the Minister to feel confident that, when he moves towards a Bill to improve the original Act, it will be based on experience and will meet the needs of the community.
§ 6.2 p.m.
§ Sir David Renton (Huntingdonshire)
The House has listened with great interest to the hon. Member for Basildon (Mr. Moonman). We all appreciate the work that he does as chairman of the all-party mental health group. We have had evidence of his tremendous interest in this subject from the remarks that he addressed to the House. I hope that he will forgive me if I do not comment on his remarks, except to say that I agree broadly with them. I want to concentrate on the subject of mental handicap.
681 I confess that when my right hon. and learned Friend the Member for Hertfordshire, East (Sir D. Walker-Smith) presented to and piloted through the House of Commons the Mental Health Act, I, as a junior Minister at the Home Office had the privilege of assisting him and was responsible for part V—sections 60 to 80—dealing with criminal proceedings.
The 1959 Act was based upon knowledge as at about 1957 when there was an inquiry into this matter. In my opinion, that Act has stood the test of time not too badly, bearing in mind that this is an area in which there has been rapid change in this century. But my right hon. and learned Friend, whom I have consulted, and I agree that the time has now come to review the position. That is what the Government are doing. My principal reaction is that the White Paper pays too great a compliment to the 1959 Act by proposing too little change in its terms. In my opinion, much more change is needed.
I shall confine my remarks to the changes needed for the mentally handicapped. That will not surprise the Minister of State, because he knows that I am chairman of the National Society for Mentally Handicapped Children and am the father of a mentally handicapped child.
The White Paper suggests no change regarding the mentally handicapped, except a change in terminology. Paragraph 1.21 states:The terms ' subnormality ' and ' severe sub-normality ' cause offence and distress and it is proposed that they should be replaced by ' mental handicap ' and ' severe mental handicap '. It is also proposed to amend the definitions of these two sub-categories.I need not read on. It is all on record.
Frankly, that is not good enough. Experience now suggests that, as we have much clearer knowledge of the capacity and understanding of the mentally handicapped and of their position in society, it is no longer good enough to lump them together with those suffering from mental illness and various other kinds of mental disorder.
I was surprised that the distinguished Royal College of Psychiatrists should deal with mental handicap in a couple of ill-informed paragraphs. I say that after consideration. A study of the paragraphs 682 shows that they are even more reactionary than the White Paper in this respect, because they do not suggest a redefinition and, indeed, they criticise the White Paper for suggesting one. That is an extraordinary situation.
I appreciate that mental handicap is not the scene for psychiatrists. That will be understood better when I point to the differences, which are often ignored or misunderstood, between mental handicap and mental illness. Although I may be preaching to the converted in this Chamber, it is important, for the benefit of the press among others, that we should get this distinction absolutely clear.
Mental handicap is a condition which means that a person's brain will not develop as fast or as fully as the brain of a normal person. Of course, the degree of mental handicap can vary enormously. On the other hand, mental illness is a condition which means that a person has psychiatric or emotional problems. A person may have a brilliant mind—he may be a genius—but still suffer from mental illness.
Mental handicap is usually determined before birth—often by genetic factors. It can happen in any family. Mental illness can affect anyone at any time in his life. Again, that can happen in any family.
As mental handicap is due to permanent factors—generally it exists before birth—it cannot be treated. It is rare for any form of mental handicap to be capable of treatment. On the other hand, mental illness is in most cases temporary. It can be treated, and often cured, by medical means and therapy. That is where the psychiatrist rightly comes into his own.
With those differences in mind, we should not assume, as the White Paper suggests, that the mentally handicapped should have the same legislative provisions to govern what happens to them as apply to the mentally ill. I say that especially with regard to the criminal provisions in the 1959 Act. I have seen something of this in operation in the courts. I am sorry to say that the action of the courts has often been harmful, undeserved and harsh to the mentally handicapped persons concerned.
I give the example of a mentally handicapped young man. He may be in open 683 employment as he is not severely handicapped. He may commit an offence in respect of which another young man without a previous conviction would be bound over or given a suspended prison sentence. But the mentally handicapped young man may find himself compulsorily incarcerated in hospital for an indefinite period until he is considered stable.
That happens after all the palaver that there has been, I am glad to say, in the courts, with medical and probation reports and whatever else is considered appropriate. The young mentally handicapped man may never have previously been incarcerated. He may have lived an open life. Inside, he finds himself acutely frustrated in an institution where he will mix with all kinds of mental cases. It is not right that we should continue to run this risk.
Let us take another circumstance which may arise as a result of criminal provisions. Some slightly mentally handicapped young people are basically good but are easily led or misled. They may appreciate—and generally do—the difference between right and wrong. I do not say that they always appreciate the difference between what is lawful and unlawful. They may commit crimes which bring them before the courts. In such cases a short, sharp lesson or a period of several years' probation would be the right treatment. However, as the person appears in the dock looking a bit of a nut case, a bit mixed up, the court judges the matter superficially, I fear. The young person may find himself unnecessarily incarcerated for a long time.
As I was responsible for the original provisions of sections 60 to 80 of the 1959 Act, I implore the Home Office to consider the matter. I was glad to see that the Under-Secretary of State for the Home Department was present earlier. I hope that the hon. Lady will return to the debate and take to heart what is said. I hope that the Home Office will come off its perch. It is time that it did so. I speak of a Department in which I spent four and a half of the best years of my life and for which I have great respect.
I consider that there is a need for separate legislation, not only for the needs that arise directly from the White Paper, 684 which I have briefly outlined. There is a need for separate legislation to replace the 1959 Act as it affects mentally handicapped people and to embrace the statutory provisions dotted all over the statute book which affect the mentally handicapped. I refer to the Children and Young Persons Act, the Disabled Persons (Employment) Act 1958, the important Education (Handicapped Children) Act 1970, which was a great advance, the Local Government Act 1972, which put responsibilities upon the local authorities, and the Guardianship of Minors Act 1973, which needs further adjustment as it affects the mentally handicapped.
If it were merely a question of consolidating into one Act of Parliament all the provisions affecting the mentally handicapped strewn about the statute book, that would be an advantage in itself. However, consolidation would not be enough. We need to bring the provisions up to date in the light of modern knowledge and experience.
Besides that, we need fresh, extensive legislation to define the civil rights of the mentally handicapped, who form a special case. They are frequently ignored.
I do not apologise for extending the scope of the debate beyond the White Paper. We must look at this as one subject. It may be said that only one child in a hundred is born mentally handicapped. Such a child—as I know—creates severe problems not only for himself but, much more, for the family. The United Kingdom and other countries are beginning to advance their knowledge of these matters. The United States, Scandinavia and Germany are far advanced in this regard. An international conference is convened from time to time to discuss this subject. There have been great results. We must apply our minds more specifically to mentally handicapped people as a separate group needing help and sympathy. We must not ignore them.
I appreciate the interest in this subject shown by the Minister of State. I have witnessed it at close hand and expect to do so again next week. That interest is greatly appreciated.
We realise that the Department of Health and Social Security and the health authorities require much more money to provide the necessary facilities—which 685 will be needed increasingly from now on—so that the adult mentally handicapped may live in more humane conditions.
Many young people who have survived with the help of antibiotics in the past 30 years would formerly have died. They have survived to become the adult mentally handicapped in considerable numbers. We must make provision for them. We must try to get the mentally handicapped of all ages out of large institutions and place them in smaller residential homes. The Minister will receive the full support from the House in diverting funds to these good causes.
A debate such as this does not take place often. We must not fail to say a word of thanks and admiration to those wonderful people—whatever their trade union, even if they do not belong to a trade union, and many of the best do not belong—who help to look after the mentally ill and mentally handicapped in all kinds of places. But for the work done by the voluntary societies in looking after the mentally handicapped, by Jove the DHSS would be in an even poorer way.
§ 6.19 p.m.
§ Mr. Robert Kilroy-Silk (Ormskirk)
I endorse the final remarks of the right hon. and learned Member for Huntingdonshire (Sir D. Renton) about the staff. However, I hope he will forgive me if I do not follow the points he made. Like him, I want to talk about a specific group of mentally disordered people. I refer to mentally disordered offenders.
We spent a great deal of time today listening to the Secretary of State telling us how important it is to have the right to give patients treatment, in many cases against their own wishes, or indeed perhaps against their own perceived interests. We have heard very little, unfortunately, about the rights which other patients have to treatment but which they are now currently being denied. As the Minister of State, Home Office, has said:It is no part of a civilised policy to put the mentally ill in prison and make prisons the receptacles of those whom no other agency in society will accept."—[Official Report, 18 March 1977; Vol. 928, c. 864.]I believe that every Member of this House will agree wholeheartedly with those sentiments, yet it is everyday practice to put mentally ill and mentally dis- 686 ordered ordered individuals into Prison Department establishments.
As the "Report of the work of the Prison Department 1976" points out,mentally ill people are entering prisons and borstals in increasing numbers and people of previous good personality, whose offences frequently stem solely from their illness, are now being refused admission to psychiatric hospitals and are, instead, being received and detained in establishments.Yet, as the prison department admits, it does not have within the prison system the facilities, the staff, the experience or the training to provide the appropriate medical care and treatment for the individuals who, through no fault of their own, are consigned to incarceration in prison.
Paragraph 258 of the same report states thatit is not possible to provide many of these unfortunates with the medical and nursing care their condition requires whilst they are in custody.That, to me, is an extremely distressing state of affairs, to say the least. On the one hand, we say that it is no part of a civilised policy to put the mentally ill into prison, but we do this daily in large numbers. On the other hand, we then admit publicly and clearly that we cannot treat them while they are in custody. Not only does the Home Office go so far as to say "We cannot treat them, we do not have the facilities to look after these unfortunates within the prison system". I will quote what the director of prison medical services, Dr. Orr, said at the forty-second annual conference of the boards of visitors on 3 November 1977. I will quote the report at length, because it is an extremely important indication of the Home Office attitude, as well as being a contradiction of what my right hon. Friend said earlier when he was asking for more resources to be provided so that we could look after people in prison:It had been suggested that the Prison Department should itself take measures within the prison service to cope with the problem "—that is, of mentally disordered offenders—but it was felt that if the prison service were seen to be effectively dealing with the problem, there would be an even greater reluctance on the part of mental hospitals to accept dangerous and possibly disturbed offenders. There was no doubt that mentally ill prisoners should not be in prison, and should be transferred to hospital; we should not take steps which might cause people outside to conclude that the mentally ill were in their proper place in prison.687 Here, then, we have the classic Catch 22 situation. Everyone says that the mentally ill and mentally disordered should not be in prison, and it is acknowledged that they cannot be properly treated or obtain the appropriate medical care or attention when they are in prison. Recognising that, the prison authorities go on to say "Neither do we intend to take any steps whatever to provide the appropriate care and attention, otherwise our colleagues in the DHSS will wash their hands of the problem and assume that the people concerned are all nicely and neatly tucked away in prison. There will then be no pressure to provide the necessary alternative resources."
That is all very well, except that the only losers are the mentally ill.
§ Mr. Stephen Ross
I entirely endorse what the hon. Gentleman has said, but I do not think that he would want to cast any aspersions on the medical officers in, say, Parkhurst prison in the Isle of Wight, which has tended to become very much an extension of Broadmoor, and where there are at least 26 psychopaths certified, and up to 70 could be so certified. The prisoners in Parkhurst are getting very reasonable treatment, as was shown recently in a television programme.
§ Mr. Kilroy-Silk
I know that the hon. Gentleman has a very direct constituency interest in Parkhurst prison. I was not, of course, casting any aspersions on prison medical officers. They do their job, as I know from the prisons that I visit, in extremely difficult and arduous circumstances. Every prison medical officer that I have seen has grabbed me by the arm, as soon as I have entered the prison, taken me to a mentally disordered offender and said "For God's sake, can't you get people like this out of these institutions?"
I was talking about officials within the Home Office, who are going round the country saying "We know that these people are not getting the proper treatment, but we are not taking any steps"—this is all on the record—" to provide them with the appropriate treatment. It is the job of the DHSS." The only problem is that my right hon. Friend's Department is not doing the job, either. As I said earlier, we have a classic Catch 22 688 situation, in which the only losers are the mentally ill.
It can be seen from recent parliamentary answers that there are many hundreds of mentally disordered offenders within the establishments of the prison department. On 30 June 1978, there were 581 mentally disordered offenders deemed to require treatment in hospital under the conditions of the Mental Health Act 1959 but for whom no hospital place could be found. Of those 581 offenders, 288 men and 32 women were mentally ill, 196 men and 22 women were classed as psychopathic, 35 men and 7 women as subnormal, and 1 woman as suffering from severe subnormality.
But it is not just the individuals who are disposed of to the social dustbins of prisons who are caught by the lack of alternative provision outside, whether it be in regional interim secure psychiatric units or in the psychiatric wards of NHS hospitals. It also affects those patients who are awaiting transfer from the special hospitals.
On 30 October last year, a total of 146 men and 46 women were deemed by their responsible medical officer, as the terminology of parliamentary answers has it, to be appropriate for transfer to less secure conditions, such as those that would exist if we had the regional secure units or the NHS psychiatric wards.
A man of 66 has been waiting eight and a half years for a transfer from Moss Side to the Royal Eastern Counties hospital. There is a woman at Rampton who has been waiting seven years for a transfer to less secure conditions. One woman and two men have been waiting in the special hospitals for seven years for a transfer. The majority of the 146 men and 46 women to whom I refer have been waiting for four years or more.
Many of us here, unfortunately, in the future, and certainly many of my constituents, will at some time in their lives have to wait—and sometimes wait a very long time—for a hospital place, but very few of them will have to wait the excessive period of eight and a half years, and none of them will have to wait in the secure and inhibiting conditions which exist in a special hospital.
I cannot speak except with the knowledge of what patients in the special hospitals, who are on the transfer list, have 689 said to me, but I can imagine the degree of resentment, of bitterness and frustration which must necessarily be engendered in individuals who have been waiting for transfer for such a long period of time. They know—and this is the important point—that their transfer is blocked, not because of a lack of resources but because, on the whole, of a recalcitrant and prejudiced attitude on the part of many of the people concerned, be they consultants, nurses, ancillary staff or trade unionists, to their transfer.
That is one half and one part of the problem which has not been properly or adequately discussed by my right hon. Friend the Secretary of State today. It is a fact, as my right hon. Friend the Minister of State full well knows. He presented me last year with a list of all those hospitals which have refused to accept such patients from the special hospitals and prisons. He gave me a long list of hospitals throughout the country which, in some cases, as a matter of principle, refused to take offender patients. They refused in some cases because consultants had refused to take patients they believed would be potentially disruptive or violent, and on other occasions—regretfully, one of them happened to be in my constituency—where there had been opposition from nursing staff, ancillary staff or their relevant appropriate trade unions.
My right hon. Friend has refused to provide me with the same kind of list for this year. He realises the controversial area into which he would be entering.
But this is an extremely important subject. We are talking about people who are ill and who are being denied their proper treatment, which everyone accepts is their due and acknowledges to be necessary for them. They are being denied it because of the refusal of NHS hospitals, for one reason or another, to admit them. It is totally indefensible for hospitals and their staff to fail to live up to their proper duties and responsibilities to patients of this kind.
Perhaps my right hon. Friend will at some time ask who runs the NHS, and for whom. Let him make it very clear that it is certainly not run for the benefit of the doctors. It is not there for the benefit of the nurses or the ancillary staff, and certainly not for the benefit of the National Union of Public Employees or 690 the Confederation of Health Service Employees. The NHS exists to benefit patients. As all hon. Members are fond of constantly saying—to the extent that it has now become a cliche—patients come first. But they do not come first; not when they are mentally ill.
Yes, there would be uproar if we were saying that we would refuse to accept heart patients, but somehow or other my right hon. Friend can tolerate a situation in which NHS hospitals can refuse point blank to take patients who are ill but whom they regard as being too troublesome, too inconvenient, to disturb their cosy, comfortable lives.
It is not merely a problem of who runs the NHS and of the reluctance of NHS hospitals to accept offender and, indeed, non-offender patients who are mentally disordered. It is also a consequence of the absence of regional secure psychiatric units.
As long ago as 1961, I think, the Glancy working party report from the Ministry of Health, as it then was, suggested that we should have something akin to what we now call regional secure psychiatric units. In 1974 we had the Butler committee on mentally abnormal offenders. Unusually, it rushed out an interim report calling, as a matter of urgency and as a national priority, for the establishment in every region of the country of what it called a regional secure psychiatric unit, able to take patients who would otherwise be incarcerated in prisons, patients who were awaiting transfer from special hospitals. The report pointed to the alarming overcrowding that existed at Broadmoor at the time. It still exists at Broadmoor today. In the interim report, it was said that this was a matter of urgent national priority.
Quite unusually, the then Secretary of State, my right hon. Friend the Member for Blackburn (Mrs. Castle), accepted the report with alacrity within a couple of months. Usually, Secretaries of State do not respond to reports for years, if they respond to them at all—even if we ever reach the point of discussing them. However, on that occasion my right hon. Friend the Member for Blackburn not only accepted the report publicly but circularised the then health authorities asking them to make suitable interim arrangements. Nothing happened. Today, 691 five years later, we still do not have a single regional secure psychiatric unit in operation.
In parliamentary answers to me, my right hon. Friend the Minister can say only that he hopes—" hopes "—that the first such unit will be opened in the 1980s. Yet this is not because—as might be a reasonable excuse—the regional health authorities have a shortage of funds. My right hon. Friend's predecessor, the present Foreign Secretary, started with a special revenue allocation in 1976 of £5 million, allocated to the 14 regional health authorities in order to enable them to make suitable interim arrangements. That sum now totals £17.3 million, distributed to all of the 14 regional health authorities. Yet four of them, Oxford, East Anglia, South-West Thames and North-West Thames, have still to submit plans to the DHSS for the establishment of a unit.
The majority of the other regional health authorities have not spent a penny of the money that was allocated to them for that purpose. The Oxford regional health authority, for example, has retained roughly £800,000, I think, in its regional reserve. Many of the others have spent minimal amounts on trying even to improve mental illness or psychiatric services within their areas. Some of them, as my right hon. Friend knows—perhaps he will shame them today by naming them—have actually used the money allocated by his Department for a special nationally determined priority to provide such things as maternity units.
We give a low enough priority as it is to the mentally ill and the mentally disordered. It is nothing short of a national scandal that when regional health authorities are given additional sums tied for a specific purpose and then use them for something else—for no doubt locally more glamorous and locally more acceptable and popular schemes—my right hon. Friend does not take far more constructive and positive action to ensure that they are doing more to live up to what the money was intended for.
The lethargy of the DHSS on this matter is not surprising. Many of the problems about which I have constantly to chide my right hon. Friend the Home Secretary have their origin in the DHSS. Many of those who are clogging up our prisons, be they mentally disordered, 692 drunks or 14 to 16-year-old schoolboys and schoolgirls, are there because it is easier for the Secretary of State for Social Services to accept that inappropriate, inhumane disposal than to provide the necessary services out of his budget, from where they should properly be coming.
It is not surprising when one sees the attitude of some of the Secretary of State's officials. Let us look at the evidence that they gave to the Expenditure Committee on the reduction of the pressure on the prison system. On 15 May 1978, a Mr. K. J. Moyse was giving evidence from the DHSS. When asked what that Department was doing to get mentally disordered offenders out of prison, he said:I am not aware that we were aware that there was any really serious problem about this until, say, a year ago. I think certainly ever since it has been brought to our notice that there is a problem we certainly accept that there is one; it is simply that the scale of it is rather difficult to assess.Could there be more complacent evidence than that? This is evidence from a senior official in the DHSS, saying that he was not aware that the Department was aware of the serious problem until it became aware of it. Yet the prison department's report in 1973 pointed out the seriousness of this problem and the inability to get mentally disordered offenders transferred from prisons to psychiatric hospitals. Yet the DHSS can either be so negligent in living up to its responsibilities or so complacent about its responsibilities that only six months ago it could suddenly discover what everyone else has been talking about for years. Indeed, the hon. Member for Worcestershire, South (Mr. Spicer) had an Adjournment debate on precisely this subject just a few weeks before that particular gentleman was giving evidence to the Expenditure Committee. I am not surprised that we experience lethargy and sloth from the Department and from a whole variety of other sources if that is the calibre of evidence given to Select Committees.
§ Mr. Michael Spicer
How does the hon. Member for Ormskirk (Mr. Kilroy-Silk) equate the story that he has been telling about the misappropriation of funds allocated for the regional secure units—and that accords with my understanding of the situation—with what I 693 understood the Secretary of State to say earlier, which was that 100 of these beds had already been provided?
§ Mr. Kilroy-Silk
But they have not been provided. Perhaps my right hon. Friend the Minister of State can clear this matter up.
§ The Minister of State, Department of Health and Social Security (Mr. Roland Moyle)
There are 100 places in interim secure units in the country.
§ Mr. Kilroy-Silk
That is precisely the sort of obfuscation and confusion that we get. We are talking about regional secure psychiatric units. They are totally different from the 100 places in interim units. They are not the same thing. Unfortunately, unless hon. Members are aware of the difference, they can be fobbed off with such answers. The Minister says that he has produced 100 places in interim units, but there is still not a single regional secure unit in existence. These units were recommended as long ago as 1974 by the Department as well as by the Butler committee.
It is no exaggeration to say that it is totally intolerable for mentally ill people to be put in prison. That is not the place for them. In prison they cannot receive the kind of care or treatment that they deserve and need and to which they are entitled. It is certainly totally unreasonable to expect the prison service to look after such individuals. Prison officers are not trained as nurses. They certainly have no training in handling mental illness. As I know from conversations with them, one mentally disordered person in a prison is extremely disruptive, and, because of the kind of conditions necessary to contain such a person, he places enormous pressures on the prison system generally.
It is a national scandal that we should allow ourselves to put sick people into prison rather than into hospitals or secure units as we should. If these people were pensioners, trade unionists or heart patients there would have been a major public outcry. People would have lobbied the House and there would have 694 been demonstrations in the streets. The people we are talking about tonight do not have access even to Members of Parliament as other individuals have. They are not represented by any powerful pressure group. They have no industrial muscle and no political clout. They cannot write to the press, they cannot campaign and they cannot demonstrate. Yet they are some of the most vulnerable, disadvantaged and deprived members of our community. They deserve far more of our care and compassion as well as of the facilities that we should provide for them.
One test of a civilised society is the way it treats those who do not have votes, those who are unpopular—and I know how unpopular is the advocacy of the cause of mentally disordered offenders, as the right hon. Member for Crosby (Mr. Page), although often on the other side of the divide from me on this issue, will testify in my defence.
Equally important is the fact that these people have no other voice. By that test alone we have failed—and that applies to both sides of the House and to successive Governments. Perhaps now we can begin that urgent and necessary progress towards establishing a so-called civilised and compassionate society.
§ 6.45 p.m.
§ Mr. George Gardiner (Reigate)
I listened with great interest to the hon. Member for Ormskirk (Mr. Kilroy-Silk) and I agree with a great deal of what he said. I was pleased that he did not seek to pin all the blame for the non-establishment of regional secure units upon the local communities involved. I have some experience of a case in that category, and since the hon. Member mentioned my regional health authority—South-West Thames—I shall give a little detail.
A proposal was put forward for the siting of a regional secure unit by that health authority. But the authority made no attempt at meaningful consultation with the public and the community. The proposal was put forward in the face of opposition from every organ and every level of local Health Service opinion. An attempt was made to browbeat the community into accepting a thoroughly ill-conceived proposition.
I freely admit that I was one of those who strongly fought the proposal. We 695 managed to kill it. Time was lost, and now the discussion revolves around the establishment of an interim unit, for which the money has already been received in the form of an allocation for a full secure unit.
The lesson that one learns from that is that, in approaching these matters, regional health authorities, if they do not adopt a totally open approach with the communities involved and with all levels of the Health Service, are bound to run into trouble. I think that lesson has been learnt in my region. The same need will exist once the units are established. After establishment there will be a continuing need for openness to and the involvement of the local community with these units. I am grateful to the hon. Member for Ormskirk for the thoroughness with which he dealt with this subject.
With great deference, I follow in the footsteps of my right hon. and learned Friend the Member for Huntingdonshire (Sir D. Renton). He presented an eloquent case on behalf of those suffering from mental handicap. I take up this matter partly because there are in my constituency two substantial institutions dealing with the mentally handicapped, and among those associated with these institutions there is great disappointment that the White Paper is not a little more adventurous in dealing with the mentally handicapped. There is particular disappointment over the proposal to retain the compulsory powers of detention. There is a strong case for excluding them and for our following the lead of some other countries in this respect.
The Secretary of State began today by referring to the growing enlightenment in public attitudes towards mental handicap and towards those suffering from psychiatric disorders. But I do not think that that same degree of enlightenment is reflected in this proposal in the White Paper. Why do we object to the suggestion that these powers of compulsory detention should be retained for dealing with those suffering from mental handicap? The White Paper says:Mental illness and mental handicap are still often confused with one another ",a point that my right hon. and learned Friend demonstrated earlier. Sadly, this is true, though it can be broken down over a period of time. For example, the Royal 696 Earlswood hospital in Redhill, which has existed for about a century, has built up a good relationship with the local community. There is much voluntary activity and it is accepted that its patients should be regarded not as lunatics but as handicapped people. That situation takes a long time to build up.
The continued retention of powers of voluntary detention for the mentally handicapped presents a barrier that prevents enlightenment from proceeding further. This presents a difficulty for those who run such hospitals when they seek to have their patients accepted in the community.
Let us be honest. This also has an effect on the mentally handicapped and their families when the handicapped persons are not in a hospital. Each hon. Member has been moved by meeting families who have had to overcome the trauma of discovering that their baby is mentally handicapped. They have gone on to accept their responsibilities as parents and to make many sacrifices on behalf of a child whose "childhood" extends in years way beyond the normal span. Those parents have gone through the process of countering the initial suspicions and reservations of their neighbours and other children. In time, this is achieved. In time, the neighbours come to understand and to give their support.
How much easier it would be for such parents if there was not the immediate, initial public assumption that there is no difference between a mentally handicapped child and one who suffers from a psychiatric disorder.
Compulsory powers are irrelevant to those who suffer from mental handicap alone. Often other psychiatric conditions develop in conjunction with this, and they can become acute. In those cases, of course, there might be a need to exercise powers of compulsory detention. But our case is that when they are used they must be on the basis of the psychiatric condition and the behavioural problems, and not purely on the basis of mental handicap as such. The Secretary of State went half-way to conceding that when he said that the "mere fact" of mental handicap should not constitute a ground for the use of compulsory powers.
The continued existence of these powers impairs the proper development of care 697 facilities for the mentally handicapped generally in more normal community settings. Let us not underestimate the effect on the mentally handicapped themselves. As we all know, there are many degrees of mental handicap. It is no comfort to those unfortunate people who know that they are easily associated in the public mind with those who suffer from psychiatric disorders, or if they are in a hospital of the type that I have mentioned, to know that others in that hospital are compulsorily detained.
The White Paper states rather blandly:There seems to be a fairly general recognition that although most of the mentally handicapped can and should receive the care and training they need on a voluntary basis, there is a need to retain some compulsory powers.The White Paper uses the words "a fairly general recognition". The Secretary of State referred to "majority" expert opinion that had been expressed to him on this subject. I should like to know of what that majority is made up. The Secretary of State acknowledged the submissions made by the National Association for Mentally Handicapped Children. We have had representations from MIND, the Association of Educational Psychologists, the British Psychological Society and the British Association for the Retarded. The British Medical Journal stated:the factors which warrant the detention of some mentally handicapped people in hospital are more usually due to added psychiatric or behaviour disorder than to intellectual retardation and diminished social competence. This argument is, indeed, acceptable: there seems no reason to retain the category of mental handicap or intellectual deficit as such ".The Secretary of State drew our attention to the recent reports from the Royal College of Psychiatrists. I share the surprise expressed by my right hon. and learned Friend the Member for Huntingdonshire about that organisation's comment on this matter. I noted just two lines, which read:The College is pleased to note that mental handicap is to remain under mental health legislation.The college states just that, and no argument is presented to substantiate or enforce that passing comment.
The Secretary of State referred to the "small group" that makes the retention of this power necessary. I should like 698 to know more about the type of cases that make up that small group. I urge the Secretary of State to think again. Whatever his understanding of the interests of that small group, I question whether they justify the retention of this blanket power over the mentally handicapped.
§ Dr. Vaughan
My hon. Friend might be surprised to know that amongst psychiatrists there is a divided view. By no means the majority agree with the Secretary of State.
§ Mr. Gardiner
I am grateful to my hon. Friend. When the Secretary of State reads the record of the debate, he will note that I am the third speaker so far to urge that these powers should not be retained over the mentally handicapped in forthcoming legislation. Perhaps more hon. Members will agree with me as the evening progresses. I should be interested to hear if any hon. Member presents an argument to the contrary and in support of the line taken in the White Paper.
I have another argument which I wish to express briefly. It concerns what the Secretary of State said about patients' consent to treatment and particularly what constitutes "valid consent". I have read the section of the White Paper with great interest and listened to the Minister's remarks this afternoon. But I should like to refer to the case of one of my constituents who, for obvious reasons, must remain anonymous. She gave me a copy of a sworn statement that she had made concerning her experience with ECT. I do not wish to be drawn into an argument about ECT as a treatment. I noted what my hon. Friend the Member for Reading, South (Dr. Vaughan) had to say about this earlier, and it is an argument on which I am not competent to give an opinion. I am concerned purely with what constitutes valid consent to the use of ECT.
I shall quote from the statement made by my constituent. I shall leave out the names of the consultants involved. She said:When ECT was suggested by a consultant psychiatrist I flatly refused the idea altogether. Since 1952 I have known that ECT was a bad thing and something I would not want to receive myself. I would not sign the consent form for the ECT treatment, neither would anyone in my family. As a result of myself 699 or anyone else in my family refusing to sign the consent form, it was decided that no more could be done for me and it was arranged that I should go home from the hospital that I was in. The consultant psychiatrist spent hours trying to persuade me but I was adamant and I refused.It was arranged that she should leave the hospital and return home. My constituent goes on:My husband visited me one morning. It was very near the date I was due to leave and then he left the hospital. He returned to visit me again in the afternoon and he was told by another consultant psychiatrist that I had signed a consent form and had already had one treatment of ECT. My husband then went home and told my children that I had been persuaded to have ECT, that I had signed a form consenting to six treatments and that I had already received one. My family were all very shocked by this.This lady has since asked to see the consent form that she had signed, but at the time she gave this statement to me the request had been refused. She cannot recall signing that form at all and it is a reasonable assumption, in the circumstances, that she was fairly heavily drugged at the time. My constituent goes on to say:My husband was asked to sign a consent form. He refused to do so.Indeed, she understands that the first consultant was of the view that the patient was not willing to receive it. She continues:As far as I am concerned I was given ECT treatment against my will. I consider myself to have been morally and mentally raped.That is extreme language, but it indicates the kind of resentment and feeling that this woman has as a result of what happened to her. I realise the difficulties here, but I urge the Minister or his successor to approach with great care the redefinition of what constitutes "valid consent" in the coming legislation and to build in the necessity to consult the relatives, next of kin or family of the patient concerned. In the case that I have mentioned, those relatives knew perfectly well what this woman's view was. I hope that the Minister will also seek to ensure that the second opinion obtained is not an opinion too closely related to the first.
I put it to the Minister that cases of the kind I have just outlined are totally unacceptable, and that whatever the merits of ECT as a form of treatment 700 they in fact add weight to the public fear and resentment concerning it.
§ 7.4 p.m.
§ Mr. Christopher Price (Lewisham, West)
Although this subject tends to receive all-party support and is not normally one on which there is any argument across party lines, I think that there is a great deal more controversy in the areas of mental health and mental handicap than one may have gathered so far from this debate. We must accept that what we are discussing today is a matter of such considerable controversy, and such widely diverse views, that it is extremely difficult to agree on legislation.
One of the reasons relates to something that the Royal College of Psychiatrists is never willing to admit—that the scientific knowledge of mental illness particularly, but also mental handicap, is in its infancy. Although there are treatments, the doctors who use them know very little about why the treatments appear to work. For that reason, I believe that the safeguards which the Secretary of State has proposed in regard to consent to treatment are important. That is also why I believe that we should have just a little more humility from the Royal College of Psychiatrists and less desire from it to stand on its own clinical judgments against allcomers—whether they be nurses, patients or laymen—than has been evidenced in its recent reports, particularly the last two reports, one on electro-convulsive therapy and the recent report in response to this White Paper.
The experience of so many Members of Parliament is that when one goes to see the psychiatrist in one's local hospital he will pooh-pooh any question of hazardous treatment and will be keen on either ECT or chemotherapy, or both. On the other hand, there is hardly a Member of Parliament who has not received letters—such as the one quoted by the hon. Member for Reigate (Mr. Gardiner)—from patients who, rightly or wrongly, feel that their experience of a mental hospital has been the most horrific of their lives.
From time to time the allegation is made that such treatment has completely blighted the rest of their lives. On the other hand, one has to remember that a few psychiatrists—such as Thomas Szaz in the United States whose colleagues thought that he was not worth listening 701 to—believe that the present trend in psychiatry is wrong, and that what we call mental illness is not an illness at all but something that should be treated in a totally different way.
I do not want to use this debate to have a discussion between the radicals and the doctors. I mentioned this point only because it is one reason for us all to proceed with more humility. It is not an area where we can look to the experts, hear what they say and do what they ask us to do. One must remember that psychiatry has not had a very good track record over the years. In the nineteenth century even Maudsley, one of the greatest phychiatrists in Britain at the time, was performing quite horrible operations, doing clitoredectomy at a time when everybody thought mental illness was directly and solely related to masturbation. That disappeared, insulin treatment came in and disappeared completely. Then ECT came in and it has not disappeared, and everybody puts his trust in what is broadly called chemotherapy.
I predict that a time will come when the chlorpromazine that is being injected in enormous amounts and taken orally, right across the Western world—very often compulsorily—will be looked on as having been completely barbarous treatment, especially when better ways have been found to deal with such conditions. That is why the Secretary of State is absolutely right to have proposed the review of hazardous treatment in the way that he has. I wish him well in his discussions with the Royal College of Psychiatrists. If our recent discussions with the Royal College are anything to go by, it will not be all that easy, because the college has very strong views on the subject. I urge him to hold his ground and to stick to the recommendation in the White Paper.
I appreciate that no doctor likes his treatment to be reviewed by someone whom he regards as a layman. But one must face the fact that from time to time many hospitals have lay procedures to review compulsory admissions. I was recently called into the Maudsley in the case of a doctor who had been sectioned and compulsorily retained. Since he was at one of my local hospitals, he asked me to speak for him and be his advocate.
§ Mr. Patrick Jenkin
It seems to me that there could be no possible object- 702 tion to having a patient's friend to argue the case, exactly as the hon. Gentleman did in relation to the doctor. But I think it would be difficult for a layman such as myself to accept that what is essentially a medical matter should become of joint decision by doctors and laymen. There is a quite narrow, but nevertheless distinct, difference between these two functions.
§ Mr. Price
The point that I was making did not relate to my role as the friend but to the fact that the Maudsley hospital appoints three of its lay governors to listen to the views of a patient's friend and the consultant psychiatrist who sections the patient. They then take a lay decision either to overrule the doctor or not to overrule him. As I undersand it, they have never overruled a consultant psychiatrist, but at the hearing at which I was involved I got them to admit that the fact they had never done so did not mean that they would never do so on principle. In fact, only five minutes before the second hearing in this case, the consultant psychiatrist thought better of the matter and lifted the section unilaterally. That is one way in which these matters are sometimes resolved.
We deserve to be told a little more about how my right hon. Friend envisages hazardous treatments. At the moment, there is a vast gulf between how people in MIND see hazardous treatments and how the Royal College sees hazardous treatments. Many people in the Royal College think of psycho-surgery, which is normally carried out by a brain surgeon, as the hazardous treatment and electro-convulsive therapy and, even more so, chemosurgery as just everyday treatment which no one could call hazardous.
On the other hand, in its reactions to the White Paper MIND has said that it welcomes the proposalsto safeguard patients against hazardous and irreversible treatment ".But it emphasisesthe need for clear criteria being established to cover the precise nature of treatments classified as hazardous ".It goes on to say, I believe very pertinently:There are instances where disabling or irreversible side effects, phenothiazine drugs or electro-convulsive therapy, may be accumulative over months rather than as an immediate consequence of treatment ".703 As the Minister's discussions with the Royal College go on, I believe that we must have clearer guidance about what is considered to be hazardous treatment and what is not. The report of the committee of inquiry on St. Augustine's hospital in Canterbury is now several years old, but it still bears reading. My copy is markedNot to be removed from the Commons Libraryand I can assure the House that it will go back there after this debate. Anyone who has read that report must have doubts both about the nature of electro-convulsive therapy and about the propriety of leaving the administration of it solely in the hands of doctors without any review. I should like to read a passage from paragraph 3.82 of that report, which criticised one particular doctor—not identified—who is called "Doctor Q". It states:Our criticisms of Doctor Q have been based on his own evidence. His casual approach to E.C.T. on this occasion, and the large number of treatments given to a particular patient disturb us deeply. Neither are we at all happy about his use of E.C.T. as a diagnostic measure to distinguish between depression and dementia.It goes on to say:We understand that Doctor Q, although retired, has facilities to treat patients at St. Augustine's Hospital. The Regional Health Authority should consider this Report before extending these facilities.It is worth remembering what happened. The regional health authority considered the report. It suspended Doctor Q, but the massive pressure from the Medical Defence Union and the Royal College of Psychiatrists ensured that he was reinstated, and in the end the regional health authority had to back down. One must remember the forces that are at work in this area and how absolutely necessary these procedures are in reviewing these hazardous treatments.
I accept the point of the right hon. Member for Wanstead and Woodford (Mr. Jenkin) that in discussions between the Royal College and the Minister it may be possible to find some formula other than the multi-disciplinary panel. That may not be the right approach. But if one has a medical majority on the panel—whatever that might be—there is no point in having the panel at all. One might just as well have a medical second 704 opinion. The point about the panel, as I understand it, is to have, in what will be a tiny number of cases, the possibility of proper lay review. I think that the Minister should stick to this proposal.
There is one other document in relation to electro-convulsive therapy that I should like to bring to the attention of the House. One of the interesting effects of the Freedom of Information Act in the United States is that one can now get hold of documents, which one certainly cannot get hold of in this country, which throw interesting light on the non-medical use made of these treatments in other places. The document I have is a CIA document, admittedly an old one dated 1951. It concerns the use by the CIA of electro-convulsive therapy to produce amnesia. It says that a particular psychiartist, who is not identified,explained that he felt that electric shock might be of considerable interest to the ' Artichoke ' "—that was the code name of the CIA project for making its agents forget about what they had been doing—type of work.He stated thatthe standard electric-shock machine could be used in two ways. One setting of this machine produced the normal electric-shock treatment (including convulsion) with amensia after a number of treatments ".He also said:using this machine as an electric-shock device with the convulsive treatment…he could guarantee amnesia for certain periods of time, and particularly…guarantee amnesia for any knowledge of use of the convulsive shock ".The textbooks say that ECT should not be used for people who need to use their memory, and that includes many of us. I hope that the Minister will make the point in his discussions with the Royal College that ECT is hazardous and should be subject to this review.
I hope that as a result of these discussions and the White Paper doctors will insist less on their treatments and allow hospitals to become true places of asylum. Many mental patients who feel that they have to leave their home and the community desperately want a place where there are people to look after them. But quite often they are insistent that they do not want electrical or chemical treatments. They want to get better in their own time.
705 The hon. Member for Reigate gave an example of a frequently occurring situation where a doctor tells a patient that he will have to have the treatment recommended or leave the hospital. I hope that the right of asylum will be accepted to a much greater extent by doctors.
Last week there was a MIND conference, "Acting on the Act", which I hope was successful. A resolution from that conference was thatAll patients should have the right to appropriate care and treatment, and choice of treatment…Most psychiatrists do not accept that. But there is no point in forcing treatment on patients against their will, even if they are detained patients. Even for those who are mentally ill, the only proper and effective treatment is that undertaken with the patient's full consent and understanding. When we come to legislate, that will be the nub of the Act and the most controversial part. The forthcoming discussions between Ministers and the Royal College of Psychiatrists will therefore be especially important. I appeal to them all to reach agreement so that we can legislate on an agreed basis.
The Secretary of State's remark about mentally disordered people in prisons disturbed me. He said that he wanted to ensure that there was better psychiatric treatment in our prisons. That raises the suspicion that the Government have given up the policy of proper regional secure units and are opting for the much less satisfactory solution of a slightly better regime in our prisons for the mentally disordered. That is a mistake and will divert us from the proper purpose of getting these people out of prison.
The prison medical service is, in the main, staffed by dedicated people. But prison officers have only an eight-week training period for the prison medical service. They do not have the qualifications and experience of nurses within the National Health Service. I was told about two years ago by the Department of Health and Social Security that just under 10 per cent. of prison medical service personnel have NHS training. The remainder have various forms of prison medical officer training. I was also told that in the 18 or 20 prison hospitals, which in many prisons are hardly more than medical wings, there are ECT 706 machines. I was assured that these machines always have one NHS qualified nurse operating them. But there is not the necessary staff or plant to upgrade psychiatric treatment in prisons. One cannot begin to get the atmosphere needed for the treatment of mentally ill people in prison. So I hope that in his reply my right hon. Friend will be more forthcoming about what is meant by upgrading psychiatric treatment in prison.
As demonstrated in a recent BBC "Tonight" programme, there is extreme concern about the level and administration of drugs in prison. There is suspicion that these drugs are used not for medical purposes but for what is graphically called the liquid cosh or a means of discipline and control. The DHSS should press the prison medical service to come into the NHS. The safeguards that exist within the NHS, although not great, could then be applied to the prison medical service.
I am disappointed that the Government do not intend to change the law in regard to section 65. There are times when one's civil rights could be more greatly eroded by being called a patient than a prisoner. Along with the hon. Member for Chertsey and Walton (Mr. Pattie), I recently took the case of William Pate to the Ministry. That case has had a lot of publicity and there is no harm in mentioning the name. Had this man been convicted of the offence with which he was charged, he could not have been in custody for more than two and a half years. He has been in custody for nine years and it is difficult to transfer him even now to a less secure unit. He is being kept in custody because he had the misfortune to be sent to a hospital instead of a prison. Although the Bill of the hon. Member for Chertsey and Walton deals with that situation, it must be put right when we come to legislate.
I am glad that the White Paper makes clear that mental illness should be restricted to what it says it is, mental illness. It should not cover alcohol dependency, drug dependency, sexual deviancy and so on. These serious problems should not be dealt with under the Mental Health Act.
Recently there was a tragic case in my constituency of a young drug addict who was in hospital after severely cutting his wrists. His family were pleading with 707 the doctors to keep him in hospital under that section of the Mental Health Act because he threatened that when he came out he would succeed in his attempt to kill himself. The doctors, rightly, in what was a very difficult decision, refused. They said that the man was not mentally ill. He had a history of drug addiction but that was not mental illness and therefore he must be released. The only way that he could get better from an addiction was voluntarily, and not under constraint. He was released, and so far there have not been any further tragedies. I believe that the White Paper is quite right to make it clear that doctors should not extend their tentacles over other areas beyond mental illness.
I am quite sure that it is common ground in these debates that the answer is to treat as many patients as possible in the community. I do not think that the answer lies in extending any sort of compulsory powers to patients within the community, however attractive this may seem at first sight. The Royal College of Psychiatrists was quite honest about this. Its representatives said that as doctors they wanted to keep control within the hospitals but they wanted the hospital sector to shrink to the smallest size possible to contain the problem. The psychiatrists considered that within the community their job was just one of a number of professions.
In my borough of Lewisham, one of the first really worked-out and organised multi-disciplinary team and crisis intervention centres has just been set up. The Minister of State knows all about this because it is in his constituency rather than mine. Having visited the centre the other day, I am quite sure that a team of every sort of professional situated within the community and aware of problems that may arise could cut the number of inmates in our mental hospitals by half and cut down enormously the incidence of Acts of Parliament and compulsory measures. I hope that that policy, with all the difficulties that it incurs in running down hospitals and building up facilities within the community, is pressed ahead with as fast as possible, because the answer lies in that direction.
The whole area of legislating on mental health is very difficult. We must give the maximum possible dignity to the patient, 708 consistent with reasonable protection for the community. I think that the balance has been reasonably well struck in the White Paper. I would have liked the Secretary of State to go much further, but I think that in the discussions that he is having at present his primary aim must be to stick to the lines of the White Paper. I am glad to see that the Opposition are approaching this with the sort of bipartisan attitude that should enable this White Paper to turn into legislation within 12 months or so.
§ 7.35 p.m.
§ Mr. Graham Page (Crosby)
The hon. Member for Lewisham, West (Mr. Price) was right to call attention to the remark of the Secretary of State that he intended to provide better psychiatric treatment in prisons. That is a wrong attitude towards the problem set out in chapter 5 of the review which deals with offenders in prison—" offender patients ", as the chapter calls them.
The hon. Member for Ormskirk (Mr. Kilroy-Silk) raised the matter extensively, not for the first time in the House. He and I are neighbours. In my constituency, on his boundary, we have two special security hospitals—Moss Side and Park Lane. They contain people who have been found to have committed an act which would otherwise be a crime and have also been found to have a mental disorder. They are detained either under section 60 of the 1959 Act—generally called a hospital order, from which they can be discharged by the doctor, the hospital managers or a mental health review tribunal—or under section 65, the restriction order, from which they can only be discharged with the consent of the Home Secretary.
From the fair number of letters which I receive from the inmates of these hospitals and cases which I accordingly investigate, I would say that there are a number of patients there who are awaiting transfer, not because they remain as a danger to the public if released but because there is no halfway house for them.
I thank the Minister of State for his great courtesy in answering the letters that I send on to him having received them from patients in these hospitals. I assure him that I do not send him all the letters that I receive. He helps me in investigating those cases, and there is no doubt that there are a number of people 709 there who would be transferred if the new units were built or if they were allowed into existing hospitals. Undoubtedly they are being barred from existing hospitals by employees of those hospitals, and to that extent they are being wrongly detained in the special hospitals. I admit that when I say "wrongly detained" I am begging the question. What, after all, is the purpose of detaining such a person who has committed a criminal act?
I agree entirely with the recommendation on page 65 of the review thatsection 65 should be reworded to indicate more clearly the essential purpose of the restriction order—that is, to protect the public from serious harm.If that were made more clear in the statute, it would serve a very useful purpose. But that does not entirely dispose of the issue whether one should detain an offender in a special security hospital for longer than he might have been in prison. This is discussed fully in the review. Should he be detained for longer than would be justified by the gravity of the offence if he were sane?
It is argued that the length of the restriction order should be equivalent to the length of the probable sentence which he would have received had he not had a mental disorder. After that time it is suggested that he should be discharged from security as a criminal and transferred to a civilian hospital under security as a civilian. I do not go as far as that because I think that that would defeat the primary object of the restriction order, which is to guard against the discharge of an offender on purely medical grounds when he remains a risk to the public.
I am glad that the Government come to that conclusion. I quote from the review on page 52:In the Government view the law should continue to enable society to protect itself from certain dangerous mentally disordered offenders by detaining them in hospital for a period longer than would be justified by the gravity of their offence.As I said in an intervention during the Secretary of State's speech, that should be coupled with an annual review. The review should be given statutory backing. A statement in statute that it is the primary object of a restriction order to detain those who might well be a risk to the public would ease the mind of the 710 public when a regional secure psychiatric unit is proposed for a certain area.
I am sure that the Minister of State knows how I suffered when Park Lane was proposed and was being built in my constituency. The residents were terrified, although they had had no trouble from Moss Side, the special hospital that was next door. However, at that time there was a tendency to talk about the releasing of offender patients purely on medical grounds without real consideration of the public concern and whether release would be a risk to the public.
I find a considerable conflict of emotions and duties when I receive a request from a patient asking me to ensure his discharge as quickly as possible. I may find from the facts I obtain on his case and his dentention that there is an element that allows me to make representations on his behalf.
Let us suppose I were to succeed and a few days later, he having been discharged, he committed rape or murder. I do not think that for fear of that happening one should funk investigating cases in which there may be something to say for the release of the offender patient. In the end I know where my main consideration lies—for the protection of the public. If that were more clearly stated in statute, we should overcome many of the difficulties that the public feel about secure units. Had it been more clearly stated when Park Lane was being built, I should not have had the trouble that I experienced with residents in my constituency at that time. I talk about "trouble", but I really mean that I had to try to calm their fears about what might happen if there were another security hospital in the area.
My only fear was that we were meeting saturation point in the area in supplying voluntary help to the hospitals. There comes a stage in any area when all the voluntary help that may reasonably be expected has been called upon. That is what happened in my constituency. If, as in my area, there are seven epileptic homes, all of them having about 100 inmates, and two security hospitals with hundreds of inmates, voluntary help is stretched to the limit.
I turn to chapter 3 of the review that deals with admissions. It has already been said that the present industrial dispute, which has resulted in hospitals being 711 able to accept only emergency cases, has a direct bearing on the subject of the debate. It has resulted in the section 29 emergency procedure—the recommendation of one doctor only—being used to the exclusion of the more appropriate two-doctor recommendation under the other sections of the Act. Not only compulsory admissions have been refused but non-emergency admissions under section 29. As the section 29 procedure is operated by the social service workers, who are on strike in my area, applications are being signed by relatives without any guidance. A serious position has arisen.
It may be that I am jumping the gun by dealing with the immediate problems. However, there is the immediate problem of the emergency procedure only being accepted by the hospitals. The stage of admission is when the relatives of those involved are most seriously distressed. The way in which a person is, if I may use that ghastly Victorian phrase, "put away" is of great concern to the public. It conjures up perhaps the horrors of "Jane Eyre". People still talk about putting a person away, and they mean it. To many families, the admission of a relative to a mental hospital is as distressing as the death of that relative. It is extremely distressing to the relatives.
It is essential that we get the process of admission absolutely right. It is essential that it is operated correctly and properly observed by those who have to operate it. We must achieve the right balance between the protection of the public, the help needed by the mentally disordered person and the deprivation of a person's liberty. On the whole, the relevant sections of the 1959 Act—sections 25 to 32—achieved the right balance. The House will remember the several ways in which there may be compulsory admission under those sections.
I return to the question of emergency admission under section 29, cases of urgent necessity on the recommendation of only one doctor. Although that may be for only 72 hours, I fear that in many instances the detention lasts longer than that before a second recommendation is made.
An application under section 29 is made either by a relative or by a mental 712 welfare officer. I have been horrified by facts given to me concerning the making of such an application by, if I may refer to them in these terms, so-called mental welfare officers. I was given the facts by one of my constituents, Mr. Tom Smith, who is the retired senior social work adviser for mental health for Liverpool. For several years Mr. Smith had been the superintendent mental welfare officer for that city. Since his retirement in June 1976 he has published some of the facts that he made known to me. He is extremely concerned about the responsibility and authority in mental health matters that are vested in junior social workers untrained and inexperienced in mental health.
That anxiety is reflected in the review. I quote from paragraph 3.9 on page 30, which states:The comments received show that there is widespread concern about the lack of specialist knowledge on the part of many social workers engaged in mental health work; this has been attributed to the setting up of social service departments and the concept of the general purpose, social worker which arose from the Seebohm Report.That is exactly what happened in Liverpool. In 1970, when the social services department was established, the instruction was issued that all social workers were thereupon authorised to act as mental welfare officers. Mr. Tom Smith, the then superintendent, who lost control of all the inexperienced workers who had been carrying out that work, has documented about 20 cases of the most horrifying errors and mistakes by those social workers. They instructed police to remove patients without any application for admission, or made applications for admission to hospitals that were not equipped to deal with those patients. There are many such examples with which I shall not delay the House. These cases show that completion of applications for admission must not be delegated to untrained and inexperienced social workers.
I am glad that the Government intend to try to put that matter right by providing a training for social workers to ensure that an aprpoved mental welfare officer, in the same way as an approved doctor, 713 signs an application. The review proposes on page 31to give the ' Approved Social Worker '—That shows clearly the responsibility and a desperate need for training social workers. There must be a responsibility on somebody to activate the detention. It is our duty to see that someone is capable of accepting that responsibility.
- i. a statutory duty to interview the person concerned before making an application for compulsory admission; and
- ii. a responsibility to satisfy himself that the care and treatment offered is in the least restrictive conditions practicable in the circumstances."
These are not just procedural matters. They are practical preparations to meet a crisis in someone's life—a moment of complexity, confusion and distress for both the patient and the relatives—when a firm decision has to be made by an experienced person and when, having made that decision, that person has to ensure that the patient is received into a hospital that is equipped to receive the patient and has suitable accommodation and suitable medical and nursing skill. I am glad that the Government intend to act positively on this issue, which will have my full support.
I have heard the most horrifying facts about patients dealt with by inexperienced social workers. I support the Government's conclusions on the points I have mentioned. I hope that they will be carried out whatever party happens to be in office.
§ Mr. Geoffrey Pattie (Chertsey and Walton)
The Secretary of State reminded the House that the White Paper sets out to review the working of the 1959 Act. Hence its title. The Act is limited in scope to compulsory powers for the admission of patients to hospital, powers relating to their detention and release, and powers relating to their rights while detained.
The Act makes provision for the mentally ill and mentally handicapped. It is undoubtedly the major extant piece of legislation in this field. It would appear from the length of time that has elapsed since the Act was passed that 20 years is about the minimum going rate for legislation. If this is so, a new Act will codify society's wishes and attitudes for the rest of this century. What concerns me more 714 than the detail of the White Paper is whether the White Paper is sufficiently wide in its scope. I cite, for example, the major question of whether it is right to include mental handicap within the ambit of this legislation. Including mental handicap and mental illness together compounds the identity seen in the public mind between the two groups. Yet they could not be more different.
The former condition is congenital and irreversible although there is still much potential to be realised, whereas the latter is an illness which is curable, like any other, to a greater or lesser degree. I know that the psychiatrists feel that the two should be kept together because mentally handicapped people can fall prey to mental illness and can exhibit certain symptoms rooted in frustration related to their own condition. I fully accept this. I feel that these mentally handicapped people should then, and only then, come within the scope of the Act as treatment is required and for as long as it is required. I accept also that some will need institutional care and support all their lives. But the presumption is now growing that this number is smaller than was previously thought. The assumption in future should be that mentally handicapped people will be best living in the community with the requisite degree of support.
The point I am seeking to make is that a new Act should deal with the problems of the mentally ill and no one else. Some of the mentally ill may be mentally handicapped. Some may be physically handicapped. Others will be physically normal. The common factor must be mental illness. We have, however, included another group, the mentally handicapped, as a totality, most of whom cannot be described as mentally ill in any way. If we were logical, we would also include the physically handicapped witthin the Act. I am not putting this forward as a serious suggestion but simply to point out the illogicality of the present situation.
Public attitudes have undoubtedly changed dramatically for the better in the past 20 years. But it would be foolish to pretend that there is not still a sizeable reservoir of ignorance and prejudice relating to both categories. We cannot blame the public if they equate in their minds a hostel for the mentally handicapped with Broadmoor patients if we in 715 this House lump both categories together in our legislation. Paragraph 1.19 in chapter 1 of the White Paper recognises:a substantial number favoured separate legislation.I find it difficult to keep up with the mathematics of the White Paper. There has, quite properly, been a lot of consultation. A sizeable number of people who are actively engaged in the care of the mentally handicapped feel that they should be either excluded or separately provided for. The Government have none the less come to a different conclusion—not that they were bound to follow the consultations—but there seems to be a non sequitur in paragraph 1.19.
The problem facing the House is that, the original decision having been made in 1959 to include the mentally handicapped, the Government said that basic fundamental questions such as this are not open for debate and that we are only debating the White Paper reviewing the working of the Act. This is rather a Catch 22 situation. This is an extraordinary contention because it implies that it is impossible to consider fundamental changes of direction.
It is not an answer for the Secretary of State to say, as the White Paper does, that other statutes are involved in the sphere of mental illness and mental handicap and that other White Papers have considered the problem. The House is aware of the existence of those other White Papers. What the public are expecting, irrespective of whether they are right to expect it, is that a new Act will be definitive and all-embracing and will not simply be about custodial elements and the rights of patients. If it is not intended to bring forward a Bill to meet that expectation, we should say so quickly. The Secretary of State knows that I am among those who would welcome new legislation.
I take this opportunity to thank the Minister of State and his Department for their assistance over my modest Private Member's Bill. I know only too well what a low priority Governments of either persuasion often afford to the mentally afflicted. When I hear that new legislation could be ready by the end of this year, I feel that I face the dilemma, on the one hand, of not wanting to delay 716 it and to seize the opportunity while it exists and, on the other hand, of urgently wishing to get any new legislation absolutely right, particularly bearing in mind the comparative infrequency of legislation on the subject.
Behind my point about mental handicap lies the major criticism that the Government have missed the opportunity to review the whole area. They have obviously deliberately decided not to do that and they are, therefore, open to criticism. They could have gone far beyond merely reviewing the 1959 Act. They have not addressed themselves as fully as they should have done to resource questions and to taking the whole issue much wider.
Many groups have legitimate interests in these matters. Earlier speakers have paid tribute to them. I note that the Royal College of Psychiatrists, in its otherwise extremely good report on the White Paper, appears to be very sensitive to the comments of MIND. It is inevitable that we shall have entirely healthy creative tension between the different interests. I welcome the contributions of the Royal College, MIND, the unions, BASW and all those involved in these matters. None of those good people should feel that there is an inbuilt bias in the House in any one direction.
I should also like to add my commendation to the work of the all-party committee. The chairman, the hon. Member for Basildon (Mr. Moonman), has made a major contribution.
§ Mr. Moonman
The hon. Gentleman is vice-chairman of the all-party committee and I am sure that he will agree that I committed an error by omitting to pay a tribute to the Psychiatric Rehabilitation Association, which has been a great support to us over the years. It would be a pity if we did not put that fact on the record.
§ Mr. Pattie
I am glad that the hon. Gentleman has repaired that omission and averted the possible danger that I might repeat it. I am well aware of the work of the PRA and, in particular, the contribution of John Wilder.
The role of hon. Members is to ensure that a balance is preserved between the interests of patients, staff and the public. 717 I have the highest regard for the contribution of MIND, but I am not a slavish devotee of its viewpoint, right or wrong. I also admire much, though not all, of the argument of the Royal College.
The 1959 Act, liberal and far-sighted as it was, enshrined what I call—without, I hope, causing offence—the principle of medical supremacy. It is the most natural response in the world for highly qualified and skilled psychiatrists represented by the Royal College to feel that, in all matters of treatment, the medical view should predominate.
The Royal College is unfairly criticised because it is seen to be as enthusiastic for compulsion and the denial of patients' rights as MIND is reckoned to be obsessive about patients' rights. The Royal College special committee's report on the White Paper recommends that the proposal on a new holding power under section 30 should have a time limit of three hours rather than six hours. That is hardly the language of those who seek to restrict patients' rights.
On the other hand, I hope that I shall not be thought to be hypercritical if I draw attention to the Royal College's comments on the role of relatives as set out in paragraphs 14 to 17 of chapter 3. The college says:as far as possible relatives themselves should be encouraged to take responsibility and continue to be involved in admission and discharge procedures rather than to relegate this entirely to a professional group (social workers) ".The word "relegate" may be a Freudian slip or, more mundanely, a typing error, but it has overtones of perceived stratification. The word "delegate" would have conveyed the meaning equally well.
The Royal College has reacted strongly to the Government's proposed new definition, in paragraph 23 of chapter 1, of treatment in relation to the mentally handicapped. The White Paper proposes a new definitionwhich makes it clear that it includes care, training, the use of habilitative techniques and medical, nursing and other professional help.I support that proposal because I am convinced that the future will lie with the inter-disciplinary concept and that increasing numbers of patients will be in hospital for relatively short periods. The whole direction nowadays is towards units 718 in district general hospitals and more community support.
Close teamwork in support of patients is vital. There are so many medical factors that contribute to the onset of mental stress and illness that it would be wrong in future to accord the degree of primacy to the strictly medical function that it has enjoyed to date.
What does not seem to have been appreciated is the urgent need for positive discrimination in favour of mental health and mental handicap because of their permanent position at the end of the queue for resources. The resource question is tucked away in four short pages at the end of the White Paper, and those involved in these matters must wring their hands again in fear of another exercise of raising hopes without fulfilment. The Royal College has described resources as "seriously underestimated". Resource allocation will certainly be the name of the game.
The White Paper has also failed to offer suggestions about the duties that should be laid on social service departments. No guidance is offered on the scope and extent of professional discretion. We shall obviously need machinery for the maintenance of standards.
We have heard talk of accountability, but there is no mention of establishing minimum standards to which all questions of accountability must relate. It seems to be generally agreed that in future the main burden of effort will be devoted to rehabilitation, getting patients back into the community and, above all, to actions designed to prevent patients from being taken into hospital in the first place. That will mean a major reorientation in favour of community-based services and, in particular, crisis intervention services. We must recognise, above all, the importance of care, support and guidance for the mentally ill at home and for their families—and I stress the importance of support for the families.
The White Paper does not specifically address itself to the problems of psycho-geriatrics and it does not discuss the question of upgrading primary mental health care in the community.
One of the so-called non-consensus areas listed by the Secretary of State was mentally disordered offenders. The hon. Member for Basildon referred to a recent 719 visit that he and I paid to Prestwich hospital where we examined the difficulties being experienced by the interim secure unit because of a campaign of obstruction being waged by the NUPE branch secretary—one of the hospital cooks. The other union involved, COHSE, made clear that it supported the regional secure unit and wanted to help to make it work. The entire programme at Prestwich is in danger, with the ripple effect going out to other hospitals, and there is a cloud of indecision and anxiety over staff and patients because of the activities of one man. Something has to be done to get the programme on the rails.
The word should go out from the House to the public that patients in regional secure units are people who cannot be admitted to Broadmoor but they are not travelling in precisely the opposite route. There should be the chance for rehabilitation and the avoidance of tragic human waste.
We look forward to a Bill being presented later this year so that we may confront the dilemma whether to go ahead while we have the chance or to delay for a while and hold further consultations. Above all, I should like the new Bill to be as close as possible to what we all agree represents the best way forward. The hon. Member for Basildon suggested that a two-part approach might be most practicable. I was taken with that suggestion. We all agree that there is a need for reform. We should be ready to move forward with that reform as soon and on as broad a front as possible.
§ 8.9 p.m.
§ Mr. Stephen Ross (Isle of Wight)
The hon. Member for Chertsey and Walton (Mr. Pattie) made a knowledgeable and well-researched contribution to the debate and argued powerfully for the exclusion of the mentally handicapped from forthcoming legislation. I should like to put on record my own limited experience in support of that view.
I speak with some trepidation because mental health is a vast and complicated subject. The knowledge that I have gleaned has been comparatively recent and is largely the result of constituency cases. There are three prisons in my constituency. I could say a great deal about them, but I shall not tonight. I did not 720 appreciate that there were so many secure homes in the constituency of the right hon. Member for Crosby (Mr. Page). I should like to return later to a point made by the right hon. Member with which I totally agree.
I should like to pay tribute to MIND. That organisation has been helpful as has the all-party mental health committee to me in the cases with which I have been concerned. Two weeks ago the chairman of that committee complimented me. I should like to return that compliment both to the chairman and to the vice-chairman, the hon. Members for Basildon (Mr. Moonman) and Chertsey and Walton. They have given up much time and energy to a cause which they both hold dear and they have also been of considerable help to me. I am most grateful to them.
I have attended two mental health tribunals at Broadmoor. The first one was the first to be open to the press and the general public, limited though it was, and it caused quite a stir at the time. I was enormously impressed by the quality and expertise of the tribunal members. Moreover, at the tribunal which I attended only in December last the members could not have been more fair or thorough. The country owes a debt of gratitude to these people.
At the first tribunal my constituent did not obtain his release, However, six months later, when he again appeared before a tribunal, he was successful, and rightly so, in my view, because he had been in Broadmoor for nearly five years. He was then released immediately. I was delighted by his success, and he has since fully justified the confidence that was placed in him by the tribunal. However, at the time I felt that it was a terrible mistake to discharge him into society without real preparation after almost five years' detention.
That is why I particularly endorse recommendation V. on page 79 of the White Paper. That would enable tribunals to delay discharge for up to three months. That time should be spent constructively, allowing the patient adequately to prepare himself for the problems that lie immediately ahead. Some sort of halfway hostel is clearly desirable. I do not believe that these places even exist in the South of England. Certainly I have not discovered one.
721 The White Paper also mentions trial leave, which I believe to be an excellent idea, or even guardianship, where family circumstances dictate that course to be preferable. To release a youngster just out of his teens from Broadmoor without preparation is to take an enormous risk. There is the possibility, mentioned in the White Paper, of recommending the transfer of a patient, who is obviously not ready for discharge, to another hospital or secure establishment where it is felt that he or she has a better chance of recovery.
I do not think that anyone in this country can be satisfied with the existing provision of regional secure establishments. I asked the Minister of State about present and future provision of small secure units for juveniles suffering from mental disorders which are considered capable of cure and was told that only one regional authority was planning a secure unit for adolescent psychiatry with about 20 places, but that it would not be ready within 12 months. That is the position, and it is a public disgrace.
The staff of Rampton, Broadmoor and other secure hospitals do an excellent job to the best of their ability. But the whole atmosphere of these vast Victorian edifices—I refer particularly to Broadmoor—fills one with foreboding for the teenager. I have in mind a constituency case of a girl just on 15 years of age when she went into Broadmoor. It is a very difficult case about which many hon. Members will know. She was detained in Broadmoor under sections 72 and 74 of the 1959 Act. I felt that she was doomed almost from the moment she entered that establishment. An article in The Guardian on 19 February dealt with the numbers at Broadmoor. At the moment there aremore than 580 men and 120 women, about one-third more than its designed capacity.The need for smaller homes set in a pleasing environment is overwhelming. A great deal more public money will have to be spent. I was pleased to hear that from the Opposition Front Bench today.
§ Mr. Ross
But it has come. We should be grateful for it.
A great deal of public money will have to be spent. I agree with those who criticise the regional health authorities which 722 have not spent the money that was allocated for that purpose. If necessary, the Secretary of State may have to direct, when money is available, that it is spent on such homes. Of course, we must also spend more money on training suitable staff to manage them.
Paragraph 5.52 of the White Paper deals with the transfer to hospital of un-sentenced prisoners. The right hon. Member for Crosby covered much of the ground to which I wish to refer. This area is cloaked in mystery. I could not fathom out the reasoning behind the decision in one case which came to my attention. It happened before I became a Member of the House. The person concerned was already in Broadmoor. His parents besieged me to try to get him out. The more I researched that case, the more unhappy I became. MIND's criticism of this area is fully justified.
I have always suspected that the report of the probation officer in the case to which I referred held too much sway. I think that it also held too much sway with the tribunal when it first met. As subsequent events proved, that official had gravely abused his position. He has now resigned from the probation service.
The right hon. Member for Crosby talked about the doubtful role of criticised social workers in this field. The trouble is that once a report is on record it takes a devil of a job to get it off. Even if it is untrue, partially true or badly knocked together, it is on record and it is used time and again. I think that the Home Office must insist on a more thorough investigation into the background of each case before these sections are invoked. Once an order has been made and the person concerned has been committed, the process of reversing that decision is prolonged and fraught with difficulty. In the case to which I referred, it took five years.
The availability of a second opinion, which is referred to in paragraph 6.28, is of paramount importance. Adequate legal representation at a subsequent tribunal hearing is highly desirable. I do not criticise those who represented my constituents at the tribunals. However, a higher level of legal experience and knowledge would have helped their cases. I am thinking of someone who was perhaps more versed in taking such cases. There seems to be a dearth of such people. Those 723 who represented my constituents are to be congratulated on their work. However, it seems odd when an American appears before a tribunal on behalf of a client in Broadmoor.
I strongly support the recent MIND conference resolution calling for legal aid to be made available for representation and for a patient advice and advocacy service to be established. I strongly support the proposal that it should be the positive duty of mental hospitals to admit patients who require treatment. I have never been able to understand the refusal of some hospital directors to take quite ordinary cases within their jurisdiction. If they are not prepared to take such cases, they should be required to give adequate reasons for refusal to admit. When I have come up against this blockage it has seemed to me that directors were taking the easy way out.
I welcome the increasing role now being played by housing associations in the provision of accommodation for the mentally handicapped. Recently I visited Portsmouth. The Portsmouth housing association is already operating in this area. The Housing Corporation published a document on the subject. Although there is a long way to go, we are making progress.
There is another good reason why mental handicap should not come under the provisions of a new mental health Bill. I am thinking of a constituent with a vaccine-damaged child who is in her teens. That case is a nightmare for the parents. They have had to raise the garden fences and take other precautions. It is a wonderful case of parental love, devotion and duty to their child. However, occasionally they would like to take a short holiday. There is no provision for a mentally handicapped child, who has committed no offence, to go to a secure place. Rightly, the voluntary bodies do not make such provision in the area of mental handicap. They do not wish to create secure establishments. This pinpoints the difference that we are trying to demonstrate. That duty should fall on the local authority.
I hope that our suggestions and objections will be heard by the Government and that when the legislation appears it will be in the form of a Bill dealing with the mentally sick.
§ 8.23 p.m.
§ Mr. Michael Spicer (Worcestershire, South)
The hon. Member for Isle of Wight (Mr. Ross) reminded us that there were three prisons in his constituency. In the rural depths of South Worcestershire there are two mental hospitals and the latest maximum security prison. Perhaps that is one reason why, over the past two or three years, I have developed an interest, which I share with the Minister of State, in the questions of patients restricted under section 65, the mentally ill and offenders, especially those languishing in prison now. This morning the Minister of State, in answer to a question, told us that the number of such cases runs into many hundreds.
I make no apology for referring to an extremely good speech by the hon. Member for Ormskirk (Mr. Kilroy-Silk), with whom over the past few years I have shared an interest in the question of regional secure units and the reasons why they are required, as well as the scandal about the lack of such provision. It is true that 95 per cent. of residents of mental hospitals are there, by definition in the Act, as informal patients who wish to be there. That is to be welcomed without qualification. The Mental Health Act 1959 is working extremely well in that respect.
I am concerned with what I believe to be the basic set of paradoxes running through the review that we are debating. I am concerned with the conditions and facilities provided for patients who are referred by court order under section 60, and particularly for those who are restricted under section 65 of the Act. I am also especially concerned with those who are not restricted under either of those sections, namely, the hundreds of people who are in prison as a result of the lack of facilities for their treatment in secure hospitals.
Chapter 5 of the review is entitled: "Offender Patients", and it is riddled with paradoxes which perfectly illustrate the dilemma faced by the authorities. The dilemma is largely of their own making. I say "largely" because the co-culprit in this matter, I believe, is the psychiatric profession, which has dithered around, giving conflicting advice, particularly on regional secure units, with such damaging results.
725 I have to admit that on a constituency basis I am losing patience with the psychiatric profession, which seems invariably to cloud its own uncertainties and indecisiveness in the most obscure jargon. As the hon. Member for Lewis-ham, West (Mr. Price) has pointed out, this would be acceptable, the profession being a relatively new one, if it were not put over with such arrogance.
I want to refer in a moment to two cases which precisely concern the regional secure units, and to the advice received from psychiatrists, although I do not think that that is the right description for it. It is in some cases more like bullying. This leads me to be extremely concerned about the profession and its role, together with the regional health authorities and central Government, on the question of regional secure units.
Paragraph 5.52 of the review indicates that there has in the past 10 years been a decline in the number of offenders compulsorily admitted to hospital. I have scrawled in the margin of my copy that the reason is that they all have gone to prison instead. It is ironic that the drop in the number of offenders compulsorily admitted to hospital, which is now round about 550, as stated in the review, is absolutely identical with the number of mentally ill patients languishing in prison. I am sure that this is coincidental; nevertheless, to my mind it is ironical. The review goes on to say that the drop in the number of offenders compulsorily admitted seems to be in part due to an increasing reluctance by hospitals to admit patients.
One of the important questions raised in the White Paper is whether receiving doctors should have a final veto in cases submitted under section 65 of the Act. I certainly understand the arguments for bringing receiving doctors much more closely into the picture—the White Paper may well have got that matter right—but I would not want doctors to have the final veto on matters under section 65.
However, without going into that, there is no question but that an unqualified onus lies on the authorities—I do not believe that they have fully accepted its significance—to recognise that the present system puts an intolerable burden on doctors and nurses working in mental hospitals. It is true that the philosophy and workings of the 1959 Act were admirable 726 in their intentions, but it is also true that they have meant that a nightmarish task exists for hospitals and their staff of coping with those restricted patients who are capable of becoming violently out of control.
That was one of the reasons why I asked earlier what proportion of those patients who are restricted—we were given a figure of about 200—
§ Mr. Spicer
What proportion of those are in special hospitals and what proportion are in normal mental hospitals? I very much hope that the Minister will answer that question.
§ Mr. Spicer
Seventy-six remain in the mental hospitals.
That is an indication of the problem. Mental hospitals as such, for understandable reasons, are not proving very adequate in providing the facilities for the kinds of offender patients I am discussing.
As the hon. Member for Ormskirk mentioned, the problem is worse than the figures indicate. The figures provided to the House by the hon. Member in relation to special hospitals—I hope that the Minister of State will comment on the figures if they are wrong—showed that 146 men and 46 women are in special hospitals whom those hospitals would like to discharge into a more intermediate hospital but a hospital which, nevertheless, is able to look after them. This is a very serious addition to the problem. It is an extremely important dimension. Part of the problem of mental hospitals in my constituency has been caused by the fact that they have met with several patients from Broadmoor, in particular, with whom they are unable to cope in the circumstances in which they find themselves under the 1959 Act. It is a very serious problem.
727 The whole crisis must be viewed against the background that nothing that any of us has been saying tonight is new. As has been mentioned, the Butler committee reported in 1975. Subsequently, the Government, time and again, have accepted its recommendations that regional secure units and interim secure units should be built. Five years after the recommendations of the Butler committee were known to the Government, virtually nothing has been done.
In an Adjournment debate on 16 June last year, I quoted the Minister of State, Home Office, who spoke in a debate in the House of Lords on 22 March 1978. I should like to repeat the quotation. He said:I think we can state this problem very simply so far as secure units are concerned. If we do not get them, a large number of mentally ill people are going to remain in prison. "—[Official Report, House of Lords, 22 March 1978; Vol. 389, c. 1886.]I suspect that many hon. Members will have examples of constituents who have been sentenced to prison in the full knowledge of the courts that they are sentencing mentally ill people. In the Adjournment debate of 16 June I raised the specific case of a constituent of mine, Richard Tolley, who was sent to prison on 9 March 1978 at the Worcester Crown court and of whom the sentencing judge said:the medical evidence in your case is considerable…you suffer from severe mental illness, which is schizophrenia, or an illness akin to it…You have in the past acted violently, using an axe, threatening members of your family…there is no suitable place in any hospital whatever outside the prison service which is suitable to you…A prison sentence is, in the absence of a hospital order, justified in your particular case.Another case that has come to my notice and, I am sure, that of many other hon Members is that of Mr. Michael Thynne. He is not a constituent of mine, but his mother has written to many hon. Members who are interested in this case. He was sent to prison for life in November 1975 at the Central Criminal court, although again he had a long history of mental illness.
These two cases are of concern for several reasons. One is that neither person could have received personal adequate mental treatment in prison, although in both cases the judges expressed the hope that they would.
728 In the case of Mr. Tolley I received a letter dated 13 March 1978 from Mr. Rayfield, governor of Gloucester prison, who gave me permission to quote him as saying:It is obvious that Richard has been sent to prison because there is nowhere else for him to go. He will be seen by a visiting psychotherapist whilst he is here, but you will appreciate that we cannot give him the specialised care he would expect to find in a hospital.That is one unsatisfactory aspect of this. There are not, whatever the authorities may say—and there should not be—the facilities in prison for coping with the mentally ill.
The second unsatisfactory characteristic of the present situation is that judges have the option of passing life sentences for certain offences, as in the case of Mr. Thynne, or, as in the case of Mr. Tolley, passing finite and often short sentences at the end of which the prisonerpatient is simply thrown back on society, once again to try to fend for himself. That is exactly what has happened in the case of Mr. Tolley.
Like the hon. Member for Ormskirk, I believe that the present position is both unfortunate and scandalous, because the Government have accepted the validity of this argument and have in the past three years allocated £17.7 million specifically for building regional secure and interim secure units. From the answers that have been given to parliamentary questions over the past six months, I find that only £800,000 of that money has been spent by the regional health authorities on the development of regional secure units and interim secure facilities.
All sorts of excuses are given for that. When I questioned the hon. Member for Basildon (Mr. Moonman) about this, he produced one of those excuses referred to by my hon. Friend the Member for Reigate (Mr. Gardiner), namely, that there is a problem in securing the approval of the local community for such projects.
That may be true, but there is certainly an example in Warwickshire, in the case of Hatton hospital. There the regional health authority, recognising the problems associated with converting part of it into a regional secure unit, held various public meetings and won the support, or at least overcame the objections, of the local community.
729 I do not say that that was a fatuous excuse, but the problem could be overcome by proper communication between the authorities and the local population.
If there is to be any accountability for public moneys and any responsibility to ensure that moneys voted by Parliament are spent on the purposes for which they are voted, the regional secure unit scandal must be seen as yet another threat to parliamentary democracy.
In Adjournment debates and in response to questions in the last year the Government, although they accept the facts, have tended—for reasons best known to themselves—to shrug off these implications. They have accepted that moneys can be spent on activities which are totally different from those for which they were allocated.
I hope that the Minister of State will be willing to make a firm statement aimed at those regional health authorities which have wilfully and scandalously misappropriated public funds. I hope that he will take a firm line and demonstrate that the Government recognise that there is a major problem which goes to the heart of our democratic and funding processes. I hope that he accepts that money must not be spent on purposes for which it has not been allocated.
§ 8.41 p.m.
§ Mrs. Lynda Chalker (Wallasey)
We welcome the debate on the White Paper. Less than three weeks ago I requested the Minister of State to allow us to have this debate. He said that it was not within his power. He has become influential with the Lord President in the last few weeks, as is shown by the fact that we are now having the debate.
The debate has shown not only a wide but a highly informed view of the problems of mental health and mental handicap. The House will benefit from it. In the last few years we have had a plethora of different reports on the problems of mental illness and mental handicap. It began with the report on "Better Services for the Mentally Handicapped" produced in 1971 by my right hon. Friend the Member for Leeds, North-East (Sir K. Joseph). That is the first base from which the arguments have been continued.
We cannot cover either in the White Paper or in tonight's debate every aspect 730 of the problems that beset us. However, for the sake of education outside the House it is worth going over one or two of the issues which might not be included in the White Paper directly but which affect the care of those who are mentally ill and the question of prevention.
The Secretary of State became a little hurt at the possibility of being criticised by outside organisations and by some of my colleagues because these issues had not been brought together. I am sure that he accepts that the Government's duty is to bring together the reports and views across the whole spectrum, not only those matters contained in the White Paper.
Mental illness and mental handicap are parts of life. They have often been brought to hon. Members' attention for the first time after they have become hon. Members. The problem of mental illness affects one in six women and one in nine men in their lifetime. We are doing much research into the problem of mental handicap, but children are still being born mentally handicapped. It is not a scene from which society can turn its eyes and simply leave it to central and local government. It is a problem that affects all of us.
My hon. Friend the Member for Reading, South (Dr. Vaughan) said that the Secretary of State's speech was a compassionate one on a compassionate issue. I do not think that any hon. Member has deviated from the pattern set at the beginning of the debate.
The size of the problem is not all that we have to cope with. There is the deep-seated fear of mental illness, the assumption that somebody who is mentally ill is less than a whole person. I do not believe that that is true. I have many friends who have suffered in the past, who have come through and who, with careful rehabilitation, are full citizens in life today.
Therefore, in re-writing the 1959 Act, we should ensure that any stigma which that Act imposes at present is as far as possible removed for the sake of those who become afflicted by pressure and stress, because in mental illness, aside from the better known diagnoses, there is a need for education and rehabilitation. This debate will go some way to advancing these roles among a few more people who have not perhaps turned their minds to the issue of mental illness in the past.
731 Though it does not affect the White Paper, one further matter which is important is that we must all remember that the stress of modern life is increasingly revealing a tendency to mental illness in industry. It has always been my hope that industry will learn to recognise the early signs of mental illness, or the approach of extreme mental stress, and take preventive action amongst employees so that it is not allowed to develop, consequently disrupting the life of the employee, his family and large numbers of other people.
There are other matters with which the White Paper does not deal but which need to be remembered when discussing the issue. One is the role that general practitioners can play in recognising the onset of mental illness and giving guidance and support to the families of those affected. I do not believe that we are doing sufficient through our family doctors at present to assist those families that suffer.
One factor which very often exacerbates this situation is that the different Royal Colleges do not always come together over these issues. I hope that the Royal College of General Practitioners and the Royal College of Psychiatrists will make sure that those general practitioners who do not have mental health expertise—perhaps because they trained many years ago and have not undergone retraining to enable them to assist in the recognition and treatment of mental illness and in counselling—can be given some help.
We heard from the hon. Member for Isle of Wight (Mr. Ross) of the role which some housing associations are beginning to play in our society. They are helping those who have previously been mentally ill but who are now, thankfully, coming back into the community. I also know of a housing association which is beginning to help those less severely mentally handicapped people.
This seems to me to be the right kind of move in our society today, where we recognise and seek to deal with that affliction or that problem wherever it may occur. I think that it is the experience of hon. Members who are associated with mental health and mental handicap that we must now give much more attention 732 to this aspect of society than we have done in the past.
Some comments were made at the beginning of the debate about resources. I am very bothered by what has been described by MIND as the "inadequacy" of chapter 9 on resources in the White Paper. When everyone speaks about resources in relation to mental health and mental handicap, the point being underlined is that we have seen so many good ideas floated but few have come to real fruition. That was why I was much attracted by the suggestion of the hon. Member for Basildon (Mr. Moonman)—and his vice-chairman in the all-party mental health group, my hon. Friend the Member for Chertsey and Walton (Mr. Pattie)—that perhaps in dealing with the problems that we face today we should be proceeding on two levels.
One is to rectify those aspects of the 1959 Act which obviously attract major support—with agreement across an even wider range than those issues that my hon. Friend's Private Member's Bill covers. We must change the law and start the process. But in no way must the law changes be allowed to become an excuse for not doing what to me is an even more major task—to change the way in which we help those people in mental ill health, and with mental handicap, to regain as normal a life as possible and to live in our society.
I believe that in a recent speech the director of MIND, Mr. Tony Smythe, said that, if we were to fail to make a connection between a statute which essentially deals with duties and rights, the Secretary of State would add fuel to the fire of those who have consistently maintained that the law on patients' rights is relatively unimportant, and even a threat to professional performance, and that we should concentrate on getting more resources for what must remain a hospital-based mental health service. No hon. Member wants the service to be totally hospital-based in the future, and that is why, when we are dealing with the law which essentially affects hospital-based patients, we must consider the other side of care, because we are all concerned that fewer people should be hospital-based in future.
During earlier comments about resource needs, there was also a comment 733 about what we Conservatives felt. We have always recognised—I do not believe that any party or Government have done enough about it—that the mental health and mental handicap services have been the Cinderellas of the NHS. We believe, as I am sure do the Government, that the priority which is now beginning to be accorded to them must continue, because in a civilised society there is no way in which we can go on putting to the bottom of the pile those who become mentally ill or who suffer mental handicap. I for one will fight again and again to make sure that this is accorded a much higher priority than sometimes has been possible in the past.
I suppose that I must enter my regular caveat when I say that to do all the things that we genuinely want to do, we must first get our economy in good shape. Only then will we be able to do so much more than has been possible of late.
One of the remarkable things in the debate has been the unanimity about the question of legislation and the mentally handicapped. Not one speaker has felt that the Government were proceeding correctly in leaving the law on the mentally handicapped under the same heading as the mentally ill. Practically every speaker has either referred to that directly or has implied it. Therefore, I rather feel that the Secretary of State and his Department have been steered away from separating the mentally handicapped from the mentally ill in the case of detained patients. I am not certain who has steered them away, but what my hon. Friend the Member for Reading, South said must surely be the guidance.
Those mentally handicapped persons who do not present behavioural problems, or who do not have associated mental illness, ought to be separated quite clearly from those who do present behavioural problems and, perhaps, a threat to other people in the community. I hope that the Department will re-examine that and make sure that it is not swayed by the Home Office or others.
§ Mr. Ennals
The hon. Lady has obviously given this matter some thought. Does she think that there should be two pieces of legislation, one dealing with the mentally handicapped and another with mental illness, or one piece of legislation that should totally exclude compulsion for mentally handicapped people?
§ Mrs. Chalker
I am not expert on this, but there are groups of mentally handicapped people whose behaviour is not associated with mental illness and who do not present a threat. These people are unlikely to be detained, and a separate and clearly defined section in one piece of legislation might enable us to achieve the object that we all desire.
The hon. Member for Ormskirk (Mr. Kilroy-Silk) mentioned those who are mentally ill and in prison. He made a forceful speech containing the figures and all the arguments. There is a need for better provision for those who perhaps for a time have to remain in prison. We must also consider whether psychiatric services can be provided for people in prison hospitals if they cannot go to a special or mental hospital with secure accommodation such as an interim secure unit.
There must be a greater degree of collaboration between the Home Office and the DHSS. In 1959 my right hon. and learned Friend the Member for Hertfordshire, East (Sir D. Walker-Smith) was Minister of Health and my right hon. and learned Friend the Member for Huntingdonshire (Sir D. Renton) was a Minister in the Home Office, and those two Departments worked closely together on the 1959 Bill. But in this sphere there is far too little collaboration and, as the hon. Member for Ormskirk said, the problem has been pushed from one Department to another and swept aside.
If these most difficult patients—and I call them patients and not prisoners—are to come from the prisons into the community, there is urgent need for guidance in the treatment of violent patients. The White Paper gives some assistance in this direction.
On to the detailed aspects of rights of patients, guardianship and the need for treatment, everyone who has studied the White Paper has welcomed the proposals in paragraph 1.14 dealing with the information to be given to all informal patients on admission to hospital. It is always sad when a person who can no longer cope decides to accept his doctor's advice and go into hospital. He is more fearful than ever. At the best of times one is afraid of hospital. But a mental hospital, especially if it is an old building, will be more frightening and threatening 735 and less clinical than our surgical hospitals, and many patients would be greatly reassured if they knew their rights in advance.
Such information will also provide additional understanding for the families of these patients who find the situation particularly traumatic. In some cases it is quite disastrous when the mother goes into hospital. This degree of understanding is very important, and it should be extended to those who may have to face treatment not in a hospital but in the community. That is why the proposals contained in paragraph 1.8 of the White Paper that there might be a guardianship role for those who are to be cared for in the community are welcome.
There is one aspect of the way in which guardianship is used which is particularly important. There should never be powers to impose treatment in the community. If a patient is in such dire straits and in need of treatment but will not accept that treatment easily, the treatment should be in hospital. That person will most likely need to be treated under section 26. In order to create greater confidence in treatment within the community, the idea of guardianship should be pursued. I am glad to see that the Royal College of Psychiatrists agrees with this in principle. For some reason, it seems to think that it is impractical, however. I have not yet discovered why.
There is one other aspect of caring for patients who initially may be informal patients in hospital or in guardianship in the community. Although I am quite certain that doctors prefer patients to be informal wherever possible, because sometimes they have to exercise their duty under common law to prevent patients from coming to harm, there may be a greater use of sectioning in order to allow this to happen where the guardianship proposals perhaps do not take effect in quite the way that some envisage.
The guardianship proposals contained in chapter 4 of the White Paper produce a number of possible options. I was interested to see that the Royal College of Psychiatrists believes that there should be qualified support for the third option, the "essential powers" approach. In its notes to Members on the White Paper the Royal College says that there are ques- 736 tions to be raised about the operation of these powers, but since this is not spelt out in enormous detail in the White Paper we shall look forward to discussing it in detail when the Bill to amend the 1959 Act comes before the House.
The other aspect is that we should ensure that, where guardianship is introduced to assist, there should always be a body that can give advice to the families of persons placed under guardianship.
I turn to the question of patients' rights and the need for treatment. There is a very delicate balance between patients' rights and the professionally judged needs of a patient. Also, there must be consideration of the risk to others and the risk to staff. I do not believe that in any Act of Parliament or any guidance operated by the DHSS we can possibly cover every case. We can make general rules, but much of the decision taken in coping with the problems of informal patients rests fairly and squarely on the leadership and experience of the staff dealing with them and the atmosphere of care that exists in the institutions.
I do not believe that we can write down in any legislation how far persuasion can go. That must be a decision of the staff in charge of the patients. There is one thing that can be done, and it is being done in a number of hospitals around the country. Each disciplinary team needs to know very clearly in advance the sort of lengths to which it can go to persuade a patient that a certain course of treatment should be pursued.
The Maudsley hospital is not one of the general run-of-the-mill mental health hospitals by any manner of means. There are in that hospital and in many others excellent examples of good working practice. The multi-disciplinary team has decided in advance of a difficult situation how it can cope with the variety of instances that may occur. The Villa ward has both informal and sectioned patients. It provides intensive care for those who are experiencing very difficult problems. Among the staff there is a confidence about how to act. There is an understanding of exactly what to do if informal patients reject the treatment that they need. The support that the White Paper gives to staff in that position is greatly to be welcomed.
737 Another fact that has emerged from the debate and the White Paper is that the problems that we face in coping with both detained patients and informal patients when they become violent or have a period of great disturbance depend to a large extent on the quality of the staff. That is significant in the light of the present staff problem.
I was surprised to hear the Secretary of State say that the nurse-patient ratio is one nurse to three patients in most of our hospitals. That has not been my experience that of my colleagues during visiting of late. When we visit hospitals and are told about the difficulties of dealing with patients, both informal and detained, we well understand the difficulties that they face when they are under pressure through lack of staff.
I shall be grateful if the Minister of State will speak about the quality of those who are entering mental health nursing training. It is not necessarily those who are already in post but those who are coming through the training procedure who will be crucial in the years ahead when we hope to implement the recommendations in the White Paper.
Another problem that is coming to light more and more where wards are severely understaffed and where the nursing staff has to deal with difficult patients is the great need for the staff to receive counselling. Often members of the staff take on their own shoulders and into their own selves many of the problems experienced by their patients. The counselling of staff is something that few of our National Health Service mental health hospitals have the opportunity to undertake. If staff are under great pressure, mistakes can occur because decisions are made without necessarily all the right influences being at work.
Staffing levels and the quality of staffing are of great importance when dealing with the mentally handicapped, especially mentally handicapped children. I listened to my right hon. and learned Friend the Member for Huntingdonshire and I visualised mentally handicapped children in disastrously understaffed wards who will probably never live in the community because they are severely subnormal and have all the multitudinous problems that will probably necessitate their being detained throughout their lives.
738 Often we see staff coping with multiple handicapped patients when they are severely below the required staffing level. I can think of Balderton hospital at Newark and many others throughout the country. That underlines what I said about giving attention to resources. If we do not, wrong decisions will be taken.
There are many other aspects of the White Paper that we welcome. For example, we welcome the staff safeguards that are contained in chapter 7.
The recommendation for the mental health review tribunals is first-class. The first four sections of the recommendation are already included in the Bill ber for Chertsey and Walton, which I hope the Government will assist to get on to the statute book as soon as possible.
In the list of proposals for changes to the mental health tribunals there are those mentioned by my hon. Friend the Member for Worcestershire, South (Mr. Spicer) about delayed discharge that might be in the best interests of the patient who is going out into the community. The suggestion in paragraph 6.5 that discharge might be delayed for up to three months is not only something which doctors will welcome in watching the progress of a patient once they know he is going out, but will also allow proper preparation for the reception into the community of those people being discharged or for their reception into another hospital of less security, which does not now happen.
I felt that there was one gap in the proposals in chapter 6. I would be grateful if the Minister, if not tonight, on some future occasion, could give his attention to this gap. Under the new proposals for mental health review tribunals, what happens to a conditionally discharged restricted patient? It appears to me that such a patient has no right of appeal to a tribunal to have his status changed. It is not clear, if the proposals in the White Paper become part of a new mental health Act, what will happen in the case of such a patient.
There are other suggestions, such as those for tribunal enlargement, which we welcome. It is already possible to have four members of a mental health review tribunal. We do not feel that it is necessarily right to have a rigid rule that a 739 social worker must always be a member of the tribunal. A social worker can at present be a fourth member, but I think it is important to retain the presence of lay members. This is one further aspect of educating and involving members of the public. A family whose relative is going before a tribunal is also given confidence if it is known that the tribunal contains a lay person as well as representatives of the medical, legal and social work professions.
There is much that one can say about detained patients and their treatment. The question has been raised about whether a detained patient who is resisting treatment should have his case for treatment considered by a multi-disciplinary group. As an individual, I am sure that the first reaction of many people is that this should be left to the medical specialist and psychiatrist. But there may be a better way of resolving the problem of whether the 5 per cent. of patients who are detained and the proportion who resist treatment should have that treatment. We have heard different approaches to the problem of mental health which will set the debate further along the right road.
I pay tribute to the work of the all-party mental health group. Its chairman made some comments earlier in the debate. It is right to say that, without the push that the group has given and without the support of the mental health special committee of BASW, of MIND and of many other bodies, we would probably not have reached this point of debate, and certainly not this point of informed discussion, even in Parliament.
We should follow the advice of the hon. Member for Basildon and approach the task in two ways. If we merely change the law and debate the individual changes outlined in the White Paper, we shall take only the first and probably a minor, step towards rectifying a deplorable state of affairs in a socially conscious nation. For too long, those who are afflicted with mental handicap or mental illness have been the outcasts of our society. We are all resolved that that time has passed and we have to put our resolution into action.
§ Sir David Renton
Before my hon. Friend finishes her interesting and splendid speech, I am anxious that she 740 should make clear that she was speaking for herself, and not for the Conservative Party, when she said that she believed that the mentally handicapped could be dealt with in one clause of a mental health Act. She must make that clear.
§ Mrs. Chalker
My right hon. and learned Friend is correct. What I said was probably insufficient. Having been caught on the hop, I was seeking to find my way out without getting into too much difficulty. I hope that my right hon. and learned Friend will forgive me. I wish to think further about that matter and I am sure that I shall be advised by my far more educated colleagues that separate legislation will be required. Perhaps I had better sit down quickly before anyone else steps in and sets another little trap.
The way in which the White Paper has, at long last, been brought forward has to be given extra impetus and it must become a priority for action in 1979.
§ 9.17 p.m.
§ The Minister of State, Department of Health and Social Security (Mr. Roland Moyle)
We have had a thorough and thoughtful debate. It is quite a tribute to the House that on an issue which will probably not affect the outcome in a single seat in this year's general election we have been able to sustain a debate of noticeable expertise, including many informed contributions, for the best part of a day. The debate has contributed a great deal to the consideration that Ministers will be giving to the future of the 1959 Act which was put on the statute book by the right hon. and learned Member for Hertfordshire, East, (Sir D. Walker-Smith), assisted by the right hon. and learned Member for Huntingdonshire (Sir D. Renton).
Hon. Members have put forward many useful ideas which we shall seek to use. I should like to express my appreciation to the all-party committee and its chairman, my hon. Friend the Member for Basildon (Mr. Moonman), and the vice-chairman, the hon. Member for Chertsey and Walton (Mr. Pattie), for the good work that they are doing. I also wish to express my appreciation of the work done by the many interested groups that keep an eye on this subject and the dedicated, professional and thoughtful way in which they go about their work. Even 741 though many of them are volunteers, they have a professional approach to the problems.
I intend to answer one or two of the questions raised by hon. Members but to devote most of my speech to mental handicap and whether that should be dealt with in the Bill, to care in the community—on which my right hon. Friend the Secretary of State was unjustly accused of complacency—and to regional secure units, which have been mentioned by a number of hon. Members.
The hon. Member for Reading, South (Dr. Vaughan) made an interesting speech and many good points. Perhaps the best was his assumption that my right hon. Friend would be putting legislation on the statute book. As that cannot be done until the next Session, I found the hon. Gentleman's comments cheering, and cheering comments are particularly welcome at this time.
The hon. Member began to undermine the credibility of his contribution when he talked about increased resources. In real terms, we are committed to a growth rate of about 2 per cent. a year in the National Health Service. The right hon. and learned Member for Surrey, East (Sir G. Howe) has criticised the Government over and over again, alleging profligacy in public expenditure. Yet the hon. Member for Reading, South forced the issue and said that more resources were needed. If more resources are devoted to mental health, there will be fewer resources for other parts of the National Health Service. The Government are committed to restraining growth in the acute services.
§ Dr. Vaughan
I was making the point that we should be frank about the lack of resources and services in many aspects of health care.
§ Mr. Moyle
The hon. Gentleman is not saying that. Therefore, what he is saying is in direct defiance of what has always been said by the right hon. and learned Member for Surrey, East. I make 742 that point because it underlines the seriousness of the debate.
The hon. Member for Wallasey (Mrs. Chalker) addressed herself to the problem. She said that priority should be given to the mentally ill and mentally handicapped but that there could be no question of increasing resources until the economy was put right. If Opposition Members are talking about resources of the size that they mentioned today, that will be some time in the future.
§ Mr. Patrick Jenkin
It is important that there should be no misunderstanding about this matter. My hon. Friend the Member for Reading, South (Dr. Vaughan) said that we should face the resources implications of what was in the White Paper. There was criticism—not only from this side of the House—that that was not being done. My hon. Friend the Member for Wallasey (Mrs. Chalker) said that we recognise the point made by the hon. Member for Basildon (Mr. Moonman) and by my hon. Friend the Member for Chertsey and Walton (Mr. Pattie) that it may be necessary to proceed with the legislation in two parts. It is common ground between the parties that the resources do not exist at the moment.
§ Mr. Moyle
That is a real clarion call to the people of this country. I am sure that they will respond to it when they understand what it means.
Let us proceed to the more important part of the debate. It is important to clear up the question of resources. My hon. Friend the Member for Basildon made the important point that we should anticipate the future as well as try to assess the current situation. The hon. Member for Chertsey and Walton said that the wider issues should also be considered. My right hon. Friend and I agree entirely with that. My right hon. Friend is to undertake an extensive review of the development of mental handicap services, for example, and will announce the details shortly.
The Government are putting forward an extensive number of documents about mental illness and mental handicap. Those documents will enable us to try to anticipate the situation as we see it in the White Paper. For example, there will shortly be a report on the training of nurses for the mentally ill and mentally 743 handicapped. There have been several reports—the reports on the way in which children in hospitals are dealt with, the Normansfield report and the White Paper that we are discussing today.
All in all, an extensive view will be taken of mental illness and mental handicap in the coming months. The exercise has already started. I hope that it will carry on and provide fruitful debate so that we can reach a good consensus on the correct way forward.
My hon. Friend the Member for Lewisham, West (Mr. Price) argued powerfully about how hazardous treatment and consent to treatment should be dealt with. Like my right hon. Friend, I shall not be drawn on that matter, but my hon. Friend's contribution underlined the importance of that matter. We shall hold discussions with the interested parties as a result of comments on the White Paper that have been submitted.
My hon. Friend the Member for Lewisham, West and the right hon. Member for Crosby (Mr. Page) referred to section 65. I should emphasise that section 65 has not been retained exactly as it is. As the right hon. Member for Crosby pointed out, it has been reworded to emphasise that its aim is to protect the public. I assure my hon. Friend the Member for Lewisham, West that section 65 will be administered against a background of annual reports on patients. That is set out in paragraph 5.29 of the White Paper.
The hon. Member for the Isle of Wight (Mr. Ross) made a number of interesting points based on his personal experience. They will be helpful in throwing light on the White Paper when we translate it into legislation.
The hon. Member for Wallasey asked about staff. The ratio is one nurse to every three patients. In 1974 there were 43,000 nurses. The latest figure shows that there are now 50,000 nurses. The matter for regret is that the proportion of fully trained nurses within that figure has gone up by only 1 per cent.—from about 54¼ per cent. in 1974 to 55½ per cent. in 1977. It has to be admitted that nursing in this area is a calling which does not appeal to large numbers of people. This area has always been understaffed because it has been difficult to recruit to it. The situation is improving, 744 but there is a long way to go. The last thing that I should want to claim is that we are fully staffed with nurses and that the situation is as it should be. We certainly have a long way to go, and we can make use of all the young people and others who wish to come forward for training for nursing in this area.
§ Mrs. Chalker
Perhaps I may make a helpful suggestion to the Minister. One or two of our larger mental health hospitals have had pilot schemes for would-be mental health and mental handicap nurses. They have taken girls—mainly girls, but also some men—at an early age to give them eight or 12 weeks' experience of what it would be like to train for nursing in this sphere. Many of these pilot schemes started with volunteers in hospitals. I hope that the Minister will examine whether that could be done over a wider area to attract more people into nursing mentally ill and mentally handicapped patients.
§ Mr. Moyle
That is a very useful suggestion. I understand that some use has already been made of it. Part of the trouble is that nurses who appear on television are usually in the acute sector, and that gives a one-sided impression of nursing as a profession. I think that it would be as well to try to counteract it.
I should like to turn to three subjects which form most of our discussions. First, I want to deal with the question whether mental handicap should be included in the proposed Bill. The point from which I start—a point which my right hon. Friend put to the hon. Member for Wallasey—is that we are advised that a very small number of mentally handicapped people require compulsory detention. It is a much smaller proportion of the mentally handicapped than of the mentally ill, but they exist. The question therefore is whether we should legislate for these compulsory powers within one or two measures.
One of the main arguments—the right hon. and learned Member for Huntingdonshire put it most succinctly in his contribution—is that the public tend to confuse mental handicap and mental illness anyway and that to put them in the same measure would highlight that confusion. I would be the last person to say that that is an erroneous judgment.
745 The alternative is to take the mentally handicapped people out of the legislation that we are contemplating this evening and produce an entirely separate Bill for mentally handicapped people—a very small number of people—which would have within it provisions for the compulsory detention of a small number of mentally handicapped people. That indeed might focus public attention on the fact that mentally handicapped people could be compulsorily detained. That might cause just as much confusion in the public mind as the right hon. and learned Member for Huntingdonshire is afraid might be caused by the course that we are now putting before the House. I place that idea before the House for consideration. It involves a fine balance of judgment. It is one in which there may be a legitimate field for disagreement. That is the problem as my right hon. Friend and I see it now. That is the way that we are going forward.
The hon. Member for Reading, South made a colourful remark when he spoke of concentrating not on getting mentally ill and mentally handicapped people out of hospital but on overcoming the barriers in the community. That is a positive way of looking at the problem.
I thought that I would set out in greater detail than my right hon. Friend what we are doing and what progress we have made towards implementing the White Paper "Better Services for the Mentally Ill" and the 1976 consultative document on priorities.
Frankly, the picture is patchy. In some ways we are making reasonably good progress. In other ways the progress is nothing like as good as we would wish. First, local authority residential provision has been reasonably satisfactory. Since 1975 the number of places in the community in this area has increased broadly in line with the consultative document target of 350 places a year, although many local authorities are not yet providing a balanced range of accommodation as envisaged in the White Paper.
Progress in providing day care for mentally ill people, however, is not satisfactory. Since about 1976 the number of day places available to local authorities has increased by about 500 a year. Even allowing for some new places for mentally ill people in mixed day centres, this is a long way from the consultative docu- 746 ment target of 1,200 places a year. It looks as though we shall increase that rate of progress over the next year or two, but the provision of day care remains one of our top priorities. We are considering what more we can do to encourage progress.
The development of field social work with the mentally ill is also needed. The White Paper suggested a nucleus of staff, within a social service department, with special expertise in mental illness. That point was made by a number of hon. Members, who advised the House that we should move away from the concept of generic social work—I think that the hon. Member for Reading, South raised this point—in this area and make sure that more people concentrate and specialise on the work in connection with the Mental Health Act 1959 and whatever might succeed it.
Probably part of the trouble in applying the generic social worker concept in this area is that the opportunities for such work do not occur all that often. Therefore, it is difficult to develop expertise without making a special effort so to do.
When it comes to the health services, we have made some progress towards the White Paper priority aim of setting up district-based psychiatric services, although the bulk of services are still provided by the large mental illness hospitals, from which we wish to move. About half of the 204 health districts are now served by a general hospital psychiatric unit, although some of them do not provide a comprehensive service to the whole district at the moment.
The number of in-patients in psychiatric hospitals and units has continued to fall. The 1977 figure was about 80,000. However, nearly 10 per cent of those were accommodated in general hospital psychiatric units. There has also been a continued development of psychiatric day hospitals. If the growth remains steady, the White Paper guideline of two-thirds of a place per thousand of the population will be reached nationally in about 17 years. This lends emphasis to the remarks of the hon. Member for Wallasey about impatience.
One of the areas of the most rapid growth and the most important developments in this respect in the past few years 747 is that of community psychiatric nursing. A community psychiatric nurse can look after 40 to 50 patients at a time. A team of six community psychiatric nurses in a district can make a very good contribution to the solution of the problem. A few years ago there were only 100 of these nurses. Now there are well over 1,000.
It is envisaged that the National Health Service capital and revenue expenditure nationally on mental health should increase in real terms by about 2 per cent. a year from 1976–77 up to 1981–82. During this time, as the number of beds is expected to decline—a point made by my right hon. Friend—the amount spent per unit would increase by 5½ per cent. a year. When my right hon. Friend the Chancellor of the Exchequer injected £41 million into the Health Service in England in the Budget last April, the authorities were asked to spend £9 million of it on improved psychiatric and geriatric hospital care.
I have indicated some of the progress that we were making in the important task of developing community health services. I stress that the provision of services for the mentally ill and the mentally handicapped is the number one priority of the National Health Service. We intend to change existing patterns of expenditure so as to shift resources to those services.
Another subject which created a great deal of interest in the debate was that of regional secure psychiatric units. The hon. Member for Reading, South led into the subject very well when he gave his reminiscences of work in a psychiatric hospital in the 1950s and talked about the keys and the clanging doors which were then a feature of life. He mentioned the breakthrough which came subsequently with the provision of chemotherapy, which has helped to such a remarkable degree. As a result of the development of those techniques, the psychiatric hospitals became open in a way in which they had never been before. This has been regarded by the staff and by the consultants working in them as a tremendous advance.
The ordinary psychiatric hospital is now a potentially unsuitable place in which to keep people in secure conditions. This has been the great revolution of the last 15 to 20 years. It has given rise to the 748 need for the solution of the problem by the creation of regional secure units. My right hon. Friend and I are very much in favour of the development of a full regional secure unit service, aiming at about 1,000 places by the mid-1980s throughout the Health Service in England. There should be no doubt about that objective.
My right hon. Friend was taken to task in his absence for saying that he wanted to see a development in the prison psychiatric service. Against the background of some remarks made by my hon. Friend the Member for Ormskirk (Mr. Kilroy-Silk) that some Home Office representatives—who should, in fact, be nameless—were saying that they would not develop psychiatric services in the prisons in case it weakened the resolve of the DHSS, it gave rise to some deep suspicions in the House.
I do not think that there is any need for these deep suspicions. There are people who will have to be treated as detained patients and others who have to be treated as informal patients. But an increasing number of people, as I have tried to indicate in my references to community mental illness services, will be treated on a day basis, outside hospital, for perhaps the whole of their illness. Their number will increase, and they will become the majority of psychiatric cases. If those people commit a crime and end up in prison, they will require psychiatric treatment. Therefore, there is a case for developing and strengthening the prison psychiatric service, and this has nothing to do with any provision made for regional secure units.
§ Mr. Kilroy-Silk
The individual, Dr. Orr, is not nameless. He was at a public function. He is a director of the prison medical service. He has said regularly that it is not and will not be the intention of the Home Office to provide adequate care or treatment for mentally disordered offenders and regular treatment and detention in a hospital under the terms of the 1959 Act. Clearly, that is putting the onus back to where it properly belongs, as my right hon. Friend will accept, with the DHSS providing these facilities either in NHS hospitals or in regional secure units.
§ Mr. Moyle
I take that point. I shall be coming to these problems shortly. 749 However, the point I am seeking to establish—I think that I have established it—is that there is a case for strengthening the prison psychiatric service, irrespective of what happens in regional secure units. That is the point that my right hon. Friend the Secretary of State was making earlier.
Having said that, my right hon. Friend and I fully accept that we must have regional secure units, but I do not think that I want to arouse great expectations. My hon. Friend the Member for Ormskirk mentioned figures about people in prison who could be treated in regional secure units. My advice, which comes from the prison medical service, is that about 2 per cent. of the prison population might be treatable in regional psychiatric units if a full regional secure unit service were to be set up—for example, psychopaths, people with whom the psychiatric hospitals, with or without regional secure units, cannot cope properly.
There was a considerable discussion about Prestwich. There is obduracy at Prestwich. Like my hon. Friend the Member for Basildon, I, too, have visited the hospital there and have talked over the situation with the management and the trade union representatives. The dispute at the hospital affects Prestwich only. It is not correct to say that progress is held up all over the country because of the attitude at Prestwich. There is, though, another mental hospital where there are difficulties.
I am in consultation with the union primarily concerned, the National Union of Public Employees, to try to get this matter resolved. Unfortunately, events over recent weeks have put a brake on the consultations. That should not be taken as indicating that the union has removed co-operation as part of industrial action. That is not so. The unions are not professionally overstaffed and the officers are involved in other matters at present. Therefore, consultations are in abeyance. However, as soon as the present disputes are settled, I would hope to resume consultations and move towards a solution of the Prestwich problem.
Having said that about Prestwich, it is also worth placing on record the fact that Prestwich is one of the more advanced centres in the provision of security, in that there is actually a functioning interim secure unit at the hospital.
750 Those who have spoken about regional secure units made one fundamental assumption which is not necessarily an accurate reflection, namely, that it is beyond peradventure and beyond question that regional secure units of the type which provide physical security are the way forward in this field. I certainly believe that to be true, but it must also be taken into account that many other people have different views about the way that provision should be made. They say that these units are expensive in terms of physical provision and staff and that there is a danger that resources will be taken away from the normal hospital psychiatric service.
Some say that these units reintroduce the closed door, the clanging doors and the bunches of keys, about which the hon. Member for Reading, South spoke, through one entrance, just as the open door has been introduced into psychiatric hospitals through another. They say that these secure units should be built some way from the normal psychiatric hospitals. In an ideal world that might be possible, but when resources are limited we have to use the facilities of existing psychiatric hospitals. They say that it is in principle wrong to lock the door on people. I am not saying that I agree with any of these arguments, but it is worth while that certain people in psychiatry should know that these arguments have been considered by the House of Commons.
In view of certain remarks that have been made about COHSE and NUPE, it is worth pointing out that the TUC is in full support of the regional secure unit programme and is jointly manning a working party with members of my Department to go into the problem and try to solve its problems.
There is then the question whether physical security is the right sort of security anyway. Wessex region has decided that it will have security not by use of bricks, mortar and locks but on the basis of a high ratio of staff to patients. The normal ratio of staff to patients in these secure units is one to one. Wessex is going for two to one. The interesting thing is that Wessex will—in 1980, not the 1980s—be the first region to have a regional secure unit operating, just because it has gone for security in this way.
§ Mr. Patrick Jenkin
The right hon. Gentleman referred to the TUC's support for regional secure units. This is an important point to stress. The union which is most involved at Prestwich, which is the right hon. Gentleman's union, NUPE, pursues a national policy of opposing, for the reasons that the Minister set out, the establishment of the interim regional secure unit. It is very difficult to justify that one union by itself, against the rest of the TUC and against a Government policy which is supported throughout the House, should take it upon itself to obstruct the operation of such a unit to the extent that food comes in by taxi, the laundry has to be done outside, and less than half the patient capacity is taken up. That is the kind of thing that the House of Commons is entitled to say is intolerable
§ Mr. Pattie
May I persue the point concerning Prestwich? The Minister of State said earlier that the interim secure unit is in operation. That is indisputable. The House should know that the staff there are working in considerable difficulties but in a first-class manner. None the less, the kind of obstruction that is taking place is exactly as was described by my right hon. Friend, as the hon. Member for Basildon (Mr. Moonman) and I saw. There are 13 patients there, although there is capacity for 25 or 26. While the unit is operating, therefore, it is nothing like as effective as it might be.
§ Mr. Moyle
The impression I got from the staff when I went there was that it had taken all the patients that were available of the calibre who at that time should have been there. I am not pretending that the situation is satisfactory, but I want to put into perspective, given the difficulties, the fact that it is a functioning interim secure unit, although it is not functioning as well as it ought to.
The question of waste or misapplication of resources was raised. My hon. Friend the Member for Ormskirk said that some money had been spent on a maternity unit. It is probably true that some of the allocation for the financial 752 year 1976–77 was spent on such purposes, but, because it was, we stepped in in 1977–78 and 1978–79 and said that if the money was not spent on regional secure units it should be spent on psychiatric services.
In the last financial year, 1977–78.60 per cent. of the money allocated was spent on secure or psychiatric facilities. Obviously, if one makes a change in policy one cannot expect a 100 per cent. change in a short time. I have every reason to believe that the figures for 1978–79 will reveal that all the money has been spent on psychiatric services, although a minority of the money is still being spent on regional and interim secure facilities.
The hon. Member for Worcestershire, South (Mr. Spicer) was under a considerable misapprehension. No money has been voted by the House of Commons for spending on secure facilities, either regional or interim. That should be made clear. The House votes money for the health and personal social services amounting to about £8,000 million. A policy decision by the Secretary of State is involved about how that money should be applied. My right hon. Friend's predecessor decided in 1976–77 that £5 million should be spent on interim and regional secure units. That amount was not spent in that way. But that was not in defiance of a vote by the House. That is where the hon. Member for Worcestershire, South is mistaken. The question of principles of democracy being at stake does not arise.
§ Mr. Michael Spicer
If the Government have allocated a certain amount of money for a specific purpose, is it not intolerable that they should take such a cavalier attitude and say that they are satisfied with a 60 per cent. expenditure and not mind about the way in which the other 40 per cent. is spent? Is that not a misappropriation of funds?
§ Mr. Moyle
It is not a misappropriation of funds. The money is being spent on health and personal social services, for which it has been voted. We should like that money to be spent on regional and interim facilities. We did not adopt a cavalier attitude. When we discovered that the money was not being spent in the way in which it had been decided, we took action to ensure that it was so spent That action has been successful. There 753 has been throughout full and close cooperation between the Home Office and the Department of Health and Social Security.
I shall indicate the progress that is being made in the regions. In the Northern region a 30-bed unit is planned for St. Luke's hospital at Middlesbrough. The Northern region has gone straight towards secure unit provision. I have just been informed by the Northern region that building started on the St. Luke's hospital site a few days ago. This is likely to be the first purpose-built provision of a regional secure unit in the country.
In the Yorkshire region, planning is advanced on a 40-bed to 45-bed unit at Fieldhead hospital in Wakefield. In the Trent region two units are proposed—a 60-bed unit at Towers hospital, in Leicester, and a 40-bed unit at Balderton hospital, Newark. The plans for both those centres are advanced.
The East Anglia region has been the subject of criticism in the debate. I am happy to say that that region has been under new leadership since last August and now has a new chairman. I have discussed the problem with the chairman. I am happy that the region has advertised for a consultant to advise it on these matters. The closing date for applications is Saturday. The chairman has informed me that a suitable number of applicants have applied. The region is confident that it will make an appointment effective from 6 April this year.
The North-West Thames region is considering possible sites for a permanent, secure unit. This is one of the regions where progress is still lacking. I shall take the opportunity to discuss these matters with the chairman of that region on a number of occasions.
In the North-East Thames region, local consultation is proceeding on the region's proposal to provide a 40-bed unit at Friern hospital. The South-East Thames region is planning to provide a 30-bed central unit at the Bethlehem Maudsley hospital, together with four 15-bed peripheral units at Bexley, Cane Hill, Oak-wood and Hellingley hospitals. The proposals are in fact with my Department for clearance.
The South-West Thames region has been attempting to get a unit established 754 for some time. I believe that the hon. Member for Reigate (Mr. Gardiner), who is no longer with us, knows about a proposed unit at Royal Earlswood, where the local population rose up—not inspired by Prestwich, but purely self-generated—with the result that the region decided to switch to an interim unit at Netherne hospital.
I have already mentioned the Wessex region, but it is likely to have the Health Service's first regional secure unit at the Knowle hospital in Hampshire.
The Oxford region is one which has not made the progress it should have made. However, it claims that all its hospitals can provide interim secure treatment throughout the region. Here again, this is a region which is under new leadership, and I have discussed the matter with the chairman, who no doubt will forward a report to me in due course.
The South-Western and West Midlands regions have, or are likely to, run into trouble from the local population. In the South-West region the whole matter is subject to a planning inquiry. It is sometimes suggested that we should provide central guidance as to how local populations should be approached when it is proposed to set up units of this kind. The problems of that approach are illustrated by the South-Western region, which, in my view, went through all the correct steps in order to get the population of Dawlish on its side. It had a considerable measure of success, but in the end it was thwarted by a certain amount of misinformed public opinion. We had no alternative but to agree to a public inquiry, and I am waiting for a decision from my right hon. Friend the Secretary of State.
§ Mr. Stephen Ross
The Minister talked about the secure unit at Knowle. Is that for both sexes? I have a feeling that it is either for men or for women.
§ Mr. Moyle
It is for both sexes. On Merseyside there is a fully functioning interim secure unit at the Rainhill hospital. We have discussed the Northwest region at great length.
I believe that hon. Members on both sides of the House, as well as drawing attention to the views of trade unionists, psychiatrists and people of that kind, 755 do not pay sufficient regard to the difficulties of planning and introducing a new concept. That is certainly as important as any of the other factors holding up the development of regional secure units.
I readily admit that the situation is far from ideal. There is a tremendous amount to be done. All I can do is to assure the House that I shall give the matter my earnest consideration with a view to expediting matters throughout the country with the greatest possible rapidity.
§ Question put and agreed to.