LUNACY AND MENTAL DISORDER.

HL Deb 24 February 1927 vol 66 cc232-57

EARL RUSSELL rose to call attention to the Report of the Royal Commission on Lunacy and Mental Disorder, and to ask whether it is proposed to introduce legislation on the subject. The noble Earl said: My Lords, it is a great pleasure to me to-day to be addressing your Lordships upon a non-controversial subject. Possibly the noble Lord opposite would not quite agree with that description of it, because I am afraid there are some points that are in controversy, but at any rate as regards the ordinary Party controversies it is a non-controversial subject. I want to call your Lordships' attention to the Report of the Royal Commission on Lunacy and Mental Disorder which sat for something like a year and a half and reported last July. I think the first thing I should say and that I believe any member of that Commission would say in referring to it, would be to express the sense we all felt of the great skill and care with which our deliberations were guided and conducted by our Chairman, Mr. Macmillan, K.C. He not only kept his Commission to their work and at their work, but he also succeeded, as in this case was very important, in getting all that was to be got out of all the witnesses who come before us, some of whom were at the beginning a little inclined to regard us, I think, as a hostile body. All of us are grateful to him for that.

There is another matter which I should like to mention at the outset and it is this. It is perhaps too much to expect that many of your Lordships will read the whole Report of the Commission, because it is of a certain length and rather detailed, but it would be a good thing for future discussions and before any legislative measure dealing with these matters comes up if your Lordships were to read a Memorandum which is called, I think, Chapter II. The exact name is "General Considerations of Policy." It deals with the aspect from which the Commission approached this subject. It is a comparatively short document and really covers what I might call the principles upon which we proceeded. This subject of mental disorder is one which has developed a good deal in recent years. It is not so very long since a lunatic was regarded, or at any rate almost treated, as if he were a criminal. He was given a bed of straw, he was chained to a staple and he was left in a condition in which it was supposed he could do no harm to any one else. I do not know that they cared very much if he did harm to himself. In that condition, not unnaturally, he did not frequently get cured.

Before I come to the Report I think it is worth while for your Lordships to consider a little the historical development, because we are still suffering somewhat from the history of this matter even after that rather brutal period. The primary consideration which was in the minds of the public in the treatment of those who had diseased minds was not cure but detention, the protection of society from people who were dangerous, and that unfortunate idea of detention has for too long run throughout the whole system. There was fear on the part of the public of the lunatic. That has also led to what is really a, popular misconception which exists very largely to-day, that the majority of lunatics are violent and dangerous people, that they have homicidal or suicidal tendencies, and that if they were left at large they would immediately run amok. That is singularly untrue to-day. In the course of my duties I went over an asylum which is near me in the country. It is extremely well-conducted, perhaps in a somewhat old-fashioned way, and the first thing I did when the superintendent asked me where I should like to begin was to ask to see first his refractory ward. He laughed in my face and said: "I have no refractory ward." I ultimately went over the whole of that asylum, containing between 600 and 800 inmates, and I can assure your Lordships that out of that large number there were not more than ten or a dozen who were noisy or in any sense of the word violent. The public does not appreciate that.

What I think is absolutely necessary if we are to deal with this serious question in the light of modern medical knowledge and treatment, is that we should get out of our minds the idea that lunatics as a class are violent and dangerous people for whom the primary treatment is detention. What they are, and what we were very desirous the public should understand them to be, are people who are unfortunately suffering from an ailment, but a mental ailment instead of a bodily ailment, and they should be treated for their mental ailment on medical lines in exactly the same way as any of us are treated for our bodily ailments when we require treatment. There is a difference, of course, and it is a very important difference. It is that in the case of those of sound mind they co-operate, at any rate as a general rule, with those who are endeavouring to benefit them and do all they can to hasten their cure and to assist in their treatment; but even that is not always true in cases of delirium. The difficulty in the case of persons of unsound mind is that the vast majority of them are satisfied they require no treatment at all and that the attempt to treat them is an outrage, that their confinement is an outrage, and that they are being wrongfully detained and wrongfully treated when they are, in fact, as sane as other people. I think it is very important that we should not only remove from the minds of the public the impression of which I have spoken, but, above all, remove this other impression from the minds of the patients, and in the modern method of treatment I think a great deal has been accomplished in that direction.

It is about twenty-five years since I was actively occupied in inspecting asylums and having official relations with them and in that quarter of a century there has been a most marvellous development. The old apparatus of locks, bars and prison-like surroundings have very largely gone and the amount of freedom which exists in the modern asylum would have been unthinkable twenty-five years ago. There is one institution—true, it is a private institution and not a rate-aided one—that I have in my mind where I think something like 40 per cent. certainly 30 per cent. of the patients are allowed to leave the institution on parole and go freely into the town, deal with the shops and associate with the townspeople. It is true of a great many institutions that not more than a percentage of the patients are kept actually under lock and key, certainly less than 50 per cent. It has been found that patients when reasonably treated will very often to a large extent behave reasonably in spite of their disease being one of unreason.

There is one class to which I should like to call your Lordships' attention a little particularly, because it is an important class and one which has helped to raise misapprehension in the public mind. That is the class of paranoiacs. A paranoiac is a person who is subject to a fixed delusion, a delusion from which he cannot escape and of which he cannot rid himself, but in all other respects he may be a sane, reasonable and logical human being. He may be clean and tidy in his habits, he may be intelligent, but this delusion obsesses him and it cannot be got rid of. Here comes in a very difficult question, that of the definition of insanity. I should not attempt myself, and I think that none of us who sat on the Commission, after we have had all the assistance which we had and after hearing all the evidence of the medical men called before us, would feel competent to write a treatise on the definition of insanity. The standard that the law lays down, however, is a more possible one to arrive at. The standard the law lays down is one of conduct.

Suppose there is a paranoiac who has a delusion that the earth is flat and nothing can cure him from that delusion. That delusion itself is perfectly harmless, it is not likely to lead to any evil consequences, and there is no reason why he should be confined. Let me take another delusion, by no means infrequent in women, and that is a delusion that some distinguished public man is their lover or their husband and that they are being forcibly and wrongfully kept from him by the intrigues of other people. So long as that remains a delusion and does not lead to any action, it is not for the law to interfere, not even though perhaps the victim is pursued with letters. But if it leads to the action of camping on his doorstep, ringing his front door bell, hampering him in his public work, then the interest of the sane has to prevail and it becomes necessary that that person should be in some way restrained.

I can give your Lordships another instance of a different kind which came within my own experience. It was a case in which a man had the delusion that he had been wrongly convicted of stealing meat from one of the large stores, and in revenge he broke their windows. He was taken to the police station and passed to the asylum. In the asylum his conduct was exemplary, and there was nothing to distinguish him from a sane man. In about a year the superintendent said that it was not possible for him to sign the necessary certificate that he had observed any signs of insanity in the last three months and he advised the committee that the man ought to be allowed to go. I was chairman of the committee at the time. I went into the case, I examined the man on his delusion and he assured me that he was entirely free of it and that, if allowed to go, there would be no more delusion. We discharged him; we had no alternative. The next day he broke the same plate glass windows, was taken to the police station again, and came back to the asylum where he behaved in the same way. After six months the superintendent made the same report to us. It being our duty to protect the property of sane citizens and traders we did all we could to see that the same thing did not happen again. We sent him to a relative in Cornwall, and saw that he was put on the train and went there. In three days' time he was back in London and broke the same windows.

That is the difficulty in the case of paranoiacs, and it is because of this class that the cry is sometimes raised that lunatics are wrongfully detained. No person seeing lunatics of this class detained in an asylum would be able to ascertain that they were in any way affected. They would think, and in some cases they would go away and report, that a perfectly sane man was being wrongfully detained. It is this class of case that has given rise to the complaints made by some members of the public about men being wrongfully detained in asylums. I think it is right, before I go further, that I should say that the Royal Commission appointed in consequence of the Harnett case, in which the jury found Harnett was wrongfully detained, made the most special inquiries into all allegations of wrongful detention, and they were not able to trace in the whole of the asylums of this country a single case in which they could say that a man was wrongfully detained. That is stated in our Report, and it ought to reassure the public, but I am afraid that the kind of public that raises these allegations against the treatment of lunatics and the conduct of asylums is sometimes not susceptible to the argument of facts.

There is another important and similar point to which we should also direct our attention and that is where people are wrongfully certified. The process of certification has attracted great attention, and here one still gets the lasting evil of the original idea of prison because, as the original idea of detention instead of medical treatment still survived when, in the days of Charles Reade and later, steps were very properly taken to protect lunatics, the public and Parliament directed their attention to the avoidance of wrongful detention and therefore certification is hedged round with precautions that ought to operate successfully. Again, I am glad to say we did not come across any case in which we could say that a man had been wrongfully certified. I am not going to say, and it would not be honest to say, that there were not cases in which sometimes a business which ought to be regarded as a very serious and responsible one was not perhaps a little too much of a routine; but there was no case in which a man had been wrongfully certified.

I venture to submit these preliminary considerations to your Lordships because, in dealing with this matter, it is important to understand the kind of thing that arises. There are a great many cases in which there is no sort of doubt about certification, and there are a good many other cases in which, in view of the doctor's report, there is practically no doubt. But, in a matter of this kind, there are, and there always must be, border-line eases, cases where the conduct has been abnormal and where on the doctor's advice the certifying magistrate must be told that it is likely that the conduct will remain abnormal, or become more abnormal and in which, on the contrary, the conduct may become better, and it may be said that the patient has been certified unnecessarily.

There is a curious thing about certification and about the early stages of this disease—that as a general rule the most violent, the most obstreperous and the most obviously lunatic of the persons to be certified are generally the persons soonest to be cured and discharged. These are the people of whom doctors have hope. Your well-behaved lunatic, with his one obsession, is the man for whom hope is generally absent and in whose case this fixed delusion is almost always associated with an idea of persecution. In his case the idea of persecution grows until he develops not merely a desire to break plate glass windows as in the case I mentioned, but a homicidal tendency towards the person he believes to be his persecutor, and it therefore becomes impossible ever to let him loose upon society.

But violent cases are generally the easiest cured and I think we were all of us very much struck, and I am sure your Lordships will be very much struck, by the enormous number of cases which it was possible to discharge. Within a few weeks, very often within a few days of certification, it was possible to let them go. Now, when we came across that fact we came across considerations which moved us to consider whether some provisional treatment could not be found by which these cases could be dealt with without actual certification. We were told by everyone concerned, and it can readily be believed, that upon persons who were certified there was placed a stigma, a stigma of a certificate that he had been a madman. The undiscriminating public thinks "Once a madman always a madman," and that stigma is apt to cling to them through life. In the case of a working man, unless he hides his identity and changes his place of livelihood, it may prevent him getting work. If he stops in the same place it may cause him to be an object of derision to his neighbours and may even in some cases cause a mild sort of persecution, which again may upset his mental equilibrium. Therefore that stigma is a very serious one.

Moreover, another stigma also follows, that is the stigma of the Poor Law. As the law is now constituted practically every person who is dealt with in a rate-aided institution—and that comprises almost the entire body of certificated lunatics in this country—is technically a pauper lunatic. In most cases also certification proceeds and takes place through the workhouse, and if not through the workhouse at least in connection with the relieving officer, who is a Poor Law official. So there is a double stigma, and we all felt that if something could be done by some sort of provisional treatment to remove that stigma it ought to be done. Your Lordships will see at once from what I have already said the difficulties with which we were faced. If you are to have an incomplete and a provisional stage is it to be upon the doctor's certificate alone, or is it to be, as in the present case, upon the doctor's certificate backed up by the order of the justices?

It may be asked: Why, if it is to be so provisional and so short, do you require the right to detain and the right to restrain at all? It is required for the reason that, as I have just told you, the most violent cases are the cases with the best hope of cure, but if they were not detained they would go raving and tearing about the streets to their own injury and the injury of the general public. Therefore restraint is absolutely necessary. A considerable portion of our recommendations is devoted to a system of provisional treatment and a sort of quasi-certification which we would not call certification, extending, if you like, for six months. All the evidence showed that the majority of those certified would be discharged before the expiration of the period and would be able to say they had never been certified lunatics. The difference, of course, is one of words rather than one of facts, but it is a difference which is of importance to the persons concerned. That portion of our recommendation is one to which we attach a good deal of importance.

Then, of course, coupled with that there is the very important question of classification at the early stages. I dare say many of your Lordships have read a book called "Christina Alberta's Father," in which there is a description of the receiving ward of a workhouse for the mentally afflicted. It is rather a terrible description, and I am afraid that in some cases it is not altogether an untrue description, because this is the sort of reception room into which are gathered those who are in process of being observed and perhaps some of those certified for whom asylums are not yet found. There are herded together every class and every kind of mental disorder. One would think—though I am not quite sure that doctors think this as much as laymen think it—that such association would have the worst possible effect upon those we hope to cure. Fortunately, I think, that is to some extent offset by the fact that in many cases the mentally disturbed live very much in a world of their own, are closely surrounded by that world and are very little affected by what goes on outside it. Still, obviously it is extraordinarily undesirable, and quite apart from anything else there are sights and sounds necessarily and inevitably in places of this sort which must be very distressing to other people there suffering from less advanced stages of the disease. Therefore, earlier classification is very desirable.

When we came to that, as indeed when we came to many other questions, it appeared at once, as your Lordships will readily understand, that this is to a large extent a question of the amount of money you are prepared to spend. Closer classification means more medical officers, more attendants, smaller wards, in many cases new buildings. It means the expenditure of public money. Your Lordships can appreciate how difficult it is at this moment to ask for or suggest the expenditure of public money. All the Commission have been able to do in their Report is to lay the considerations before Parliament and to point out what I hope is true, that the adoption of these recommendations, while no doubt involving the expenditure of public money, would give a return not only in actual dividends of the smaller number of lunatics having to be maintained at the public expense but in the quicker return to health of citizens of the country.

But it is undoubtedly the case, I think, that in most of the rate-aided asylums at this moment it would certainly be better to have a quite definite increase in the number of medical officers and a quite definite increase in the number of attendants. Wards are too large and individual attention is too difficult. There again, I do not wish your Lordships to be misled in any way. If you take the average asylum, say for 1,000 cases, unfortunately there is a very large percentage of that asylum population for which medical treatment is no use. There are the hopeless cases, the advanced cases of general paralysis of the insane, the ordinary senile dements and cases of that sort, for whom all you can do is to make their life as passable as possible until its termination, but for whom medical skill can do nothing in the way of cure and for whom the doctor is only necessary to treat as far as he is able such physical ailments as may occur to them. That class does not want an increase in medical attendants. There are other classes in perfectly good physical health, such as paranoiacs in which after a certain stage you cease to have very much hope. But at the same time constant watchfulness, constant care and constant individual observation of those whom you have any hope of preparing for discharge is the best and only way of getting maximum discharges from asylums.

I have referred already to the uninformed public and the view which they take of these things. It was very early brought home to us, as your Lordships, I am sure, will readily believe, that the chief pride of the superintendent of an asylum is not the number of inmates that lie, manages to keep but the number of inmates that he manages to set free and to restore to their friends and relations and to their country. That is what every doctor aims at. The advances that have been made in the last twenty-five years have not been due to the Legislature, they have not been due even to the excellent work of the county councils in control of these institutions, but they have been due primarily to the initiative of the medical men themselves, who have sought and are constantly seeking to deal as best they may with these unfortunate cases, to treat them in the best way they know and to discharge them cured as soon as possible.

When one speaks of cure, I think one ought to say that what you can do for a mind diseased is exactly what Shakespeare said—it is to minister to it. There is no drug that will cure it; there is no specific treatment that will cure it; you can only do with it that which doctors now recognise that they do with physical diseases—namely, put the patient in the best condition to fight the disease himself and to recover from it. Doctors no longer think that they take diseases and cure them; they admit now that, in the case of physical disease, what they do is to put the patient in the position in which he is able to cure it himself and endure the fight until it is over. That is really all that you can do with mental disease. I put that point to one of the most distinguished doctors that appeared before us. I said: "It comes to this—does it not?—that you have to admit that, having done the best you can in the way of treatment, you must leave the cure to God"; and he said: "That is practically the position."

We think that the adoption of the recommendations that we have made may do a great deal to lessen the asylum population, because there are certain classes that can be cared for with less expensive treatment and with less medical supervision, and we think that under such a system there will be quicker discharges and also that it may be possible to arrange to relieve the asylums of cases, of which there are quite a number, in which the person resident in the asylum could quite safely be allowed to live outside the asylum if only there were available some relative, some friend, some home in which attention could be given and in which he would be looked after. Many of these unfortunate people have to remain in the asylum chiefly for the reason that it is their only home, and that it would not be safe to set them at large to meet the stress and the battle of the world, because they would at once relapse and come back. Indeed, it would not be fair to do so.

There is a further question, and a very important one, which, before we come to any legislation, I hope the Ministry of Health will consider, and no doubt your Lordships also, and that is the extent to which, in any provisional treatment, it is necessary to invoke the justices. The justice is invoked because he is the representative of the public, and he is invoked in consequence of the old and utterly fallacious idea that the doctor, as an enemy of the human race, is trying wrongfully to put an innocent man in prison. That is really the reason for invoking him. What can the poor justice do? He can only satisfy himself, so far as he can, by conversation with the doctor. In some few cases he can satisfy himself, by actually seeing the man, that it is an obvious case, and in all cases he can hear what a man has to say and take what steps he thinks proper. I do not deny for a moment that it is a safeguard, but it is a safeguard which is not in fact required, at any rate in ninety-nine cases out of a hundred.

Whether it is necessary to keep him for the hundredth case, even in provisional treatment, I do not know. Let your Lordships consider the case of one of yourselves, or any friend of yours, suffering from some fever which ends in delirium. You are restrained by force, you are not allowed to get out of bed and walk on wet grass in the cold morning without any clothes. But nobody calls in a justice to sanction that restraint. Of course you are grateful for it when you are well, but at the time you have no more responsibility for your treatment than one of these unfortunate people. You may possibly resent the restraint. There are cases where people have to be held down by one or two other people, but no one thinks of calling that wrongful imprisonment or wrongful restraint. If only we could get rid of the unfortunate atmosphere in which this matter has been wrapped up and could apply to some extent the same considerations and the same tests to these unfortunate people, I think we should be making a great step in advance.

If I am told, as the noble Viscount opposite may tell me and as the Ministry of Health may think, that even the one case in a hundred is proper to be looked into and proper to be safeguarded, I should not for a moment deny it; but if I am told that we are removing a real safeguard, I doubt it. I would suggest to the House that an infinitely better safeguard than the intervention of any justice exists at the present time, and that is the fact that the reception in an asylum of any certified lunatic has to be reported at once to the Board of Control, who have all the papers connected with the matter. Your Lordships are aware, no doubt, that what is now called the Board of Control is the successor of what used to be called the Lunacy Commission. It is composed of people who are most expert in this matter, people who spend their whole lives, day in and day out, considering these cases, visiting asylums and dealing with the complaints of patients and with the whole system, and they are fully competent to detect and to put right without any delay any sort of wrongful cases that arise. I confess that I think that there exists in this country no real risk of a sane man being "railroaded" into an asylum, if I may use an American phrase. If you succeeded by some good fortune in getting him there, you would not be able to keep him there for more than three or four days. I think we ought to remember, when we talk about losing the protection of the justice, that we have a very much more important, a much better informed and a much more skilled protection in the Board of Control, with ample powers to enforce their orders.

There is one other point to which I should like to call your Lordships attention, and that is the present rather curious position of what are called licensed houses, which are generally known as private asylums. These are institutions run for profit in which lunatics are taken care of and to which, if they can afford to pay, they may be admitted. They are for private patients as opposed to what are called public patients or pauper lunatics, and at present the procedure for certification is rather different and in some cases patients have perhaps a little less protection. There is a very natural and a very proper feeling on the part of the public that there is a possibility of danger in a place that is run by a proprietor for his own profit, and it is, of course, perfectly obvious that his duty and his interest may conflict. If he has a patient who is paying £500 a year—and sums even in excess of that are paid to some of these private asylums—he may have the financial temptation to delay or to hinder the discharge of that patient when he ought otherwise to be discharged.

It is a perfectly legitimate feeling. I do not think that it has any foundation in fact, but it seems to me that the way in which to deal with that legitimate fear is not the way in which Parliament dealt with it in 1890. In that year this fear was clearly present to the mind of Parliament, and licensed houses were looked upon as suspect, to put it at its lowest. What Parliament said in 1890 was: We will not abolish licensed houses, we will not destroy this private property —and I do not conceal from your Lordships that it is very valuable and lucrative private property—but we will say that no new licensed houses shall be established, those existing shall be allowed to die out, and no increase shall be permitted in the number of beds in existing houses. One supposes that in 1890 the hope of Parliament was that this vested interest would be extinguished without compensation. The results hoped for have not been achieved. There are fewer licensed houses now than in 1890, but by no means so very many fewer as to suggest that the process of extinction would take place within a reasonable time, and I venture to suggest that this is not the right way to deal with the subject. Parliament, when it legislates this time, must make up its mind, aye or no, whether the licensed house is fit to exist or not. If it is not fit to exist Parliament must abolish it. If it is fit, we have suggested, and I think the Report suggests, that there should be what I call free trade in licensed houses; that is to say, subject to the approval always of the Board of Control, it should be possible to set up new and fresh licensed houses, and this limitation upon their creation should be abolished. One advantageous effect would be that geographically they would be far better distributed than they are at present.

The alternative is obviously rather a difficult one, if you are going to say you will abolish the licensed house. If you are going to say that you are going to abolish the licensed house you are going to say that rich people, when afflicted in this way, are not to be allowed to be treated where they choose—to select their own environment or to have it selected by their advisers. We were told, and I believe rightly told, that the majority of people who are able to pay for private treatment would prefer to make their own choice rather than be forced into some public institution. That again raises a difficulty. Into what institutions are you going to force them to go? Clearly not into rate-aided institutions, which accommodate the pauper lunatics. You would have to build public institutions out of public money and you would have people possessed of their own money living in institutions for which public money was not really required. That is hardly reasonable. Again, what sort of accommodation would be provided? If a man says that he wants £1,000 a year accommodation, is the county council or a committee of the county council to be called upon to provide varying types of accommodation, as in the case of a great hotel? Is not the tendency likely to be that the accommodation will be standardised? That seems hardly reasonable from the point of view of those who require special accommodation and are prepared to pay for it themselves. You have in this House, in Lord Sandhurst, one of the Lord Chancellor's Visitors, who is far more acquainted with private asylums than I am, because it is his duty constantly to visit them, and I think he was one of the people who gave evidence before us. That standardised accommodation would be very much resented by the class affected. It seems to me to be carrying a theoretical proposition rather far to set up a new public institution for people who do not want it and are willing to pay for themselves elsewhere.

There is also the question of the Board of Control itself. At the present moment the Board of Control is very much understaffed. It is urgent that it should have its members increased, and have more people to do inspection work. It is almost impossible far it at the present moment to hold the number of meetings which it should hold for the consideration of problems which constantly arise, because important and well-informed members have to be running up and down the country doing the absolutely necessary inspection of asylums. The numbers of the Board certainly should be increased, and even if the Government feel unable to do anything else with regard to the Report of the Royal Commission, I think they will have helped the matter if they increase the numbers of the Board of Control, and, by the experience gained, help to shape the measure which they will, I hope, at some time introduce.

What I really want to ask to-day is, what hope is there of legislation being introduced and at what time? One recognised, when it was thought that the Poor Law was going to occupy the attention of Parliament this year, that that was an enormous subject and that the same Department, the Ministry of Health, would be dealing with it, and therefore it was quite impossible to hope that lunacy reform might be one of the subjects dealt with this Session. The King's Speech and subsequent debate have assured us that Poor Law is not going to be dealt with this Session. Is not this a good opportunity for at any rate introducing, perhaps into this House, a Bill for dealing with this subject, and for carrying out such recommendations as commend themselves to the Government, so that the public may have time to be instructed and to learn?—because I confess at once that in many respects you are dealing with a very uninstructed public, and that is one of the difficulties in another place.

Cannot something be done this year? The Minister of Health has no other great proposal before Parliament. There was a reference in the King's Speech to other Departmental measures. Might this be one of those other Departmental measures? It is a very important one. I urge that the Government should at any rate give their minds to this matter, and perhaps the noble Viscount when he replies will be able to give me some indication as to the extent to which their minds have been given to it. It is nine months since the Royal Commission reported. They must have had time to digest even that bulky document, and have had time to begin to consider whether they will legislate, and how they will legislate. That legislation is difficult and complicated, I admit. The draftsmanship of the Bill will tax the skill of the best Parliamentary draftsmen. It is a pretty complicated Act as it is, and it would be a good thing if the problem could be simplified. Many of those who have to administer the present Act tell us that the complicated procedure very often makes it difficult to know what to do, and in some ways unnecessary difficulties created by the Act are got over by a sort of, what shall I say?—well-intentioned breach of the letter of the law almost in some cases—all in the interest, of course, of patients.

If we are to be told that no effective legislation can be passed this year, I think we might at least be informed that towards the end of the Session there might be presented to this House, be it only for First Reading, some Bill embodying the conclusions at which the Departments have arrived, so that persons at large could study it and the public mind could be prepared. But if the question of the Poor Law is coming on next year that means that there is no hope for this measure next year, and that you are going to postpone the reform for three or four or five years after the Report of the Royal Commission. I recognise that it does often happen to the Reports of Royal Commissions, but in this case you would, I think, by adopting most of our proposals, effect many very important objects.

Among other things you would succeed in reducing the actual interned asylum population and you would be able to release many of them; your action would in many cases, I think, lead to better treatment and better chance of cure for those who are there, and many would never reach the doors of the actual asylum at all, particularly if something in the nature of a clearing-house were set up in large urban centres. You will certainly do good work if you strengthen the Board of Control, and something at some time or other must be done to meet the licensed house question. All these are matters which involve day by day the treatment of patients, and to put them off for years is putting off the beginning of a reform which in the view of all of us who were concerned in this long and interesting Inquiry, is a very important reform. I cannot do more than commend it to your Lordships with such arguments as I have at my command, but I do urge that it is a matter which should not be lost sight of.

LORD SANDHURST

My Lords, I had some hesitation as to whether I ought to address your Lordships on this subject, for the reason, referred to by my noble friend in his speech, that I occupy a humble office in the administration of the Lunacy Law; but, for that very reason I have a special interest in the subject, and have been obliged to form some personal opinions upon it. Therefore I take the liberty to make a few observations. There was considerable disappointment three years ago when the Mental Treatment Bill, which was piloted through this House with infinite pains and great ability by the noble Earl, Lord Onslow, and which would have achieved several objects recommended in the Report of the Royal Commission, failed to pass. It is chiefly with those reforms that I desire to deal.

My noble friend has enlarged upon the necessity for early treatment, which is almost, I might say, a closed book so far as argument is concerned. There is no want of unanimity among those conversant with the treatment of the insane as to the absolute necessity of getting hold of the patient at the earliest possible moment, instead of getting hold of him, as is pointed out in the Report, at a time when the disease is so marked that the symptoms are obvious and the treatment is becoming more difficult. I do not wish to enlarge upon that any further, because my noble friend has dealt with it, but there is one matter connected with it to which I should like to draw attention—namely, the subject of voluntary boarders. In the registered hospitals, I think I am not exaggerating in saying, something like a third of the patients in some of them are voluntary boarders. In the licensed houses there are also a large number of voluntary boarders. In Scotland, owing, I think, partly to a somewhat different interpretation of the law, the number of voluntary boarders is even larger than it is in England, but a rate-aided patient cannot in this country be a voluntary boarder.

That is a subject upon which this House has already expressed its opinion. There is really no controversy about it. The reception of voluntary boarders into rate-aided institutions was accepted by this House when the Mental Treatment Bill was before it, and I remember at the time of the Dissolution which prevented that Bill being carried into law I was talking to a medical superintendent of an asylum in the West, and I said to him: "Well, I am afraid this Bill is lost," and he said: "Yes, only last night a patient was imploring me to take him as a voluntary boarder, and I was obliged to say to him that the law did not allow me to do it." It really is a case of one law for the rich and another for the poor, and is a matter which urgently calls for reform.

Another matter to which I think my noble friend did not refer, except allusively, is the question of after-care. If the noble Viscount who usually presides over our proceedings were here he would remember that in 1923 he attended a meeting of the Mental After-Care Association, and at that meeting he foreshadowed the Mental Treatment Bill which was introduced in that year. He also foreshadowed that in that Bill provision would be made to enable local authorities to provide for the after-care of patients, either directly or through voluntary institutions. And, so far as the introduction of the Bill was concerned, that promise was carried out. The Mental After-Care Association does invaluable work in this direction. It is one of the most deserving charities in the country, one which I do not hesitate to commend to the favourable consideration of noble Lords. But it is perfectly obvious that the care of patients leaving asylums at the time which is most critical for them, and whose homes do not provide facilities for that sort of care and observation which is very necessary, should not be left to, and cannot be adequately attended to by, any charitable institution. This reform, which, as I have said, like the other, has already been approved in principle by this House, is again recommended by the Report of the Royal Commission, Those are subjects which urgently call for the sympathetic consideration of His Majesty's Government.

There is a further subject to which I should like to call attention, and which is referred to in the Report of the Royal Commission, because it really does interpose difficulties in the way of carrying out the law as it stands at present. I refer to the very natural hesitation which the medical profession feel in certifying patients. Recent cases have alarmed them and they feel that in certifying a patient, even in the best of faith and with all the care they can take, they are not adequately protected against subsequent litigation. My noble friend has pointed out the extreme difficulty of dealing with some of the cases of insanity which find their way into the asylums and of determining whether the patient in an asylum is really insane or not. The difficulty must be greater still with a patient outside an asylum who is only seen by a medical man in an interview, short or long, it may be a quarter of an hour or it may be an hour, but it is a single interview. He may observe symptoms which to him in this interview convey clearly indications of insanity but which are extremely difficult to reduce into writing, still more difficult to reduce into words which would satisfy a jury whose sympathies have been worked upon by an ingenious counsel. The result is that you find cases in which it is clear that for the benefit of the patient as well as of the public it is desirable the patient should be placed under supervision, yet in which it is very difficult to find medical men who are willing to certify.

The Report suggests that the onus of proof in regard to good faith and reasonable care should be shifted, that instead of the medical man having to show that he exercised due care and acted in good faith, it should be for the complaining patient to show that the medical man was actuated by bad faith and did not use reasonable care. That would be a good thing as far as it goes, I do not doubt, but I feel that it is hardly enough to inspire confidence in the medical profession. At the same time I feel that there is great difficulty in going any further. It may be worth while to throw out a suggestion which may possibly merit consideration. It is that the damages recoverable in an action for wrongful certification should be limited to the period of one month, at the end of which a special report has to be made to the Board of Control, or at the end of which a fresh order for the detention of the patient would have to be made if the scheme of the report is carried out. That would limit the period during which the detention could really be attributed to the certificate, because it would bring the period to the point at which another responsibility came in. I know of no precedent for limiting the damages in that way, but is does seem to me to carry out the principle adopted by the Court in the Harnett case, with which many of your Lordships are doubtless familiar. I only throw that out as a suggestion which may be worth consideration. It is a matter which is of some urgency at the present time, but I fully recognise that these are things which cannot be dealt with in a violent hurry.

The matter is in a way ripe for legislation and overdue, but it is an advantage perhaps that the Mental Treatment Bill was not passed at the moment at which it might have been, because we now have the luminous Report to which the noble Earl has referred. It will enable the Government to deal with the matter much more comprehensively than was proposed in the former Bill and if, as I understand, there is a prospect of amending the Poor Law as well, inasmuch as the Report contemplates alterations in the relations of guardians to the administration of asylums in which they have patients, it would be necessary to co-ordinate the Poor Law as amended with the Lunacy Law as amended. It may therefore be an advantage that the two things should be considered together. All I desire to urge is that if legislation is introduced next Session, which I am afraid is a Session already rather overcharged with potential legislation, I hope that such legislation will be proceeded with to an issue.

VISCOUNT GAGE

My Lords, the two noble Lords who have just spoken have done so with such clearness and knowledge that I am particularly sorry to have to begin, as I think I had better do quite frankly, by confessing that the information I am authorised to give them is extremely limited. The noble Earl, Lord Russell, spoke for a considerable period on this subject and I do not think the Ministry would disagree, at least in principle, with the majority of his remarks; but I think both he and the noble Lord, Lord Sandhurst, have said enough to convince the House that although many of the results the Commission set out to attain are in themselves universally admitted to be desirable, the steps that it would be necessary to take to bring those aims and objects into being might give rise to considerable controversy on grounds quite apart from the purely medical and scientific aspects involved. For instance, the example has been given of the Harnett case. The prolonged litigation that arose on that case is an example of how far the legal status of the medical profession is involved in the law as it stands at present. It also shows with what care it would be necessary to consider alterations of any kind in order to reduce to a minimum the possibility of similar cases arising out of the obscurity of the law.

It is not only in regard to the concrete recommendations of the Commission that this care is needed. On certain points, as for instance the licensed house, which was referred to, the Commission itself expressed divided views. I do not think I need labour that point, but the House will no doubt appreciate that the Government feel there is need for the very closest consideration of this and similar questions in all their aspects, scientific, legal, financial and administrative, before they decide on their policy or enunciate it. In view of the fact that this Report was presented in July of last year, the Government feel that they are entitled to claim a rather longer period for the necessary investigation than has been available up to the present. In this connection I might point out that the Commission itself took two years over its own deliberations. Again, the present administration of the Lunacy Laws, as has been said, is closely interwoven with the Poor Law administration. Upon this the Report says:— We are of opinion that Lunacy Law and administration should be divorced from the Poor Law; but as this may be one of the results of the contemplated reform of the Poor Law, our proposals under this head must necessarily be tentative. Until the Government's proposals for the reform of the Poor Law are in slightly more crystallised form it would obviously be almost useless for it to discuss the administrative side of the Commission's Report which forms a considerable proportion of the Report.

In reply to the other questions which were referred to by the noble Earl, I am sorry that the Minister cannot authorise me to give specific answers because he feels that such a discussion, before the Government's investigations are concluded and before the administrative side is properly settled, would enable him, only to make a very partial statement which might very easily, as the noble Earl will admit, cause unsettlement and controversy outside this House. That would be both unnecessary and undesirable. I am authorised, however, to tell the noble Earl that the Minister considers that there can be no dispute in regard to several of the principles which he mentioned, as for instance, the desirability of treating the mentally afflicted at the earliest possible opportunity after the disability has been made manifest and also the desirability of removing the Poor Law stigma. I can also assure him that the Government regard this Report as a most valuable document, and that they will not fail to adopt such of its recommendations as it may be found possible to do when the investigations of the Government are completed, and when they are in a better position to consider the relations of this Report to their Poor Law Reform proposals.

It is not very much, but I hope the noble Earl will be satisfied with these assurances and will be satisfied that there exists a strong disposition on the part of the Government towards accepting the majority of the Commission's Report, at least in principle, and that the unwillingness of the Minister to indicate his exact views on the points specifically raised by the noble Earl is not so much dictated by any idea of evading the points at issue but is due simply to the fact that the Government are most anxious to treat the Report as a whole. I will, of course, draw to the Minister's attention the suggestion which my noble friend made with regard to a draft Bill, and also the proposal which my noble friend Lord Sandhurst made regarding the suggestions for the period of detention and the safeguards for the medical officers involved in those cases.

VISCUNT HALDANE

My Lords, the noble Lord who represents the Government has obviously been very much hampered in the statement he has made. He has not been furnished with very full materials and he has to avoid committing the Ministers who are responsible. It is a little unfortunate, and I cannot, help wishing that the noble and learned Viscount who presides on the Woolsack had been able to come here and take part in this debate. Like him, I occupied the Woolsack at a time when the Woolsack was closely associated with the administration of the Lunacy Law, more closely than it is to-day. The Board of Control has now been substituted for the Lunacy Commission with which in the old days, when my noble friend Lord Sandhurst was one of the Visitors, I was closely associated as Lord Chancellor and had a great deal to do in connection with the lunatics. Not only so, but I presided here for days over cases in which we had a lunatic, and an extremely clever one, addressing us from the Bar and exhausting every technicality to influence our judgment.

I listened to-day with the greatest interest to the speech of my noble friend Lord Russell, who, with great lucidity, gave us an exposition of the conclusions to which Mr. Macmillan's Commission has come. No doubt on those conclusions many points of difficulty will arise, such as the noble Earl opposite referred to, but, after all, on the main principles there is no room for a great deal of controversy. What I suggest to the Government is this. It is very unsatisfactory to let a thing slide with the sort of assurances that the noble Lord was able to give us. It would be much better if the Ministry of Health, whose business it is, were to set to work to have a Bill drafted. They have got some very competent people at the Ministry of Health who could do that along with the Parliamentary draftsman. Then let that Bill go to the Lord Chancellor, to be looked at from the point of view of the liberty of the subject, of which he is the custodian. It can then be considered with reference to the Chancery lunatics and all the other classes of lunatics with which the Lord Chancellor is more intimately concerned. When that is done a great many of the difficulties will have disappeared. I speak from experience of the preparation of such a Bill, especially after the careful work which the Royal Commission has done in this Report.

Then I hope that the Government—not with the intention of passing the Bill this Session, but with the intention of getting the public judgment—will introduce it, perhaps in this House, which is the most convenient place in which to introduce it. We can then consider it briefly and it can go over to next Session. The important thing is that it should be introduced and printed so that we can have the criticisms of the public. That is a far better course, to my mind, than that which was adumbrated by the noble Lord opposite. He could not do more to-day, but, on consideration, the Minister will see that progress can only be made if there is a large body of public opinion behind it. Until the Bill is produced there will be a cloud of suspicion about it. When it has been printed and discussed with the aid of a large number of people who are experts on the subject, like Mr. Macmillan, Lord Sandhurst and Lord Russell, people who can contribute to the discussion of the Bill, then we shall be able to put forward something at a subsequent date which will command general assent. Therefore, I press the Government to set to work at once with a view of getting it into a shape in which it is possible for us to consider it later.

THE LORD PRESIDENT OF THE COUNCIL (THE EARL OF BALFOUR)

My Lords, I need hardly say that I do not rise to add anything material to what my noble friend has said. He has explained the position of the Minister of Health, and I can only repeat the promise that he indicated and implied, that the Minister of Health will most certainly give full consideration to all that has fallen from the very competent speakers in this afternoon's debate. I have listened with very great interest and profound attention to what has fallen from the two noble Lords who spoke with such special knowledge of the subject. I think the speech of the noble Earl on the Front Bench opposite was one of very profound interest, and I am certain that all your Lordships, who had the good fortune to listen to it, will feel he has given a most admirable survey—no doubt from his own point of view, but representing a large body of the most expert opinion—and a most interesting survey of the question as it stands to-day. I am sure that all he has said and all that the noble Lord, Lord Sandhurst, has added to what he said will receive the most careful consideration of the Minister of Health.

Your Lordships are well aware that in dealing with these great and complicated subjects one of the great difficulties which faces any Government and any Minister is the difficulty of time. These questions are very complicated, and, although it is perfectly true that with the progress of knowledge, with the progress of medical science, with the progress of administrative capacity, a very large measure of agreement is gradually reached and has, I believe, been reached by those who have been working with the noble Earl and the noble Lord opposite, still inevitably there are questions which arouse great differances of opinion, even outside that large body of public prejudice to which the noble Earl referred in more than one very important and very interesting passage of his speech. I have already indicated to your Lordships how valuable I think that speech has been, but I think one of the most valuable effects of it to those who read it will be to alter the general attitude of the uninstructed public mind towards what have been, and perhaps still are, some of the most difficult aspects of this most difficult question.

I can only repeat my noble friend's assurance that the Government are most sensible of the importance of this question. They cannot dissociate it, and obviously ought not to dissociate it, from other problems, from the Poor Law. The Poor Law Bill itself is one of great difficulty, magnitude and complexity, and I do not think the Ministry of Health, represented by my noble friend, can be seriously blamed if they ask for more time to consider a Report which, though it has been in the hands of the public for a certain number of months, is of a kind which cannot be dealt with straight off even by the ablest of Parliamentary draftsmen or the most expert of civil servants. I think the debate this afternoon has been most interesting and instructive, and I hope your Lordships will be content with the statement my noble friend has made, meagre though that inevitably is and little as I am capable of supplementing it with further details.