§ 3.7 p.m.
§ THE EARL OF FEVERSHAM rose to call attention to the implications of the recommendations contained in the Report of the Royal Commission on the Law relating to Mental Illness and Mental Deficiency, 1954–1957 (Cmnd. 169) and the provisions required for their implementation; and to move for Papers. The noble Earl said: My Lords, I beg to move the Motion which stands in my name on the Order Paper. The Royal Commission on the Law relating to Mental illness and Mental Deficiency was appointed in 1954 and published its Report in May of last year. Those of your Lordships who have had an opportunity to read this massive and extensive Report will agree that the distinguished persons who were members of this Royal Commission have taken great pains to investigate most thoroughly the complex subject of mental disorder. They have produced one of the outstanding social documents of this century, and it is in keeping with our knowledge of the stature of its Chairman, the noble Lord, Lord Percy of Newcastle, whose qualities of wisdom and statesmanship are well known not only in your Lordships' House but throughout the country. I am sure that you will share with me my regret: that the noble Lord is unable to be in the House this afternoon to take part in this debate.
§ The recommendations of this Royal Commission carry additional weight because the findings of the Commission were unanimous. Her Majesty's Government have said that consultations on these recommendations are important if the best information can be incorporated in any future legislation. It therefore seems appropriate, and perhaps necessary, that your Lordships' House should have an opportunity of discussing this Report. My only qualification for moving this Motion is that for many years I have been Chairman of the National Association for Mental Health.
§ Perhaps I may at the outset say a word or two in general terms on why this Report should be kept in the forefront of our minds and why it cries out for our attention. The bewildering vastness of mental disorder is fully demonstrated in the mass of evidence that was brought 814 before the Commission; in fact, the Report says, in the Appendix, that illness caused by neuroses amounts to between one-quarter and one-third of all absence from work due to illness, and that 44 per cent. of all hospital beds in all our hospitals are required for the mentally ill and mentally deficient patients. This means that there are about 200,000 patients in mental hospitals and mental deficiency hospitals.
§ Surveys show that, of new patients admitted to mental hospitals, one-third are discharged within twelve months and four-fifths within two years. These figures are encouraging, but we cannot gloss over the fact that between 70 and 80 per cent. of the population of mental hospitals are long-staying patients; that between 60 and 70 per cent. have been in hospital for over five years, and 10 per cent. for a longer period than thirty years. The Commission had no mandate to refer to certain other aspects, but the organisation with which I am connected have reason to believe that every year 80 million man-days are lost to industry through absenteeism due to neuroses. That is a very startling figure, and represents more than twenty times the number of man-days lost to industry through industrial disputes. It is estimated that one in every four patients who attend a doctor is suffering from some kind of illness of the mind. When the Report was debated in another place it was stated that of those who came into touch with our mental health service, about 450,000 people were disordered. The cost of our hospitals, sickness benefit and the amount of loss of wages totals some £200 million a year.
§ All this contrasts very seriously with the generally accepted dictum that the stability of our nation is built on the soundness of the family and the soundness of the individual. I belong to that school of thought which believes that the greatest requirement for the wellbeing of society in this modern age is that each individual should have a complete integration of his body, mind and spirit, and that the individual cannot function with full effectiveness if any one element of this interdependent trinity is seriously impaired. The rapidity of new inventions has revolutionised our way of life. Speed, mobility and diversity have torn up the old anchors and imposed many new 815 stresses and strains upon the individual and also upon the family. I suppose it is true to say that today it is infinitely more difficult than ever before to have a balanced personality and stability of mind. I believe that this is borne out by the figures which I have already given to your Lordships' House. I am hardly surprised to meet thinking people who say that in these days of weapons of mass extermination the only hope of survival is for man to devote greater resources to discovering more about himself and his mind, and to learn more of the factors that impel him, through emotional or irrational motives, to act as he does.
§ I have purposely referred to these startling facts and forecasts to show that mental disorder is widespread and that dependence on mental stability is vital. Your Lordships might well conclude that it is extraordinary that so little public attention has been given to this subject. I attribute this to two causes: first, to an almost primitive fear about mental illness which, until recently, has been due to ignorance and a sense of shame, and which has hindered public acceptance of an enlightened approach; and, secondly. to exaggerated claims by some schools of specialists which have increased, rather than allayed, suspicion. And this feeling has been inflamed by what I would call irresponsible sensationalism in a small section of the popular Press. I hope that none of your Lordships will assume that I align myself with those cranks who give the impression that the human make-up can be changed overnight or that every trait of personality can be explained away. In fact, I state most emphatically that most reputable doctors in this field recognise that we are only on the threshold of knowledge. I hope that the noble Lord Lord Cohen of Birkenhead, who I am glad to see is to participate in this debate, will share that view. I am sure he will agree with me that we are now at the stage where new frontiers are being opened on a world which invites extensive exploration and promises a wealth of discovery.
§ Against a background of overcrowded hospitals, old-fashioned ideas, incomplete knowledge of the mind and lack of research, the noble Lord, Lord Percy of Newcastle, and his Commission considered the evidence and the opinions 816 which appear in this Report. They brought forward many practical and sensible recommendations, one of which—relating to the de-certification of mental defectives—Her Majesty's Government, I am glad to see, have already put into effect. This is a major and very important change, not just one minor administrative change, as the Manchester Guardian reported in to-day's issue. Your Lordships will not want me to review all the recommendations of the Commission, and I certainly have no intention of doing so; but perhaps I might refer to those changes which most concern me; and I hope that your Lordships may hear the views of other noble Lords on other recommendations.
§ The keynote of the Report of this Commission is the emphasis on treatment, as distinct from custodial care. The main objects of the changes are to put mental patients, as far as possible, on the same footing as patients in other hospitals. My Association submitted evidence to the Commission, and we were pleased to find that the recommendations in the Report were largely in line with our own policy. This applied particularly to the revision of the old classification of mentally disordered people. New terminology is needed to mark a step forward from ancient prejudice and fears. The Commission designate three groups: the mentally ill, the psychopaths and the severely sub-normal. I agree that the best principle on which to classify patients is to provide the treatment or care which each individual needs. Your Lordships may be aware of the difficulty which the Commission found in trying to arrive at a definition of a "psychopath." In my view, such is the complexity of a psychopathic personality that the Commission had no other course but to recommend that every case be assessed individually within the broad terms that they have suggested.
§ My Lords, I also entirely approve of the Commission's recommendation that the term "certification" should disappear. The law should be altered so that, whenever possible, suitable care can be provided for mentally disordered patients with no more loss of liberty than happens to people who need other forms of treatment. New procedures should be regarded by the public simply as a means of providing a patient with the care that 817 is suitable to his needs at the time. Certification and all the mistaken ideas associated with it should be forgotten. However, some machinery must exist for the welfare of patient; who are unwilling to accept treatment, and for the protection of the community. The pendulum of public emotion swings dangerously between the desire to lock up every potential murderer in a mental hospital and the belief, provoked by Press campaigns, that all hospitals should be emptied of patients, whether they be rightly or wrongly detained.
§ I would submit that the public need guidance on these matters. The Commission proposed a simplified procedure of certification, and at the same time to give a safeguard to these people in the form of a right of appeal to a review tribunal. May I suggest that the simplest form of procedure should be used, so that patients and relatives may easily understand their rights of appeal? I agree with the Commission that the review tribunal must be independent, and it is essential that it should appear to be so. To achieve this end, there should be an adequate representation of lay members serving on such tribunals.
Although these legal and administrative reforms are very important—and I am conscious that I have done less than justice to them—I think your Lordships may agree that perhaps the most far-reaching recommendation contained in the Report is that the responsibility for community care should be firmly placed on the shoulders of local authorities. The Commission say, in paragraph 47, on page 17:
The aim of treatment or training is to make the patient fit to live in the general community. No patient should be retained as a hospital in-patient when he has reached the stage at which he could return home if he had a reasonably good home to go to. At that stage the provision of residential care becomes the responsibility of the local authority.
That is to say, the provision of social workers to support patients in their homes, and the provision of residential accommodation in the community, will be the responsibility of the local authority. Superintendents of mental hospitals tell me that if the Commission's recommendations on community care were to be put into effect, about 20,000 long-stay patients could be dis-
charged. They are people who no longer benefit from skilled nursing and who could leave hospital, provided that they had a good home to go to or that there was a hostel run by the local authority to which they could go.
These people who have lived for a long time away from the community require expert help and support if they are to be absorbed again into the community. It is quite useless to postulate the importance of prevention and after-care, and to allow thousands of patients to be discharged from hospital, unless the local authorities are able and prepared, with trained workers, to accept the burden which will fall upon them. Those of your Lordships who know about social work will agree with me that it is essential to support families who have these problems in their midst. If these recommendations are accepted, it is, I think, imperative that families who will be asked to take patients back into their homes should have the help and advice of people who specialise in this field. The Commission say, in paragraph 715, on page 241:
And if the general re-orientation of the mental health services which we have recommended, in the direction of a considerable expansion of local authority community services, is to be achieved, we have no doubt that the provision of community services for all groups of mentally disordered patients should be made a duty.
I would say to Her Majesty's Government, in the strongest possible terms, that unless the status of the mental health services is improved the patients discharged will be back inside the hospital within a few weeks, and the chaos to the community will be unthinkable.
But, of course, the mental welfare services will not be improved unless money is made available. The whole of this question hinges on finance. The Commission say in paragraph 609, on page 210:
We have felt it right to assume that a fair share of our national resources will be allocated in future to the mental health services, both by the central government and by local authorities, and that it is recognised that in many areas these services have a considerable amount of lee-way to make up.…
The Report continues:
It may be inevitable that financial considerations will limit the speed at which the necessary improvement of the mental health services can take place, but we trust that even
in present conditions this will be given a high priority.
Even in these days of financial stringency and the implications of the block grant, the Government must devise some method of giving local authorities a financial incentive. The Commission say in paragraph 610:
Whether the money for services which are agreed to be necessary is raised through rates or taxes makes no essential difference to the general public from whom both rates and taxes are raised, and neither the county and county borough councils nor the central departments should allow themselves to be influenced by this consideration.
§ If the community services are to work, it is also essential that there should be full co-operation between the hospitals and local authorities. A narrow division of responsibilities is disastrous, yet that narrow division does exist to-day. It exists between the staffs of hospitals and the staffs of local authorities. Again, this is largely due to the fact that hospitals are administered by hospital boards drawing on central funds and mental welfare services are administered by the local authorities who draw on local rates. The point is that some form of liaison and exchange of information must exist, so that every case can be continuously understood and treated, whether the patient is in hospital or living in the environment in which the illness occurred.
§ For my part, I regret that these two groups of community services, one specially concerned with mental disorder and the other not, should ever have been regarded as distinct. After all, the mental health of a man is a condition of the whole man, taking into account his background, his pursuits, his friends and his ordinary life. Therefore, its preservation is the interest and the concern of the whole community. There are a few hospitals, and only a few, which depend for their very considerable success upon a complete integration of all these services, medical and lay, through the local authority, and it is in these hospitals that the value of a comprehensive mental health scheme is self-evident. I should be glad if the noble and learned Viscount the Lord Chancellor, who I am glad to know is to take part in this debate, would be so good as to indicate what the view of Her Majesty's Government may be in this regard.820
§ There are some outstanding examples of places where a comprehensive mental health scheme works effectively and successfully. I would refer particularly to the city of York, which has a prototype of what all local authorities should adopt. It is of interest, I think, that York happened to be the place which established the first mental hospital in this country, and it is encouraging to know that its long tradition of care for the mentally ill and disordered is being continued, for York is in the forefront of local authorities to institute a comprehensive scheme, which is greatly to the advantage of all patients who receive treatment in that area. There are other areas—for example, Oldham and Nottingham—which can be claimed to be very good in this respect.
§ In my submission, the Government should appoint an inspectorate. In the past, the Board of Control fulfilled a useful purpose. Its original rôle is now thought to have ceased, and the Commission recommend that it should be abolished. But if the new standards envisaged by the Commission are to be achieved, I believe that an inspectorate should be set up to ensure that progress is made and that progress is on the right lines. With the desire for the care of the mentally ill, as I am sure that your Lordships will recognise, goes the desire for progress in research. The total number of hospital boards in the country are divided almost equally between the mentally ill and the physically ill, but the proportion of research into mental health to research into physical health bears no comparison. In fact, the paucity of research in this field is scandalous: only £58,000 of public money is being spent on mental health research this year. This is less than 2 per cent. of the public money spent on the whole of medical research. Schizophrenia alone is the greatest single cause of serious illness in the country, yet last year research into schizophrenia received only the paltry sum of £11,000.
§ How do Her Majesty's Government intend to deal with this problem? What are they proposing to spend on research? We shall never make progress until the State makes a determined effort to promote the discovery of new knowledge of the mind. If the Government decline to stimulate research, who will? I do not undervalue the work of some dedicated 821 people who are pursuing many lines of investigation, but they are backed by slender resources and are few in number. In my estimation, we need a permanent foundation investigating the normal behaviour of the human mind and the effects of various influences upon it. If we were better able to understand the normal mind, we should perhaps see more clearly the causes of mental breakdown. We need to know more about the mental make-up of the normal human being, and about the effects on him of environment and of physical, and indeed chemical, influences.
§ It was the late Mr. Walter Elliot who said in another place (and I think that he was probably right) that no ambitious student starts research which may lead him into an investigation of mental processes because there is no future in it. We are not tackling research in this country with sufficient realism for young doctors to give it a future. Perhaps that is why a number of eminent people in this field have gone to pursue their studies abroad. If Her Majesty's Government regard research in this field as vital. I think that they should give a more practical demonstration of their feelings.
§ Changing the law will not stimulate research; nor will it eradicate mental instability. But it could mark the beginning of a resolute campaign to strengthen the mental health and happiness of the nation. The Percy Report contains a blueprint for the development of the mental health service. I have been able to refer to only a few of the important questions posed in this Report, but I hope that I have indicated that we should have new legislation; and I hope that the noble and learned Viscount the Lord Chancellor and the noble Lord, Lord Strathclyde, will say to us this afternoon that many of these recommendations will be embodied in a Consolidation Act. It would be a start of rare and special importance in the history of social welfare. My Lords, I beg to move for Papers.
§ 3.30 p.m.
My Lords, I know that the whole House will wish me to express our thanks to the noble Earl, Lord Feversham, for raising this subject and our admiration of the weighty speech to which we have just listened. The noble 822 Earl speaks with special authority in this field, and his remarks will be widely followed inside and outside your Lordships' House. If I say that he has fulfilled, and even exceeded, the very high expectations we had when we came into your Lordships' House to-clay, he will realise that is a genuine form of tribute.
I think, also, we should wish to join the noble Earl in expressing our regret that the noble Lord, Lord Percy of Newcastle, is unable to be with us to-day" and in sending to him our cordial message of appreciation of the work he has accomplished in this Report. I agree with the noble Earl, Lord Feversham, in praising this Report very highly: it is comprehensive, courageous and progressive. I do not say that it is easy reading; I cannot say that for the Report. The noble Lord, Lord Percy of Newcastle, is an excellent writer, and I cannot help feeling that if he had written every word himself, without assistance from anybody, the Report would be much more readable—of course, he may have done, but I have no reason to think so. Reading the Report is "stiff going", and I am glad to think that a pamphlet will appear shortly, written by that well-known expert Mr. Rolph, and published by the National Association for Mental Health, of which the noble Earl is Chairman. I have seen an advance copy of the pamphlet, and I would suggest that any noble Lord who wants to know what is in the Report without spending many weeks, and even months, with a towel round his head could do a great deal worse than buy the pamphlet when it appears.
I think I can say that I agree with almost everything that the noble Earl, Lord Feversham, said. I hope that he and the House will forgive me if I repeat some of his points, although I shall try to be as independent of him as possible. There is a great deal in what the noble Earl said about the whole matter bingeing on finance. He called the Report a "blue-print", and I do not dissent from that description, although it is not a concrete programme of the type (shall I say?) of the Beveridge Report. A plan of that sort would require decisions as to how much we were prepared to spend. I feel that the noble Earl was absolutely right in making it plain that, however wise the doctrine here, and however much of an inspiration it provides, we cannot 823 transform the lives of these mental sufferers; we cannot, as a community, make such a difference as we should wish to make to their lives, unless we, as a community and through the Government, are prepared to spend far more money on these matters than has been spent in the past. I do not say that money is everything, and the noble Earl, Lord Feversham, did not, either. I agree that the advance of knowledge itself can bring great benefits. In recent years there have been notable advances: the shock treatment, the tranquillising drugs and other discoveries of psychiatric techniques (which I have not come here to-day to mock) have undoubtedly made the life of the mental patient a great deal happier and have brought about many cures which otherwise would not have been effected.
I am still fairly new to this field, but in such mental hospitals as I have been able to visit I should have been laughed at if I had asked to see a strait-jacket. The padded cell appears to be on the way out, at any rate in the hospitals I have visited, and I hope that that will become universal. The element of forcible restraint is little in evidence today. The progress of physical medicine and of psychiatry have gone hand in hand. To-day we can calm the patient who would otherwise be violent, without strapping him up or locking him up except in the most extreme cases. It is realised, also, by and large, that in the great majority of cases forcible restraint brings a sense of claustrophobia and is itself a factor adverse to cure.
As I say, I do not wish to create the impression that money is everything, but, as the noble Earl, Lord Feversham, has said, even to continue these advances, research is essential. The figure given by the noble Earl is staggering; and as he said, it is scandalous parsimony that we should be spending only 2 per cent. of our total expenditure on medical research on research into mental health, when nearly half the hospital beds are devoted to mental cases. I do not mean, of course, that the other forms of research should be reduced—far from it—but there is obviously an overwhelming case for a vastly greater scale of research into mental health than has ever previously been put forward or been contemplated by any Government. There are many 824 ways in which money is essential. Apart from buildings, there is the question of the remuneration of the staff, which must play a part in that status on which the noble Earl, Lord Feversham, touched.
The Commission itself was largely concerned with law, procedure, the distribution of finances, which was dealt with fully by the noble Earl, and, to some extent, organisation. Certainly an overhaul was long overdue. The law is in a chaotic condition, or, at any rate, there is so much overlapping and entanglement that no ordinary man can make his way through it without being certain to come unstuck. I notice the Commission. in describing the law, said that some of the expert witnesses…sometimes went wrong over details".And they added:We do not blame them; we only hope we have avoided errors ourselves".That is the highest opinion that we can have, and even at that level, apparently, error may not be avoided. Obviously a consolidating Act is long overdue.
Is it possible to simplify the message of the the Report without distortion? Is there a single clue? The Minister in another place summarised the major recommendations under five headings, and the noble Earl, Lord Feversham, has set them out clearly to-day. I agree with what i think was the emphasis of the noble Earl: that one particular idea is dominant throughout. The philosophy of the Royal Commission is that physical and mental illnesses are both illnesses to be dealt with on a medical basis, and the public should see them both as aspects of a single problem; and mental deficiency should be fitted into the same picture. The Royal Commission is well aware that the public will take a long time to assimilate this standpoint, but almost all the recommendations seem to flow from the conviction that this relatively new philosophy can be applied in practice. This conviction, I need hardly say, is not just the vapourings of cranks but the highest collective wisdom of those who have devoted their lives to these subjects. Certainly wherever I have been in recent times I have found the general standpoint of the Commission regarded by those who are doing the job as axiomatic and basic.
I should now like to make a few detailed comments on the findings of the 825 Royal Commission, and I make no disguise of the fact that in what I have to offer to the House I have not drawn on my unaided wisdom but have consulted with one or two very eminent people in this field. First, I would say a word about the question of voluntary admission. At the moment voluntary admission to a mental hospital requires that the patient be over the age of 16 and able to give a valid signature to a form of application for treatment. This denies voluntary treatment to the mentally confused, to the mentally infirm, and to the seriously enfeebled, as they cannot give a valid signature on a form of application for voluntary treatment. It is most welcome that the Report recommends that no such signed application form should be required, and that all patients suffering from any form of mental disorder should be able to be admitted quite informally for necessary treatment unless they or their relatives positively object. Such patients will then receive their care and treatment under the same terms as those suffering from any other form of illness, surgical or medical, without any powers of detention.
There is a point here of which I have given the noble and learned Viscount, the Lord Chancellor, some notice. It appears out of keeping with this liberal viewpoint concerning admission to find in paragraph 299:The Hospital Authorities should have authority to withhold from patients any incoming letters which it would harm them to receivc.I am advised that the requiring of this seems doubtful, and the censorship of incoming letters would certainly tend to create a feeling of suspicion. I hope the noble and learned Viscount the Lord Chancellor will be able to reassure us that that particular proposal will not be adopted.
Then I come to the question of the unwilling patient. Here I agree with the noble Earl in his pleasure at the disappearance of the word "certification", and undoubtedly the elimination of the justice of the peace is in line with informed opinion to-day. The recommendation of the Commission is that two medical recommendations, together with an application by a relative or by a mental welfare officer, should authorise the hospital to accept the patient, if thought suitable, and to detain him for 826 either twenty-eight days' observation, if so recommended by the doctors, or for one year's treatment. Here, again, I have submitted a point in advance to the Lord Chancellor. It is open to argument—and it is, I know, the view of some very learned people—as to whether this proposed period of one year's detention is not too long. Of course, the patient may be considered fit for discharge at any time during the period, but reasonable critics would surely be far more likely to accept the period of six months in the first instance, with a mental health tribunal review if the doctor thought further treatment under detention advisable.
A point for further consideration is whether it would not be preferable to call the first six months, "temporary treatment"—because I agree with the noble Earl in thinking that words do matter in this kind of text—rather than "compulsory admission". Having got rid of the word, "certification", the word "compulsory" would imply its own unsavoury association. Could we not call it "extended treatment" following a review by an outside tribunal? These are rather detailed points, but they have given concern to the authorities.
Then we come to the recommendation upon which the noble Earl touched: that for legal and administrative purposes three main groups of patients should be recognised. He described them to the House, and I do not find any criticism of the suggested group "mentally ill patients" (that is one group) to cover the disorders of a normally-developed mind. But I find a good deal of criticism of the other two suggested groups, the "psychopathic patients" and the "severely subnormal patients," as they are defined in the Report. I am not quite sure what the noble Earl himself thought about that classification, but perhaps when he speaks at the end he may think it right to say a word. Certainly everyone who is interested will welcome the attempt to deal with patients with psychopathic personality in a realistic way, but there is some doubt whether it is practical or clinically permissible to include "patients at present classified as feeble-minded" in this psychopathic group. That is what the Commission proposed. It is surely better to recognise a psychopathic group reserved for abnormal personalities with anti-social 827 tendencies, and to reserve the third group for subnormal personalities, including the high-grade and the feeble-minded. Then you would have that division and you would have your three groups: the mentally the psychopathic group with normally-developed minds, and the subnormal. I submit it is a better classification than the one suggested by the Royal Commission.
I appreciate—and I think this is generally conceded—that it is extraordinarily difficult to draw up a programme for the abnormal personality group, including alcoholics and drug addicts. I do not know whether any noble Lords have tried to help a friend who has become an alcoholic. It is extremely difficult to know what to do with them. In the last resort you may find yourself compelled to secure their inclusion in some kind of institution. But they cannot be held there for long, because when they sober up there is no way of holding them. I hope that that does not fall to the lot of noble Lords. I am speaking in the vicarious sense, and not personally. This problem is one of the hardest, but it is only a relatively small part of the whole.
It is suggested to me that admission for twenty-eight days observation and treatment of patients of this kind should be permitted at any age on two medical recommendations, but admission contrary to the patients' wishes for a longer period should be restricted. As things are to-day, it would seem undesirable that people over the age of twenty-one—unless they have been convicted of some offence against the law—should be restrained for more than twenty-eight days. If we had special hospitals or institutions—of which we often hear, but which do not seem to be available—for the treatment of abnormal personalities and which really could help the sufferers from abnormal personality, then perhaps after twenty-eight days' preliminary observation some kind of special review tribunal could have authority to give people of this kind treatment at an appropriate institution. They might be restrained and treated for a period of six months. One thing is quite certain, and that is that, to take alcoholics as an example, you cannot treat anybody for alcoholism in twenty-eight days; it would need certainly six months. I am not 828 suggesting that we have the institutions which would make it possible to deal with adults against their will when they have not committed a crime. But if we had institutions, it is open to argument whether this longer period should be permitted.
I agree entirely with the feature of the Report which the noble Earl stressed, particularly the emphasis placed on the guardianship in community care. In such cases the local health authority has control, as a parent over a child, and transfer from hospital to guardianship should be carried out with the least possible formality. The recommendation that:in future it should be the positive duty of local health authorities to provide after care (or all patients who need itinstead of after-care being permissible only, is certainly very important. The noble Earl knows a great deal more about that subject than I do. I would certainly endorse everything he said about the responsibility of the community for these mentally handicapped people. I. would add only the thought (which was in his mind, no doubt) that the voluntary bodies should be fully used by the local authorities in carrying out these statutory duties. I understand that that would be perfectly possible. There are voluntary bodies which are doing excellent work, and I would certainly hope that the voluntary principle would not be neglected. If it were, I cannot see that the job will be done in the foreseeable future.
I have completed a few rather episodic comments, but I should like, before I sit down, to say one or two words of a rather broader character, for which I certainly claim no authority except my own powers, such as they may be. I admire this Report, but none of us will wish to treat it as Holy Writ. The wisdom or otherwise of the detailed suggestions will be determined only by trial and error as the years pass. But the guiding principle shines out like a beacon: the welfare of the individual patients. That sounds so obviously the Christian, the civilised, approach—indeed, it sounds a little platitudinous—that one may be inclined to wonder why it has ever been qualified by other considerations, and whether, if they had validity in the past, they have lost it altogether now. There may be people 829 who say it cannot be as simple as all that, and may ask what has come about to show that we were so utterly wrong before.
Perhaps the House will permit me a few comparisons with the modern philosophy of our penal system, with which I am at the moment more familiar than with our mental arrangements. In the sphere of penal reform, we claim to lay increasing emphasis on the reform of the prisoner, and that is certainly comparable to our stress on the welfare of the individual mental patient. But in our penal system, in trying to preserve public order we cannot ignore altogether the elements of deterrence and prevention which are analogous to security in the mental field. Nor, in the penal arrangements, can we ignore altogether another element—some people call it retribution; other people do not like that word—at any rate the connection between the measure of the guilt and the punishment. In theory this connection between guilt and punishment does not enter, and has never entered, into mental treatment, but I venture to say that as a society we have, consciously or unconsciously, tended to blame or ridicule or sneer at the mental patient in a way we do not blame or ridicule or sneer at the physical patient, even where the physical injury or illness is caused by the man's own fault. We are at fast beginning to treat the welfare of the mental patient as the overriding consideration.
As regards security, it is not that security is going to be neglected; but modern medicine and psychiatry, as I have suggested earlier, together with our general enlightenment—in some respects we are getting more enlightened—are beginning to teach us that security can be provided without interfering with the welfare of the patient and with less interference with his liberty than was ever supposed in the past. In regard to the blame or the ridicule placed on the mental patient, I think that to-day the best Christians and psychiatrists—not to mention Christian psychiatrists; there are a number of them about these days—are united in recognising the importance of mental handicap in human decision, without losing faith in the normal freedom of the will. As I think the Report says, and as I think the noble Earl and everybody in this House says, mental 830 sickness is true sickness and must not be condemned on moral grounds. You can say that, without going on to argue that crime or immorality is sickness. If we had several days we could discuss this subject at great length. I am aware that the borderline between mental and moral failure is still to a great extent uncertain. It is in that border area that research has to be multiplied, if progress is to be made. All these things are beginning to be clearer to-day than ever before.
I think we can talk of reel progress having been made and still being made; and still greater progress will be made if we are prepared to do what is necessary. There is a real chance at last of the removal of this terrible stigma from the mental patient, and of the encouragement of patients to seek treatment who have hitherto hung back, overwhelmed with shame, until the condition became such that they have finally been overwhelmed with disaster. There is a real chance that the community will wake up to its responsibility. If I am right, I think that the Report of the Commission will have marked a real step forward in a struggle to which many devoted men and women have sacrified and are sacrificing their life's exertion. From this Report will flow in the long run vastly greater benefits than even the more optimistic of us can foresee at the present time. I would endorse very strongly the speech made by the noble Earl.
§ 4.5 p.m.
§ LORD COHEN OF BIRKENHEAD
My Lords, may I, at the outset, join in expressing my warm admiration and gratitude to the Commission for its wise and liberal Report, and assure your Lordships that the principles and the concepts on which the recommendations of the Commission are based are universally accepted by my own profession. They have been welcomed by many of the societies who devote themselves to a study of mental health, and every medical journal has had eulogistic leaders on this Commission's Report. It marks another milestone on the path of enlightened and humanitarian progress which has marked medicine in this country in the past century.
It is over thirty-five years ago that I first entered a mental hospital as a student, and the mental hospitals were then dominated by the concept of mental 831 disease, in fact if not in theory, which had been in existence for over a century. The afflicted patient was still regarded as being "possessed of some devil." He had to be isolated from the community for the community's protection and not necessarily for his own welfare. The word "asylum", a pleasant word which indicated inviolability, was changed; it received the stigma to which noble Lords have referred. There was evidence of restraint; if not the shackles and fetters of a century earlier, there were padded rooms and straitjackets, and certainly locked doors. In fact it was almost impossible to enter the corridors of any mental institution without the jangling of keys by one of the nurses.
In the past twenty or twenty-five years there has been an increasing recognition of the physical factors which contribute to mental disease. That has led to a reorientation of outlook on the part of medicine away from those barracks, even with 2,000 or 3,000 beds, with monotonously uniformed nurses and monotonously dressed patients, apathetic, without any interest or occupation. The noble Lord, Lord Pakenham, said that this reorientation is a relatively new philosophy; but, if a son of a "Redbrick University" might commend an aphorism to a distinguished alumnus of one of those illustrious institutions redolent of an extinct culture, I would remind him that nothing moves or has its being which is not Greek in origin. It was Plato who told usThere are physicians of the soul and physicians of the body and yet the two are one and indivisible.I might remind your Lordships that until the Mental Treatment Act, 1930, every patient in a mental institution was certified and came under the discipline which I have described, but in the last twenty-five years there have been two factors which have changed our outlook. The first is that in place of custodial care for the benefit of society, with all the necessary legal implications of such custodial care, we have directed our attention to the clinical needs of the individual patient. In so directing our attention we have brought to bear upon the patient the services provided by local authorities, health and welfare services and the like. Indeed, within the last 832 twenty years mental institutions have become mental hospitals in fact and not simply mental hospitals in name. They have become places of treatment for the mentally sick and not asylums for the custody of the mentally afflicted. What the Royal Commission has done is to crystallise the matter in language which might perhaps be an obscurity for the noble Lord, Lord Pakenham, but which is clear to those who for twenty or thirty years or more have been brought up in a hospital atmosphere. I agree with him, however, that there is probably no field of medicine in which there is more verbal confusion than there is in the psychiatric world.
I should like to stress the significance of the magnitude of this problem to which the noble Earl, Lord Feversham, has referred. He has said that there are half a million beds in this country devoted to the in-patient treatment of the sick, and that of that half a million beds some 44 per cent. are devoted to the treatment of the mentally afflicted; but those 44 per cent. of beds deal only with 3 per cent. of the total in-patient population of our hosptials. The explanation, of course, is that in mental hospitals the stay of individual patients is usually for many years, and sometimes permanently. There is a hard core of mental hospital patients (some 80 per cent.) who remain within the hospital for an almost indefinite period of time. But perhaps I can bring home to your Lordships the significance and urgency of the problem if I tell you that one in 250 of the population of this country occupies a bed in a mental hospital; that one child in twenty born in this country will at some time or other have treatment in a mental hospital; that one child in ten born in this country will suffer from some form of nervous breakdown, and that one in 100 children born in this country are within the definition of "mentally defective". A large part of the work of doctors, both in hospital and general practice, is devoted to the treatment of the mentally and nervous afflicted.
Reference has already been made to the part which instability of the nervous system, and instability of the mind, play in the genesis of such conditions as drug addiction, crime, juvenile delinquency, prostitution and the like. It is perhaps only fair to say that within the last few years there has been a remarkable change 833 in public opinion towards the mentally afflicted. For example, in 1946 there were about 35,500 admissions to our mental hospitals, but in 1956 there were 88,000 admissions to our mental hospitals—not that this indicates that there were many more mentally afflicted patients, but that less severe cases were going into the hospitals; that the stigma of mental hospital treatment was no longer as great as it had been previously, and also that there had been public recognition of the value of the newer methods of treatment, such as convulsive therapy, leucotomy and other surgical methods of treatment, the use of tranquillising drugs and the like. As significant of that, of the 88,000, 75 Per cent. were voluntary admissions to the mental hospitals, a situation which might well have been undreamed of twenty years earlier.
Then there is that great experiment to which the Royal Commission referred, the experiment at Mapperley, which serves Nottingham, in which on March 1, 1957, there were 1,054 patients in the hospital of whom only one was certified; there were four on three or fourteen days' observations orders, and all the rest were voluntary or non-statutory patients. Again, when I first commenced the study of medicine, and indeed for many years later, no general hospital in this country, except half a dozen, had an out-patient department which dealt with psychiatric patients. To-day, there are 500 outpatient departments in the hospitals of this country, of which 400 are in general hospitals, indicating that there has been an integration of the psychiatric and the physical aspects of illness, and that in that the general physicians and surgeons and the psychiatrists are playing an important part.
We have also going on at the present moment experiments in administration, which tell of the value of day hospitals, of domiciliary consultation, of the provision of consultant psychiatrists in outpatient departments, nurses, occupational therapists and the like. A very interest-experiment which was recorded only a month ago, to which The Times and the Manchester Guardian and other papers made laudatory reference, is that which is being carried out at Worthing, where there are two populations, each of about 160,000, draining into mental hospitals. One acts as a control, as it were, in 834 comparison with the other. From the one the number of patients to the mental hospital in 1946 was 314, from the other the number of patients admitted was 364. In one of those centres there is a day hospital service, which means that the patient goes to the hospital during the day, has appropriate treatment and returns to his home at night. In the other no such service was provided. Where the service was provided within a period of ten months the admissions to the mental hospital had dropped by 59 per cent., whereas in the other area where no such provision had been made, the admissions to the mental hospital remained approximately at the level they were before—actually about 4 per cent. higher.
Anyone who goes into a mental hospital to-day will no longer find locked doors, except on very rare occasions. He will see nurses no longer in a monotonous uniform but in the uniform of any general hospital, and he will see the patients in their variations of dress sitting around a television set, discussing various problems, listening to wireless; concerts are provided for them, cinema shows, and the like, and the difference in their appearance and attitude is quite unbelievable. It is true that hitherto we have been very remiss in our methods of treatment from the purely humanitarian standpoint of the patient.
The noble Earl, Lord Feversham, spoke of the problem of research, and asked me whether I would say a word or two about it. I gladly do so. I do not think that we can measure the amount of research which is being done in this field simply by the fact that last year, out of a total of some £2,689,000 spent by the Medical Research Council on medical research, only about £58,000, or, as he says, 2 per cent., was devoted to research in mental disease, because quite a lot of money is being spent in other fields—neurology, anatomy, physiology, and so forth—all of which may have their bearing on the elucidation of the problems of mental health. For instance, to-day we bring to the problems of the mental patient all the armamentarium of modern physics and chemistry and biology.
The electro-encephalograph records abnormal changes in the electrical potential in the patient's brain, and produces a record of waves which indicate certain 835 abnormalities, and these are being explored at the present time. It was known many years ago that a child deprived of its thyroid gland developed a cretinoid type of idiocy and an adult developed myxœdema madness. It was known many years ago that to deprive certain individuals of necessary constituents of the diet, such as Vitamin B, would lead to mental changes. It was well known that certain infections—syphilitic disease of the brain, for example—led to general paralysis of the insane. But what we are doing to-day is to bring to bear on all these problems all the modern advances in our knowledge of biochemistry, for example, and of physics and of biology.
It has been shown—and I quote this simply to illustrate the problem—that there are certain mentally deficient children whose mental deficiency depends upon the fact that they cannot properly deal with a particular amino-acid in the body which is called phenylalamine. If these children are given a strict diet they are enabled to overcome, or at any rate to neutralise, this specific change in their metabolic process and the mental deficiency is prevented. To-day investigations are also being carried out in the field of what is known as psychopharmacology, in which certain drugs which produce confused states, hallucinations and the like, are found to bear a relationship to substances normally produced in the body; and methods are being devised whereby other drugs might counteract these specific effects.
I will not weary your Lordships with any further details in the field of mental health research, but I want to stress that in the genetic field, and even in the strictly biological field, many advances are being made. Your Lordships will have read, five years ago, a remarkable book by Professor Lorentz, called King Solomon's Ring, dealing with the primitive instincts of animals; and Tinbergen has recently published a very important monograph on the subject of instinct. We have little doubt that this, and the work which has been done on conditioned reflexes and the like, might help to throw light on human behaviour.
It is also important to add that there are other organisations, many of which are voluntary bodies, interested in mental health research. The Nuffield Provincial 836 Hospitals Trust—which was responsible for the experiment at Worthing has spent £115.000 in the last few years on mental health research in the socio-medical field; and the organisation with which the noble Earl, Lord Feversham, is associated—the Mental Health Research Association—has also spent considerable sums of money. It is also fair to stress that whereas ten years ago there were only two professorial chairs of mental health in this country and two university departments, there are to-day ten such chairs and a number of departments headed by directors. They form centres of active research which are supported very largely by money which they receive from the University Grants Committee.
I am not for a moment saying that enough money is being spent in this field, but I would remind your Lordships (and I was a member of the Clinical Research Board of the Medical Research Council for many years) that what is lacking in this field is, to a large extent, ideas and men. But, as the noble Earl, Lord Feversham, has said, the men must be given the appropriate incentive if they are to work in this particular field. We need new "thinking caps" and we need research into the fundamental sciences, for a chance observation in one of those fundamental sciences might provide the key to the mysteries of some of our mental health problems.
I do not propose to discuss in any detail the question of new nomenclature. Nomenclature always gives rise to a certain emotionally-toned response. When I was in America early last year I heard that the definition of a neurotic was a man who built castles in the air, that a psychotic was one who lived in them and a psychiatrist was one who collected the rent. We have certain problems with names. There are those who claim that "names will never hurt you," but there is no doubt that many of the names which were used in the mental health field hurt a number of people. We have Cowper's verse about:Those who to the fascination of a name Surrender judgment hoodwinked".I think it is fair to say that it is the new nomenclature introduced by the Report of this Royal Commission which has attracted most criticism from my own profession. I do not blame them for not trying to give a definition of a 837 psychopath, for I should find it occasionally extremely difficult to differentiate between some of the endearing eccentricities of some of my friends and the abnormal behaviour to which some phychiatrists might give the name of a psycopathic personality. I believe that ultimately the labelling must rest on the judgment of the individual psychiatrist, based on his experience and wisdom. It is important, of course, that there should be no question of making the liberty of a subject dependent upon the expression of the opinion of one psychiatrist.
I feel that I have detained your Lordships overlong. I believe that this Report is the starting point of great opportunity. In 1948, local authorities were deprived of their hospitals. If this Report is implemented they now have a magnificent consolation prize, because they can make to the mental health service of the country a contribution which will be quite unparalleled by any contribution which has been made in the past. Wisdom and co-operation are needed, and I should like for a moment to join issue with my noble friend, Lord Feversham. He suggested that one difficulty of working with the National Health Service Act was that it had a tripartite basis: the hospitals and consultant services, the general practitioner service and the local authority service—and that it was difficult to weld them. Frankly, I do not believe that that is so. There are in this country many instances where the service is working with perfect smoothness because the will to co-operate is there. I would go further and say that whatever administrative structure may be superimposed on any new enactment which aims at ensuring co-operation will have no effect, unless the will to co-operate is there.
We shall all hope to hear from the noble and learned Viscount the Lord Chancellor what steps Her Majesty's Government propose to take to implement their acceptance in principle of this Report. Her Majesty's Government have already indicated that certain recommendations can be implemented under present enactments, but it is clear that many will require legislation, and we hope that that will be forthcoming within a reasonable time. For I need not remind your Lordships that there have been two previous Commissions on mental health 838 There was the Radnor Commission which sat fifty years ago; and although it is widely thought that that Commission dealt solely with the feeble-minded, it dealt in fact with the whole field of psychiatry then known. It surveyed this field and it made valuable recommendations, none of which was ever implemented or embodied in the law.
Then thirty years ago the Macmillan Commission made recommendations based upon what seems to be an entirely modern concept of mental disease. If I may quote, they called for:The eradication of old established prejudices and a complete revision of the attitude of society in the matter of its duty to the mentally afflicted".And I have culled three sentences from that Commission's Report which might well in their modern ring have been included in the Percy Report. The first is:The keynote of the past has been detention: the keynote of the future should be prevention and treatment".The second is:Those who desire the elaboration of legal machinery are apt to lose sight of the common sense of the matter".The third is:The problem of mental illness is essentially a public health problem to be dealt with on public health lines".I agree that at that time, thirty years ago, there were difficulties in the implementation of the recommendations of the Macmillan Committee; but the changing outlook in mental health, and especially the provisions of the National Health Service Act, should now ensure that this country leads, as it has led in the past, the victorious attack on one of the remaining citadels of despair and misery in the field of medicine.
§ 4.32 p.m.
§ THE LORD CHANCELLOR (VISCOUNT KILMUIR)
My Lords, I greatly welcome the opportunity given by these two Motions for this House to hold a debate on the subject of mental health. Every one of your Lordships will agree that it is most appropriate that we should discuss the Report of the Royal Commission on the Motion of the noble Earl, Lord Feversham, who speaks with such great authority and experience on the subject. I should like personally to congratulate my noble friend on the moving of the Motion and on the form and sense 839 of his speech which he gave to the House. He speaks, as I have said, with great authority and experience on the subject; and we all know and admire the service he has given during many years of active leadership in the voluntary associations interested in mental health. As your Lordships have heard, he is now the Chairman of the National Association for Mental Health, and has held that post since the Association's formation ten years ago. Before that, he led the earlier organisations which were amalgamated in 1948 to form the National Association.
I was very glad to hear from the noble Lord, Lord Pakenham, his belief in and plea for the activity of voluntary associations, because I believe that in this sphere of activity, as in many others, voluntary societies have initiated new lines of development, treading out paths which it later became the duty of public authorities to widen and strengthen into highways for general progress. In saying this, I am not forgetting the long history behind our public mental health services. The noble Lord, Lord Percy of Newcastle, and his colleagues show in their Report how important it is, when considering the present state of the law and the administration of our mental health services, to bear in mind the course of our social history in the 150 years since the passing of the Lunacy Act of 1808. I am glad that my noble friend Lord Cohen of Birkenhead was prepared to go even further back and to take us to the era of Plato; and I am sure that the whole House looks forward to hearing on a future occasion a synthesis of the Republic and the Viennese school of psychology of Freud and Jung and Adler, especially in regard to dreams. But apart from that I am not going to go further back than the period I have already mentioned for the purposes of this speech.
I think it is true that our present law and administration are still influenced by the fact that our mental health services broke away from the Poor Law long before our other public health services, and were administered quite separately for over a hundred years. As has been pointed out (and it is essential that we should have it in mind), nowadays we accept as axiomatic the inter-relation of physical and mental health We think of psychiatry as part of general medicine. 840 It seems entirely natural that mental hospitals should be part of our comprehensive National Health Service. But the Royal Commission have reminded us how recent these ideas are: they have developed during the working life of most of the people who are running our medical services to-day, and they are still far from fully worked out in practice. The Royal Commission's illuminating account of this historical background, which your Lordships have found, or will find, at the beginning of each part of their Report, is typical of their thorough and firm handling of a complicated subject. We owe a great debt of gratitude to Lord Percy of Newcastle and to all the members of the Royal Commission. There are still many of us in this House who sat in another place with him and remember him as a colleague; and I am sure we are all delighted with the work he has done, faced with an extremely complex section of the law.
The Commission have dealt firmly with the fundamental issues. They have succeeded in presenting clearly principles which underlie, or should underlie, the administration of our mental health services, and the special legislation which the special characteristics of mental disorder make necessary. They have also worked out in considerable detail a set of new procedures which they suggest should replace the present complicated code. The result is a Report which has been widely acclaimed as of outstanding importance, and as my noble friend Lord Cohen of Birkenhead has pointed out, the Report has also been widely welcomed both in the general Press and by the professional and other associations representing the many different groups of people directly concerned with the problem of mental disorder. Some doubts and criticisms have been expressed, and some of them, no doubt, will be discussed further in this debate. But they have centred on comparatively few points. For the main principles of the Report and its general approach to the subject, and indeed for the great bulk of its detailed recommendations, there has been almost unanimous support.
May I say again that the underlying principle of the Report, as I understand it, is that people suffering from mental illness or disability should be treated, so far as possible, on the same footing as 841 other sick or disabled people. The Commission recognised, as we all must, the need for special procedures as safeguards when it is necessary to use powers of compulsion in order to detain a patient in hospital, either in his own interest or for the protection of the public. The noble Lord, Lord Pakenham—I will not say criticised, but certainly was rather arrested by the use of the phrase "compulsory admission"; and I was relieved to find that he infinitely preferred this term to that in current use—namely "certification", because this is so often misunderstood. We know that, strictly speaking, the certificate relates only to the state of mind of the patient at the time of admission and authorises compulsory detention. Nevertheless, the term has come to be associated with permanent mental instability. The Royal Commission's term, "compulsory admission", means neither more nor less than it says. I think that everyone agrees that there is an advantage in abandoning a term which has led to a lot of misunderstanding.
One of the basic recommendations of the Royal Commission is that in the law and in its administration we should abandon the assumption that the procedures which authorise compulsory detention must be used unless a patient can express a positive desire for treatment. In future, the Commission say, it should be assumed with mental patients, as with all others, that they are content to enter hospital when this is recommended by their doctors and agreed by their families, if they do not themselves object, even if they are not capable of expressing a positive willingness to do so. This seems most reasonable. An old person who has become confused mentally or a man knocked unconscious in a motor accident is not asked to sign an application before being admitted to a general hospital or to an old person's home and is not refused admission on a voluntary basis because he cannot sign one. The present requirements have the effect that many who are not unwilling but cannot give a valid signature have to be certified before they can enter the only hospitals which provide the treatment they need. Under the Royal Commission's recommendation this would not be necessary. Patients could be admitted to mental and mental deficiency hospitals with no more 842 formality than when entering any other hospital. Then, of course, they would not be subject to detention against their will.
This recommendation has been widely welcomed. The Government have been advised that it can be applied to mental defectives within the terms of the present law, and for these patients the Minister of Health has already asked hospitals and local authorities to regard completely informal admission as the normal method of admission to hospital in future. Hospitals have also been asked to review their present patients and to recommend the discharge of the order of detention in all cases in which the patient can suitably remain in hospital on an informal basis. The review of patients already in the mental deficiency hospitals does not mean that many patients will be leaving hospital, still less that dangerous patients will be set at large. The patients already in hospital who will be discharged from order under this review will be those who are themselves content, and whose relatives are content, that they should remain in hospital so long as is necessary, even if the powers of detention are brought to an end. Patients will not normally he discharged from the hospital itself unless they are fit to leave and suitable arrangements have been made for their care outside.
At this stage may I answer the point made by the noble Lord, Lord Pakenham, about the censorship of patients' letters? At present, the superintendent of a hospital has statutory powers to withhold letters if the contents are objectionable or to keep up the correspondence would be bad for the patient. This applies to incoming and outgoing letters, other than those addressed to certain named individuals and public authorities, of whom I am one. One of the objects of admission to and detention in hospital is to protect the patient from relatives who wish to exploit him. It is reasonable for the superintendent to be able to protect the patient against exploitation by correspondence. I completely accept the point that letters should be withheld only under statutory authority, as is done to-day. I can assure the noble Lord that Her Majesty's Government will keep the point in mind, and I shall look carefully at what he said in his speech to-day.
843 We recognise that until more facilities are available for their care in the community, the hospitals must continue to look after many patients who, if the Royal Commission's recommendations were fully implemented, might eventually be cared for in the community by the local authorities. I should like to emphasise, as there has been a certain amount of misunderstanding on this point in some newspapers, that the new arrangements apply at present only to mental deficiency hospitals and not to hospitals for the mentally ill. Patients are already accepted in hospitals for the mentally ill as voluntary patients if they are capable of signing a voluntary application form. Completely informal admission to these hospitals, as distinct from mental deficiency hospitals, would not be possible without a change in the law. I do not want to inflict on your Lordships all the statutory references, but I have them here if any noble Lord should be interested; and I should be pleased to send them.
This introduction of informal admission to mental deficiency hospitals is the only one of the Royal Commission's major recommendations on procedures which can be put into effect without an alteration in the law. Therefore, may I say directly to my noble friend Lord Feversham that the Government accept the need for new legislation to replace the present Lunacy and Mental Treatment Acts and Mental Deficiency Acts, and that it should be broadly on the lines recommended by the Royal Commission, subject to a few modifications which we consider desirable in the light of views expressed since the publication of the Report. When it may be possible to introduce such legislation is a point on which, of course, I cannot give a strict commitment at the present time. I would assure my noble friend Lord Feversham, however, that in my view it will be a major piece of legislation, and I look forward to its coming before Parliament.
May I say a word or two on the criticisms? We have had some discussion on the categories of patients. As my noble friend Lord Cohen of Birkenhead said, this is one of the points on which there has been most criticism of the proposals of the Royal Commission. And, indeed, it is not an easy matter to decide the 844 terms to be used in the law to describe various groups of patients. Let me take, first, a point on which I think there is general agreement. We are all agreed that many of the terms used in the present law are now out of date. Because of the overtones they have acquired they tend to perpetuate an attitude towards mental disorder which is now outmoded. The new terms recommended by the Royal Commission for future use have, however, as I have said, aroused considerable differences of opinion—I think this was a point which worried the noble Lord, Lord Pakenham. The use of the term "psychopath", in the wide sense which the Royal Commission proposed for it, has been a stumbling block for many who dislike the idea of using one term to cover not only aggressive anti-social psychopaths but also patients with limited intelligence, who may need care and support but who are normally well-behaved. Some people (I think my noble friend Lord Feversham has rather tended in this direction) have criticised the term "severely subnormal", although this term has not aroused so much comment as the term "psychopath" and seems acceptable to the majority of opinion.
These are extremely important points. I would assure your Lordships that the Government agree that careful consideration must be given to the categories of patients to be recognised in future legislation and to the question of definitions. It obviously would be an ill-requitement of the care with which your Lordships' House has addressed itself to this debate if I gave a final conclusion to-day. I should like to consider all that has been said in this debate. It is a matter to which I have been devoting thought, and I assure your Lordships that I shall devote a great deal more thought both to the question of the names to be used, and of the definitions, and to how far they should go in the legislation. A further point raised by my noble friend Lord Pakenham (I must not prejudice his future political career by using that term, but I sometimes slip into using it in the personal sense; I must call him "the noble Lord") was as to the division of certain forms of psychopaths. I hope he will not take it amiss from me if I leave the answer on that point to my noble friend Lord Strathclyde. I am dealing with the other points raised by the noble Lord.
Perhaps I may interrupt the noble and learned Viscount to say that, even if I had a political future—and that is not so—I should always be much honoured to be called his friend in any context.
§ THE LORD CHANCELLOR
I am grateful to the noble Lord.
Similarly, in regard to Scotland (the Report, of course, does not cover Scotland) it is not because of any cavalier attitude towards my native land that I do not try to deal with the important question of the Scottish problems. My noble friend Lord Strathclyde will be speaking later in the debate, and his knowledge of this subject is so infinitely greater than mine that I am sure noble Lords would much rather hear it from him.
I pass now to discuss for a moment the work of local authorities. The expansion of mental health services, particularly by the local authorities, recommended by the Royal Commission would not require new legislation, as it could take place under powers which the responsible authorities already have under the National Health Service Acts, the National Assistance Act and the Mental Deficiency Acts. For England and Wales the Government fully accept the principle underlying the Commission's recommendations. At the same time, of course, they must take into account, as my noble friend Lord Feversham recognised, the general economic and financial situation, and the situation created by the proposed introduction of a general grant instead of a percentage grant for specific local authority services. But the Government wish to see development on the lines recommended by the Commission to the fullest extent practicable, and intend to invite the local authority associations to discussions.
The emphasis which the Royal Commission placed on the expansion of local authority services should not be taken as implying that there has been little progress in it is section of our mental health services in recent years—I think it is fair that I should indicate that. The number of training centres for mentally defective children has more than trebled since 1948. In the five years from 1951 to 1956 the number of boys and girls receiving training increased from just over 846 4,000 to well over 9,000. New centres have been provided at the rate of between twenty and twenty-five a year; and it is a matter to note that they have been given priority in the limited capital development which the Minister of Health has been able to allow in the local health authority services. This is a measure of the importance which the Government have placed on the development of mental health services, quite independently of the Report of the Royal Commission.
One of the main recommendations of the Royal Commission is that local authorities should provide residential homes and hostels for persons with some degree of mental disability who could suitably live in the general community, rather than in hospital, if they had a suitable home in which to live with a certain amount of care and supervision. I think my noble friend Lord Feversham attached importance to that aspect of the matter. Again, in fairness to local authorities I think I ought to point out that such residential homes would not be an entirely new development for the local authorities. For many years up to 1948 they provided hospitals and colonies for the mentally ill and mentally defective; and as welfare authorities they still provide old people's homes which may cater for, among others, those to whom the infirmity of old age brings some mental as well as physical deterioration. Some local authorities also, independently of the Royal Commission's recommendations, have in the last few years shown an interest in providing hostels for mental defectives whose own homes are unsatisfactory. From these hostels the patients go out to work, or to an occupation centre, whereas if no such homes were available they would have to go into hospital. I mention that matter because I do not want anybody to be discouraged—and I am sure my noble friend Lord Feversham feels the satne—by any impression that we are being ungenerous to what those who have made progress in the past have done in that direction.
I should like now to answer the next specific question put to me, which was: What is the Government's view on comprehensive schemes for helping hospital and local authority mental health work? We consider it most important that hospitals and local authorities should work in close co-operation and (this has been 847 emphasised frequently) that the National Health Service and the schemes in York, Oldham and Nottingham, which the noble Earl, Lord Feversham, mentioned, are very successful. We agree with him about that, and we hope that similar schemes will develop and become effective elsewhere. The noble Earl will, however, appreciate that we cannot force particular arrangements on the responsible authorities locally; each must be allowed to work out its own pattern. I hope that I have gone as far as the noble Earl would expect in expressing the approval of Her Majesty's Government for such schemes, and our admiration for those to which he particularly drew our attention.
We are conscious of the fact that an expansion of community centres on the lines recommended by the Royal Commission would require much careful planning and would present a real challenge to the local health authorities. The local authority associations have already expressed general agreement with the recommendations in the Report, and there is no reason to think that they will not be able to meet the challenge satisfactorily. Of course, this does not mean, as my noble friend Lord Feversham was careful to point out, that miracles of increases in staff and new buildings can be expected overnight. The services can develop only gradually, so I have uttered that warning note. I do not want my noble friend to think that it is a note of postponement. The meetings which I mentioned, which my right honourable friend the Minister is anxious to have with local authority associations, are a matter for the near future, a matter for present action, and I do not want him to think that our desire is to postpone them.
May I say a word about the local authorities' staffs, because I think that is an important aspect which has been emphasised by every speaker, including my noble friend Lord Cohen of Birkenhead. The Royal Commission recognised that if local authorites are to expand their services on the lines recommended they will need to employ many more social workers, as well as other staff. At present, local health authorities employ about 30 psychiatric social workers and about 1,000 mental welfare officers. As your Lordships who are interested know, 848 psychiatric social workers are professionally trained, and the numbers are not sufficient for the various services where they are most needed—the hospitals, the child guidance service and the local health authority services. The shortage is due mostly to the limited number of men and women who have the necessary aptitude and suitability for the university course. We hope that the local authorities will be able to obtain more psychiatric social workers and also—I hope noble Lords will agree—that it will become increasingly common for them to work jointly for local authorities and for the hospitals in the same locality. That is another aspect of the same desideratum of my noble friend Lord Feversham.
Local authorities must also continue to rely very largely on mental welfare officers who are not qualified as psychiatric social workers, but who bring to their work a variety of background experience. I should like to make it clear that Her Majesty's Government are most conscious of, and grateful for, the steady, unspectacular but important work that these officers do. For many years now they themselves have wished to have a national scheme of training, in order first to improve and then maintain their standards of service. I would remind the House that a Committee, under the chairmanship of Dr. Eileen Younghusband, was appointed in 1955 by my right honourable friends the Minister of Health and the Secretary of State for Scotland to consider the proper field of work and the recruitment and training of social workers of all levels in the local authorities' health and welfare services. This Committee'; terms of reference includes mental welfare officers, and the Committee has heard views from representatives of mental welfare officers and from others interested in mental health, including Lord Feversham's own National Association for Mental Health. I have no doubt that the Committee will take into account the expansion of local authority services as is recommended by the Royal Commission. I hope that my noble friend will think it right, as I do, that the decisions on the future training of mental welfare officers, should await the report of the Younghusband Committee.
THE EARL OF FEVERSHAM
My Lords, I am sorry to interrupt the noble and learned Viscount, but the training of 849 psychiatric social workers and mental welfare workers, who are the social workers of the local authorities, is, as the Lord Chancellor has explained, the subject of study by Dr. Younghusband's Committee. No indication has yet been given, however, as to when we shall receive the recommendations of the Committee. Its terms of reference include the status and remuneration of all social workers, and there is an uneasy feeling that it may take not months but years for that Report to be issued. In the meantime, the training which is so necessary for psychiatric social workers and mental welfare workers is not at the moment being facilitated by anybody. Therefore the position is that local authorities have social workers who themselves want to be trained but have no facility for receiving that training.
§ THE LORD CHANCELLOR
My Lords. I take both my noble friend's points—the position at the moment, and the question of making available the recommendations of the Committee. I will look into these points particularly, if he will allow me, and either he can put down a Question on them or I can get in touch with him. I should like to assure him that I realise his point, and I shall put it specifically to my right honourable friend the Minister of Health that what would be deemed most undesirable by the noble Earl, and by those who share his interest, is any appearance that the Younghusband Committee is being used as a method of holding up these important considerations. I will convey that danger to my right honourable friend, and I am sure he will give it the most urgent consideration.
THE EARL OF FEVERSHAM
My Lords, I thank the noble and learned Viscount 'very much for that undertaking.
§ THE LORD CHANCELLOR
May I deal next with one or two specific points which my noble friend Lord Feversham raised? He has emphasised some problems which were not themselves within the Royal Commission's terms of reference but which must be considered in any general re-assessment of our mental health services. I think that he had very much in mind how the Government propose to grapple with the problem of long-stay patients in our mental hospitals and with the basic problems of the cause and 850 cure of mental disorder. I think it can be said—and this has been the tenor of the debate—that great advances have been made during the last twenty years in the treatment of many forms of mental illness. During the last few years there has been a significant trend towards treating patients so far as possible without bringing them into the hospitals as inpatients. This can be done through outpatients' clinics, of which the noble Lord, Lord Cohen of Birkenhead, spoke, and day hospitals, and through medical and social services provided in the patient's own home.
It is true, however, in spite of these advances there has not been any substantial decrease in the number of patients actually in our mental hospitals. Those hospitals are still looking after large numbers of patients who entered them many years ago when modern methods of treatment were unknown. Recent work in some hospitals has shown that much can be done to improve the condition even of those long-stay patients; and some have been discharged to their own homes even after a great many years in hospital. It might be possible to discharge more if there were suitable residential homes in which they could live with a certain amount of care and attention, as the Royal Commission pointed out. The expansion of local authority residential services should help to relieve this problem, but it is not possible to say how far modern methods of treatment and research will succeed in reducing the hard core of patients who have not responded to treatment in the past. The authorities responsible for medical research are very conscious of the magnitude and importance of the problems of mental health and are doing everything possible to encourage suitable research.
My noble friend Lord Cohen of Birkenhead has answered, to some extent, Lord Feversham's point there. But as Lord Feversham referred particularly to schizophrenia, and said that only £11,000 was spent last year on research into this disease, I should like just to give some explanation of that point—because it is extremely important. The £11,000 was, in fact, the amount spent by the Medical Research Council on grants and fellowships to independent research workers on this subject. If account is taken also of the work done in the Council's own research units, the total spent on research 851 into schizophrenia in 1956–57 was about £27,000—nearly half the Council's specific expenditure on research into mental disorder during the year. The Medical Research Council's units at Cardiff, at Chichester and at the Maudsley Hospital in London are engaged on three main types of research, all of which have particular application to the problem of schizophrenia. The Council's total expenditure on research into mental disorder in each of the last two years was more than double what it was three years ago. I am not saying that is an answer, but it is, as we say in the law, something to be said in mitigation; there has been a considerable increase on as short a period ago as three years.
My Lords, I do very respectfully—because he can speak with so much greater authority than I—agree with my noble friend Lord Cohen of Birkenhead that research does not depend only on the allocation of funds. It is also necessary to find research workers with suitable training—and as my noble friend Lord Cohen of Birkenhead pointed out, with promising ideas. Training alone does not necessarily give rise to inspired ideas. The allocation of money to a set field of work is not necessarily the best means of advancing knowledge. We realise the importance of continuing to recruit good young workers to psychiatric research, and we have been ready to encourage any promising new line when it appears. As the noble Earl, Lord Feversham, pointed out, there is bound to be a vocational element in this if we are to get the right material. That is the point I desire to make.
But I want to point out also, as the noble Lord, Lord Cohen of Birkenhead mentioned, that other valuable research work is being done under the auspices of independent trusts and funds, such as the Mental Health Research Fund, the Royal Medico Psychological Association, the Leverhulme Trust, the Nuffield Foundation, and the Ford Foundation. Research is also taking place, quite apart from that sponsored by the Medical Research Council, in many of the universities and hospitals—including London, where, as I indicated, a great deal is being done at Maudsley and at Oxford, Cambridge, Durham, Birmingham and Leeds. I am 852 sure that the noble Earl, Lord Fevers-ham, will agree that it is also important to remember that research is an essential part of good clinical practice. The continuing observations of doctors practising psychiatry in mental hospitals and elsewhere is an important element in the sum total of research and progress. This cannot be measured in money, nor described in terms of a specific research programme; but it has been the basis of many of the advances in treatment made in the last thirty years. I hope that my noble friend will take what I have said in the spirit in which it is offered—as an attempt to give a picture of the re search going on. It is not intended—nor would it have the least chance of success—to prevent my noble friend from urging his point with the force we have had to-day.
My Lords, all I want to say, in conclusion, is this. On this general subject we all recognise that this is a period of swift development in psychiatry and allied branches of medicine. Our administrative services and our laws must keep pace with these changes. It is an exhilarating and a challenging time. The Government are determined to face the problems which it presents and, in consultation with the local authorities, to make the maximum progress that our resources allow.
§ 5.20 p.m.
§ LORD GREENHILL
had given Notice of his intention to call attention to the law relating to mental illness and mental deficiency in Scotland; and to move for Papers. The noble Lord said: My Lords, if it would not embarrass the noble Earl, Lord Feversham, I should like to add my own hearty congratulations to him on the informed and well-constructed speech that he delivered here to-day. I should also like to congratulate my noble friend Lord Pakenham, and to say how pleased I was to see him take up the cudgels in this subject and probe into certain aspects of it which perhaps required a little elucidation. I was fascinated by the speech or the noble Lord, Lord Cohen of Birkenhead, in which he indicated how much progress had been made within recent years in this very difficult subject. If there was anything that I missed in his contribution it was perhaps a reference to the possibility 853 that members of his own profession, particularly those in general practice, still harbour a modicum of resistance to anything which has to do with mental trouble. The word "psychiatrist" I think almost annoys some members of that profession.
On the other hand, I am encouraged to say that within the last few years, with the educational activities of the B.B.C., its television programmes, its radio talks, the immensely interesting publications that the Penguin Series have issued in their series on psychology, recent numbers of the New Scientist, where references have been made to the views of eminent psychiatrists on new branches of treatment including that of psychopharmacoly, to which the noble Lord, Lord Cohen of Birkenhead referred, one has the feeling that there has grown up a large and increasingly interested body of the general public in this important problem. The Report is, I think, a milestone in the history of the law on mental defectiveness. But I would say that it is only an early milestone; I think there is a long road still to travel, and one hopes that great advances will lie ahead in this particular field.
My own purpose in intervening in this debate, in addition to the purpose I have in my notes, is this. As the noble Earl spoke, I felt that this particular Royal Commission Report. comprehensive, informative, and progressive as it is, tended to ignore the fact that in Scotland we also had a Report which, but for the outbreak of war, would have been published earlier, but was published shortly before the introduction of the National Health Service and the abolition of the Poor Law, and which demanded alteration in the law. As recently as 1956 a White Paper was issued by the Scottish Health Department, called, I think, Amendments of the Law in Mental Health and Mental Deficiency, which invited observations on suggestions made therein.
I would go further and say that Scotland could claim, perhaps without boasting, a rather advanced position in the field of treatment both in mental illness and in mental defectiveness. But I should like to strike a note of caution, in the sense that the Government, even if they follow up the recommendations of this comprehensive Report with new legislation and administrative changes, should 854 not assume that the problem has for ever been solved, but that what is done is merely a part of a continuous process in the long road of remedial treatment that we are now considering.
While problems of mental illness and mental deficiency are common to both countries, indeed, to every industrialised country in the world, there are differences in the legal systems of England and Scotland which prevent complete uniformity in procedures. Again, one of my purposes in intervening was to draw attention to the difficulty of trying to bring up to date the law in regard to this immensely complex subject of mental illness and mental defectiveness. In the very nature of things, it seems to me that the law is bound to be exact and rigid, its decisions depending, as they do, on facts proved by the submission of reliable evidence. But since public opinion is usually in advance of legal precedents, especially in a rapidly advancing subject such as the one with which we are now dealing, it seems to me almost inevitable that there should be a gap between the needs of the time and the law as it is in force. The example that occurs to me is to remember the hundred years or so of the M'Naghten Rules and their subsequent improvement, if I may say so. by the adoption of the Scottish concept of diminished responsibility, where the effect has been, I think, to regard some of these troubles as more appropriate for the psychiatrist than for the courts.
I should perhaps explain that, though I have discussed this subject with the superintendent of a mental hospital, with the superintendent of a mental defectives' institution, with friends who are consultant psychiatrists and with men who are engaged as administrators in local authorities, such views as I express are my own and do not necessarily commit those with whom I have discussed the matter, although my feeling is that in general they would probably agree with my point of view.
One of my difficulties has been how best to convey to fellow laymen the nature, the magnitude and the complexity of this problem, because I think, without immodesty, that we should be deceiving ourselves if we pretended that the attitude which we have heard adopted this evening towards this most 855 complicated problem is shared by the general public. One has the feeling that the standard of knowledge, the appreciation of the problem, is much higher in your Lordships' House than is the case probably in any other assembly; and in trying to convey to those who are laymen like myself the complexity of this problem I have, by way of analogy, pictured to myself a kind of spectrum of behaviour in which at the infra-red end you would get those who are hopeless and helpless, and at the infra-violet end you would get those who bordered on the line of genius; the intervening colours not merely being held by a band but rather floating into one another—the band is broad and hazy and it is extremely difficult to try to assess in which particular band one comes.
Then, on the assumption that there is this clear spectrum of mental behaviour and mental outlook in the population, we have to remember that it is complicated by the fact that the colours themselves do not remain stationary; and that when, in addition, one adds a third dimension in which there is a depth of acuity in the condition of each of these, one gets a series of complications which only some kind of complicated statistical analysis could effectively bring to the notice and understanding of the ordinary man. It is in that foggy picture that the law insists upon a division being made between categories. Accordingly we have agreed to two broad categories—mental defectives, on the one hand, and mentally ill people, on the other. And although we know that there is no clear line between them, and although we try to explain the difference by saying that in one case there is some kind of organic trouble which is incurable and in the other some emotional trouble which may or may not be amenable to treatment, the fact is that the division is rather artificial.
Then we have the subdivision whereby, in the case of mental deficiency, a line is drawn at the age of sixteen below which the local authority and the education committee are responsible and above which the mental institutions are responsible. They, too, have their own subdivisions in order to categorise the different patients. These are inexact and imprecise distinctions, necessary perhaps 856 for regulation and administrative purposes, but not inherent in the treatment of the people affected. The legal implications are to be seen in the circular letter which the Ministry of Health sent to English authorities on January 15, to which the noble and learned Viscount on the Woolsack has referred and of which there has been some criticism. So far as I am able to judge the reaction in Scotland, I should be inclined to say that there is doubt whether that is a wise provision to make.
There are those who imagine that mental defectives are dull people of low intelligence but they are not quite the dumb creatures that the general public sometimes think. Without wishing to be in any way sensational I would say that if noble Lords—and especially the Minister of State—are interested in what these mental defectives are capable of doing, they should ask the superintendent of the Lennox Castle institution for mental defectives for a view of some of the instruments which the so-called "mental defectives" have made for themselves. It is not difficult to understand why the institution would hesitate very much before allowing the egress or ingress of these particular patients from or to the hospitals. It must not be thought that, because we have categorised a man as a mentally defective, he is capable of the freedom which apparently this English circular has now offered to these patients.
In the field of mental illness the difficulties may be different though they are equally complex. As in the case of mental defectives, there are many subdivisions. Not every mentally ill patient is a psychotic. The much larger, and socially more important, section in this field are those suffering from various degrees of neuroses to which the noble Earl, Lord Feversham, has referred. Some require in-patient treatment, others require out-patient treatment; and there are some who could be treated in their own homes. Here one feels that with the possibility of a larger staff there would be the possibility of psychiatrists undertaking more domiciliary visits in order to give home treatment. As the noble Earl, Lord Feversham, has already indicated, a great many of those suffering from neuroses are even attending their ordinary work at their own jobs but are 857 unhappy: they are unsettled, perturbed in mind, and they need some kind of attention. As noble Lords will know, one of the vital parts of this whole business is that treatment should be given as early as possible, so giving a greater chance of cure and improvement.
But whatever the mental state of the patient, it is generally accepted nowadays that admission to any decently equipped hospital should be as free as possible from formalities. All will agree that a balance must be struck between the freedom of the individual and the safety of the community. Provided that balance is preserved, there should be no legal obstacle in the way of that patient's getting the necessary treatment. But, of course, it is in the application of these principles and the kind of legal framework in which they are made to operate that vigilance and caution are necessary.
I am anxious not to take up too much of your Lordships' time by repeating what has already been said, perhaps more ably, by other speakers; but there are one or two specific items on which I should like to touch. The Scottish Health Department have received memoranda from bodies, and I would particularly ask that they pay attention to a document headed "The Summary of Main Decisions" sent in by the Scottish Division of the Royal Medico-Psychological Association. I will read one paragraph only and it deals with the Board of Control, which the Royal Commission in England recommended should be abolished. This is what the memorandum says:The Division unanimously decided and felt strongly about this matter. They were unanimously in favour of the Board of Control in Scotland being retained. It was felt that the lead shown by Scotland in mental health in the past and present is partly due to the independent nature of the board of control. It was felt that they should retain both their executive and administrative functions and their judicial powers. Also that the position was different from England and that Scotland was small enough for the Board of Control to continue to play a most active and practical part in he welfare of mental hospitals.I might add that I know personally some of the members of this Board, and I can vouch for their experience, their sense of responsibility and the assiduity with which they attend to their work.
I should like also to refer to a matter which may, in one sense, be not wholly relevant but which is referred to in one of the documents I have. In Section 62 858 of the Mental Deficiency and Lunacy (Scotland) Act, 1913, it is provided that a curator bonis, a judicial factor or receiver, may be appointed to safeguard a defective's property. The Board have power to make application to the Lord Advocate for the appointment of a curator bonis for any person whose property is, in their opinion, not duly protected owing to his mental incapacity, and that notwithstanding that such person is not being detained and taken charge of as a lunatic or mental defective. I understand that, since one of the functions of the Board of Control is to preserve both the health and the property of the patient concerned, it is possible where there is a small estate in question for the "authorised officer" to approach the Board of Control; then the Board of Control, I understand, approach the sheriff and the case is heard. An appeal is allowed by the person for whom the order is sought, and there is a judicial procedure by which a decision is given one way or the other.
But here I would cite the case of a man who, after a very promising early career and after showing distinct ability as a soldier in the war, unfortunately became a little unbalanced. He was sent into one of the mental hospitals, where he was given the usual treatment—insulin, and so on—and was not made very much better. He was then sent to another psychiatrist and after a time was advised to undergo what I regard (with great respect to the noble Lord, Lord Cohen of Birkenhead) as the barbarous operation of a prefrontal leucotomy. There followed a short time during which it was felt that perhaps this patient had improved; but after a little further time passed he became, in the words of his distressed father, nothing but a "cabbage". The personality of this individual was changed completely. Such funds as he had were not dissipated in the usual sense of being thrown away, but he had not the necessary intelligence to stand up for himself.
The question, therefore, arises: why should it not be possible in a case of that kind to obtain an order? It may be said that if the father himself were to apply there may not be difficulty; but, for obvious reasons, such as the fear of publicity and the suffering that he and the family have already had as a result of 859 their domestic tragedy, he would be very reluctant to make the application himself. If it be possible in the case of an individual with not very much at stake to get the authorised officer to make application to the sheriff (through the Board of Control), why should it not be possible to do so in this case, in which the facts are openly apparent, with the possibility of getting additional medical certificates if that should be necessary? Why should it not be possible to obtain a judicial order in this case, simply because the father, for understandable and laudable reasons, is reluctant to come out into the open and to say that he is an applicant? Is there nothing within Scottish law which would permit a judicial order to be obtained without the necessity for the father himself to apply? I am not asking for an answer to-night, but I hope that something will be done to overcome that terrible difficulty.
There is another kind of case to which I should like to draw the attention of noble Lords. A good living, upright, God-fearing woman unfortunately became mentally deranged, and, after treatments, again a prefrontal leucotomy operation was performed. I speak as a layman, but I was told that that woman has become a drunken, dissolute woman. It is a case of cause and effect, if you like; but again there was a change in character. What I have been asked to submit to the noble Lord is the question whether it is not possible for this woman, for her own good and for the peace of mind of the family with which she is staying, to go into a mental hospital. Why cannot she be taken again into a mental hospital and looked after there instead of being kept in her relatives' home? I do not know what the answer is to that question, and I simply put the question as it was put to me.
No one in the course of this afternoon's debate has referred to what has been a problem, and that is the certification of old people before they can be taken into a hospital or home when they have become senile. One hopes that now there will be no need to undergo the formalities of the past, and that these old and senile people will be taken in without undue formality and without having to be certified, because, as noble Lords well know, in spite of the improved attitude of the 860 general public towards mental illness in general, there are complications and consequences involved to members of a patient's family. There are consequences for other members of the family if a parent or any relative has been known to have been certified, notwithstanding the fact that the illness is not insanity according to the usual meaning of the word but merely part and parcel of senility and a process through which a person normally goes.
It is recognised that the recommendations of the Commission, if imposed upon local authorities in Scotland, will mean a considerable increase in financial expenditure, both capital and revenue. If I am any judge of their views, I would say that they feel that, while they admit to a shortage of accommodation, difficulties of staffing and a shortage of psychiatric social workers, they are prepared to co-operate in every possible way and willingly to undertake community care service if only there is some indication that the whole of the cost, especially the rateable part of the cost, will not devolve upon them. In regard to the liaison arrangements between different parties in this matter, noble Lords will be aware that when a patient is sent to the hospital authorities by the local authority there is, I think, a 100 per cent. grant. When a patient is dealt with through the education authority there is a grant of only 50 per cent. Some kind of liaison arrangement ought to be made whereby the financial difficulties may be fairly easily overcome.
I am reluctant to take up more of your Lordships' time. A great deal of what I should have liked to say is already included in memoranda that are available, and therefore I would end on this note. We all agree that the advances which are being made now in the treatment of mental illnesses are most encouraging. We have reason to believe, as the noble Lord, Lord Cohen of Birkenhead, indicated, that the advances in future will be extremely rapid. We all know, too, that the public attitude has become most receptive in regard to mental illnesses, and no longer is there quite the same fear as there was in the past—there is still some fear but it is not as great as it used to be.
We must, however, exercise caution in the introduction of changes of name and 861 terminology as have been suggested. I feel that there is a popular belief that the term "psychopathic personality" refers merely to an aggressive type of personality and not to the duller type. As noble Lords will be aware, if they have followed articles in the medical journals, there is a good deal of hesitation about the adoption of a term which has different connotations in different countries, and it would be better to clear this up before adopting it as part of the general terminology of this field. I would conclude on a hopeful note. While we have heard the staggering figures of the incidence of mental illness, it is true to say that some 30 per cent. of those suffering from severe mental illnesses recover spontaneously, whether treated or not, and one hopes that the other 70 per cent. will be amenable to treatment by up-to-date methods.
§ 5.52 p.m.
§ LORD COTTESLOE
My Lords, I am glad that your Lordships are devoting an afternoon to a discussion of this Report, even though it has had the effect of almost emptying your Lordships' House, because it is a matter of the greatest interest and importance, and it is one that is little understood by those who have not had to concern themselves with mental illness. Few of the public know the extent of mental illness and mental deficiency in this country at the present time; few realise what enormous strides have been made in the treatment of mental illness in recent years, and few appreciate the degree to which the law relating to such illness, which is the subject of the Royal Commission's Report, is out of relation with the facts and with the requirements of to-day.
The Royal Commission have done a great service in their full and careful consideration of these matters. To those of us who have to do with such matters their Report is an immense encouragement. I think that they are much to be congratulated on their realistic approach, and particularly on their unanimity, for unanimity is not the most marked feature of the discussions of those who concern themselves with mental disorders. As to the scale of mental illness and mental deficiency, of which I have said the public have little realisation at present, my noble friend Lord Feversham has given your Lordships the figures for the country as a whole. In my own hospital region, the North West Metropolitan 862 Region, where we have a population of about 3¾ million, we have, in round figures, 35,000 hospital beds in use, staffed and available. Of those beds, 18,000 are general hospital beds and almost as many, almost 17,000, are mental and mental deficiency hospital beds. These are the figures for a single one of the fourteen hospital regions in England and Wales, and they reinforce what my noble friend has said about the scale of the problem.
As to the progress that has been made in dealing with it in recent years, the figures of admissions to mental hospitals, given more fully by Mr. Vaughan-Morgan in another place, some of which were quoted by my noble friend Lord Cohen of Birkenhead, are very striking. They show that the national admission rate increased from 59,000 in 1949 to 88,000 in 1956; and, of course, an increase in the admission rate means a corresponding increase in the rate of discharge. Of the 88,000 admissions last year, no fewer than 69,000 were voluntary patients.
These figures are striking, but they are no more than symptomatic of the revolution that has taken place in recent years in the treatment of mental illness and in the whole approach to it. More and more, as the recesses of the human mind come to be explored and understood, it is realised that mental illness is not a thing apart. However distressing its manifestations, it is just an illness to be treated and cured like physical illness. Of course, it cannot always be successfully cured, and it is often very grievous. So is physical illness. But as mental illness is more fully understood, and as the techniques for its treatment are developed and perfected, so it is more and more widely understood that those who suffer from it should not be shunned and incarcerated, a race apart, but should be housed and treated, so far as may be possible, like sufferers from other illnesses and alongside sufferers from other illnesses. The pattern of the future is the open psychiatric ward, in or adjacent to the general hospital.
And just as preventive medicine and the development of clinic treatment is reducing the number of people who need to be treated in hospital for their physical ailments, so the development of psychiatric clinic treatment and of day hospitals 863 holds out every promise of great reductions in the number of mentally ill for whom residential treatment in hospital is essential. The work of Dr. Qerido, in Amsterdam, the remarkable figures of the Worthing experiment, which I think were quoted by my noble friend Lord Cohen of Birkenhead, and the results of the work being done in Toronto all tell the same story. There will always be sad and incurable cases, individuals who must be separated from the community at large. I do not want to paint an unrealistic picture, but the picture I have shown is, nevertheless, the background against which the present law relating to mental illness must be judged. When it is so judged, it is seen to be out of date, not quite so much out of date, but nearly so, as the eighteenth century concept of the mental hospital as a sort of prison into which the mentally ill could be conveniently thrown and conveniently forgotten. Against that background, it is no wonder that this Report, with its wise, understanding approach to these matters, is widely welcomed.
May I turn to one or two of its specific recommendations? The absence of legal formality over admission, the reduction of the use of legal powers of detention to the minimum necessary and the removal of the need for the "designation" of mental hospitals by the Minister—all these are clearly most desirable. I think, however, that the right of the hospital to refuse admission, which would emerge from the Commission's proposals, may need a little more thought. I fear that a difficult or unpleasant patient may sometimes be prejudiced unless some system can be devised, parallel perhaps to the system of medical referees operated by the emergency bed service in general hospitals, to secure the admission of a patient for whom hospital treatment is really necessary but whom no hospital is willing to accept.
Then the proposed repeal of the existing Lunacy, Mental Treatment and Mental Deficiency Acts, and the classification of patients into not two but three main groups, the mentally ill, the psychopathic and the subnormal, is, although there is some little question about the dividing lines between these groups, almost universally welcomed. I am bound to say that I cannot see very much to be gained by the use of the term "severely 864 subnormal" in place of the term "mentally defective", but these matters of terminology and definition are not easy. I think that even the most informed of your Lordships, if asked to define a psychopath, might feel somewhat like the man who said: "I cannot define an elephant, but I know one when I see it."
In Chapter 10 of the Commission's Report the recommendations for the development of hospital and community services for young psychopathic patients are, I think, universally approved. But I agree with my noble friend Lord Feversham, and with other noble Lords who have spoken, that in some ways the most important, and certainly the most controversial, section of the Report is that part of Chapter 10 which makes recommendations on the division of functions between the hospitals and the local authorities. I am sorry that my noble friend Lord Cranbrook cannot be here this afternoon. He is Chairman of the Eastern Regional Hospital Board, and this is a matter on which he has strong views. I do not think he would object to my telling your Lordships that he regards these recommendations as neither desirable nor logical. I should have thought that they were logical enough; but what really matters is not whether they are logical but whether they will work, and whether they will operate for the benefit of the patients.
Like my noble friend, I have some experience of local government, and I am happy to say that my Board have the closest and friendliest co-operation with and from the local authorities in our region. But I must admit to very real doubts about the practical effects that would result from the proposed transfer of patients and buildings from the care of the hospital authorities to the care of the local authorities. If such a transfer is to be carried through successfully, it will certainly need to be carried through with the greatest care and without any sort of undue haste. I was particularly glad to hear what the noble and learned Viscount the Lord Chancellor had to say on that matter.
Finally, there is the proposal that the Board of Control should be dissolved. I am quite sure that this is right, but I should like to say that in my region we have welcomed the reports made by the Board's Commissioners—and I think that 865 is the general view also of them in other parts of the country—which have at times been most helpful. I should certainly hope that some system of regular inspections of mental hospitals will be continued in some form, at least during the transitional period while the changes resulting from the Royal Commission's Report are being carried through; and I think there is a good deal to be said for having permanently some form of inspectorate. Many people suppose that the appointment of a Royal Commission is merely a convenient device for avoiding action on some matter of public interest; and certainly the fate of the recommendations of many Royal Commissions supports that rather cynical view. I hope that this Report will be an exception to the general rule, and that the assurance of the Lord Chancellor, that the Government accept the principal recommendations of the Report and intend in due course to introduce legislation to implement them, will be a tremendous encouragement to all those who concern themselves with these problems.
§ 6.6 p.m.
THE LORD BISHOP OF SOUTHWELL
My Lords, I should like to say a few words before the debate is finally wound up. To keep them as short as I can, I will cut out some tempting generalisations in which I had intended to indulge and confine myself to one particular point. It seems to me that almost all the questions raised by the Royal Commission's Report are concentrated in their most violent form in the State institutions. As the Commissioners themselves have said:The patients in Rampton and Moss Side Hospitals probably present more difficult problems than those at any other hospitals in the country.I happen to know something about Rampton, which has been very much in the limelight recently. There have been sensational articles in the Press; there has been a court case in which application was made to the Lord Chief Justice for a writ of habeas corpus on behalf of one patient, and a very sensational but tendentious book has been written around the story of that particular boy.
In one way and another, the whole setup of Rampton is very much before public opinion. A number of questions have been consistently and searchingly 866 asked, and replied to, if not answered, in another place in the course of the last few weeks. Public opinion is greatly concerned about this place, and alarming stories have got around about it. Rampton happens to be in my diocese, and naturally I know something about it. I go there periodically, and I conduct services in the chapel from time to time. The senior professional staff I know personally and well. This place does not pretend to be anything but what it is. Yet I do not know of any institution, whether run by the Church or by the State, in which I feel a stronger sense of vocation—I almost said dedication to a ministry—than I feel in the staff common room at Rampton. Here are people, able and dedicated men, doing a difficult and discouraging job under the most depressing conditions, and they deserve all the encouragement and support that anyone can give them. They are obviously wholeheartedly devoted to their patients and their work, no one more so than the medical superintendent.
They have almost everything against them. Rampton stands in most desolate country on the Lincolnshire-Yorkshire-Nottingham border—a map reference rather than a place. It stands in a kind of administrative no-man's-land between the Ministry of Health, the Board of Control and the Home Office. The staff there are largely cut off from the stimuli and amenities of normal life, and all the pressure is towards a kind of introversion from a claustrophobic kind of existence which is the one thing from which they ought to be spared. That is partly due to under-staffing. It is essential that these people should not be over-driven, and that the medical superintendent should have time to be seen freely, and should be constantly accessible to patients and junior staff. These people are able to say what the clergy say, which is that we could do the job much better if there were more of us.
I am anxious to see justice done for the reputation of a group of men who are being rather cruelly and, to my mind, most unfairly attacked and criticised. By their own offices, they are unable to say or do anything whatever to defend themselves. If there is anything wrong with the State institutions, it is not fair to blame it on the staff. I think that there is a lot wrong with Rampton, and I am not here to suggest that everything in the 867 garden is lovely. I am not here to whitewash it or to make it easy for Ministers to run away from the questions it raises. I am saying only what I believe to be true, and I should like your Lordships to believe that what I am saying now and what I will say in a moment I say entirely on my own responsibility. I have not been put up by anybody to say it; I am not anybody's mouthpiece.
Apart from the professional staff there is the nursing staff. There are many allegations running around now about brutal ill-treatment. Allegations are made everywhere. They are made continually in prisons; they have been made in nunneries before now, and I am not concerned to argue that there never has been or never could be a human failure. After all, an institution in which there was never a human failure would not be an institution in this sub-lunar world at all. Most of these stories have got about because of the book to which I referred, which has lately been published. The most damaging imputations there rest on a skilful use of innuendo rather than on evidence which a court would admit.
It must be remembered that in an institution in which the patients are, by the nature of things, not responsible for their actions—I use the phrase in the popular sense, and not in the sense of a legal definition—assaults on the nursing staff and the attendants are much more probable and, in fact, are more frequent than they are in prison. It must be remembered that patients are apt to do serious damage to themselves and to one another, or to the nurses, if they are not restrained. In the nature of things, from time to time it is inevitable that some degree of physical force should be used. But every attendant when engaged is instructed that in no circumstances must any force be used beyond the minimum necessary; and, secondly, that if he sees any patient ill-treated it is his bounden duty to report it. If there is widespread and general ill-treatment, that presupposes, does it not, a conspiracy, organised and absolutely watertight, embracing all the staff, all the medical officers, with the medical superintendent himself at the head of the racket, in which no human sympathy, no sense of duty, not even a physical desire to be sick, ever betrays an accomplice or breaks up the 868 ring. If your Lordships can think that probable, I cannot. Those are not the things that worry me.
I am going on for a moment to make one or two remarks about the set-up itself. The State institutions were erected for "defectives of violent or dangerous propensities". They are under the Ministry of Health, but they are not managed by the Hospital Management Committee, but by the Board of Control. Therefore, the Mental Deficiency Acts are, as it were, built into the structure of these institutions; and I believe that that has been half the trouble. The present Acts, as the Commission sayembrace attitudes which were current in the late nineteenth and early twentieth centuries, many of which are not generally accepted now".The first thing that worries me is the general mix-up of the population at Rampton. The Minister was asked lately in another place what proportion of the total population were there because they had been sentenced or convicted by the courts. The Minister, or his deputy, said that he did not know, which was, I thought, rather a give-away admission. I can tell your Lordships. Out of altogether 670 male patients, only 189 are there because they have been sentenced by a court or transferred from prison—that is, have been convicted of breaking the criminal law. They are the hard core, and in the interests of public safety some of them have to be kept under high-security regulations.
Of the remainder, 423 come from other mental deficiency hospitals because they cannot be adequately treated or controlled in other institutions. They are of all grades, from almost the sub-human with the physical stigmata of their affliction, through the epileptics and encephalitics and the whole spectrum, up to the people who, to the casual visitor like myself, appear to be perfectly normal when spoken to. Finally, there are 59 who have been transferred from Borstals or approved schools. At this point the Home Secretary comes into an already pretty complicated pattern. I want just to correct one false impression. It is widely believed—I used to believe it myself—that there are large numbers of children somehow mixed up with this unhappy crowd. That is not true. I think visitors see the children of the staff 869 families running around. There are only nine patients under 16, all boys, and they live in a hostel a quarter of a mile away, outside the perimeter of the institution altogether. The three of them who are capable of any education go to the local school; the rest cannot.
What really worries me—I do not know whether your Lordships will share my feeling—is the position of the people, the majority of the population here, who have not been sentenced or convicted by the courts. I do not forget that this is a hospital, not a prison, and I do not forget that the reason people come to these institutions is not because they have broken the law but because they are the kind of people they are. The basis of classification in these institutions is not the degree of a patient's criminality, not how much evil he has done, but the gravity of his mental disorder. That is understandable enough from a medical point of view, but it does mean that mental patients under treatment are, inevitably, living together with murderers, rapers, or goodness knows what in the same mental category. I find that sort of situation extremely hard to defend. The other point is that, though I admit that this place is a hospital, not a prison, nevertheless you have the hard core who have been sent there by the courts because they have broken the law, and all the rest because somebody thinks that they might do so one day if they were left at large. I do not know what the noble and learned Viscount the Lord Chancellor will think, but it seems to me terribly hard to defend that position or bring it inside the ordinary pattern of justice as understood in this country.
The Royal Commission urge that compulsory detention should not be applicable to psychopathic patients over the age of twenty-five unless they have actually broken the criminal law. It seems to me that here a whole group of extremely difficult questions have to be tackled.
Further, what about the young offenders, ex-Borstal boys and girls? I know some of them; I have confirmed some of them. To the ordinary casual visitor they seem to be perfectly normal. I know well enough that it is not so; that one has to be with them all the year round before one can judge that. But the official 870 answer is, "These people are here because there is nowhere else for them to go". They have run away from an approved school, or run away from Borstal—perhaps they have done it twice; and there is nowhere else for them to go. It seems to me there ought to be somewhere else for them to go and that, somehow or other, the Ministry concerned ought to feel an obligation to think up some alternative.
The boy Peter Whitehead, whose case touched off all the chain reaction about whom the book was written, ought never to have been sent to Rampton, I am perfectly certain. For that matter, he ought never to have been sent to any institution. His original crime was—as it is perhaps with 75 per cent. of the population in Borstals and approved schools—that he had been begotten by the wrong parents. What that boy needed was not institutional treatment, but guardianship or a foster-parent. The authorities obviously made a mistake. But that only underlines in my mind the recommendation of the Commission that everything possible should be done to widen the range of extra-institutional preventive and welfare work; and the more that is done the fewer of these unhappy people are likely to find their way into Borstals and then to some place like Rampton.
Finally, over the whole institution there broods the dark shadow of certification. I cannot speak too highly of the courage, the faith and the devotion of the staff—I hope I have made that clear. But over the whole place, like the shadow of a hawk, is the power of certification, with all its social stigma, with all its terror. As the law stands, these particular mental patients could not get mentally treated any other way, but by the same token they are all subject to an indeterminate sentence. It seems to me that that induces an awful sense of hopelessness and despair, a sense of having passed out of the world of human rights into a different kind of impersonal order, administered at the mercy of some remote control in London, the Board of Control, with whom one can communicate only on an official form. I believe that all that militates against the hope of recovery; it may make patients unco-operative and resentful, and therefore earn them disappointing reports 871 on medical examination and yet further prolongation of years of treatment. There are people who have been for fifteen or twenty years immured—many murderers are not in prison so long as that—and at the end of that time they are completely unfitted for any kind of normal life anywhere.
My Lords, I hope I have not tried your patience. I have tried to pay my tribute to the staff, who are being maliciously traduced in various quarters at the moment. I have tried to give a personal opinion, on my own responsibility, to draw attention to various matters which cause me, at least, a good deal of grave misgiving. I must not forget that this is a debate on the Report of the Royal Commission. The adoption of the recommendations in the Report would impinge upon the situation in the State institutions under three heads. First, it would involve a drastic scrutiny and restriction of compulsory powers. Secondly, it would mean bringing the institutions more directly under the Minister of Health, having them managed either by the ordinary hospital management committee or by a special board of experts, with strong local representation, to which the staff and patients would have easy and regular access. And thirdly (and I think most important of all), a heavy sense of grievance and fogs of despair would be rolled away by the setting up of the Mental Health Review Tribunals which the Commission recommends, to which both patients and their relatives should have, and should know that they have, regular and easy access. I believe that would do a great deal to bring about some sense of hope and confidence, and it would. incidentally, relieve the medical staff of an extremely onerous and invidious responsibility.
§ 6.31 p.m.
§ THE MINISTER OF STATE, SCOTTISH OFFICE (LORD STRATHCLYDE)
My Lords, this debate has well reflected, in my opinion, if only from the eminence on this subject of those noble Lords who have taken part, its very great importance. I think everyone who has taken part in the debate has welcomed and praised the Report, and I can assure your Lordships that the Government will give full consideration not only to what is contained in the Report but to all the 872 points that have been mentioned during the course of our debate to-day. My noble and learned friend dealt fully with the Report, and fully explained the Government's attitude towards it. In the course of his speech he also answered many of the points that had been made; but he left it to me to answer the point made by the noble Lord, Lord Pakenham, about the detention of psychopaths, and also to deal, so far as I am able, with the points that were raised by the noble Lord, Lord Greenhill.
Perhaps I might first deal with the point raised by the noble Lord, Lord Pakenham. The noble Lord suggested that persons of abnormal personality, including alcoholics and drug addicts, might be admitted to hospital for twenty-eight days' observation on two medical recommendations, but that admission for a longer period should be very restricted. Then he went on, I think, to suggest that if special hospitals were available it might then be reasonable for these patients while under observation to be ordered perhaps as much as six months' compulsory treatment. In attempting to deal with these interesting suggestions, I should like to make it clear, first of all, that the Royal Commission did not suggest that their psychopathic group should cover all alcoholics and drug addicts. The paragraphs in the Report which refer to the matter are paragraphs 338 and 339. There they pointed out that though psychopathic personality may result in addiction to drugs or alcohol, by no means all drug addicts or alcoholics could be regarded as having a psychopathic personality. They stress very strongly—and this is a point of great importance—that their proposals would not allow the compulsory detention of any person except on the basis of medical diagnosis of a recognisable mental disorder.
The suggestion by the noble Lord that a further period of treatment for alcoholics and drug addicts might be authorised while they were in hospital for observation would, of course, greatly extend the power of detention beyond that contemplated by the Royal Commission. I would suggest to the noble Lord, Lord Greenhill, that that also covers the point which he raised in connection with the woman who had received treatment and thereafter became a drunkard, and who he felt should go back into a mental institution.
I rise respectfully only to say to the noble Lord that, while my suggestions may have gone beyond the Report of the Royal Commission, that would not, in itself, be a refutation of my proposals. The noble Lord has simply informed me that my proposals differ from those of the Royal Commission. He has, so to speak, left it there, and, with the greatest respect, that does not exactly answer the proposal.
§ LORD STRATHCLYDE
The answer to the noble Lord's question was simply this: that the Commission said that their proposals would not allow the compulsory detention of any person except on the basis of medical diagnosis of a recognisable mental disorder, and that does not necessarily follow because the man is a drunkard or a drug addict. I think that that is the real answer to the noble Lord.
§ LORD GREENHILL
My Lords, may I also interrupt, to ask this question? The woman about whom I spoke had been in hospital; she had been treated and presumably cured. Then, as I suggest, she became ill again but is not being taken back into hospital, although, I should imagine, she is certifiable and certainly a nuisance to her family.
§ LORD STRATHCLYDE
That was exactly what I gathered from the noble Lord. If he will read to-morrow what I have just said, I think that therein he will find the answer to the point he was making.
My Lords, I am sorry to interrupt the noble Lord again, but it is not very late for the House of Lords, and I am sure that he will not mind my saying that my proposal was that a special institution should be established. The Royal Commission is not discussing that possibility, and, with all respect, I cannot consider that the noble Lord has answered my point in any way.
§ LORD STRATHCLYDE
I am sorry that the noble Lord feels that way. I have previously said that the noble Lord was seeking the establishment of further institutions. I am afraid I cannot deal with the matter any further. I feel that 874 I have adequately answered the noble Lord's point.
There are one or two matters that l should particularly like to mention. One is the need for suitable publicity on the subject of mental health, another the part that can be played by voluntary work in helping mental patients—that was a matter to which the noble Lord, Lord Pakenham, drew attention—and thereafter the points raised by the noble Lord, Lord Greenhill. The Royal Commission's Report received a great deal of attention in all sections of the Press when it was published. Similar notice was taken of the recent circulars issued by the Ministry of Health on informal admission to mental deficiency hospitals, which my noble and learned friend and other noble Lords have mentioned. Those were reported not only in the national newspapers but in a large number of local newspapers as well. The Government welcome the increasingly sympathetic attitude now generally adopted in the Press towards mental patients and the work being done for them by our hospitals and local health authorities.
It is, I think, most important that the general public should be well informed on this subject, and that the successes already achieved in driving out ignorance and prejudice should continue. Here, again, the Government welcome the work done by the National Association for Mental Health through its publications and by arranging conferences and lectures in all parts of the country. Both the Ministry of Health and the Department of Health for Scotland also help in a variety of ways. They maintain contact with the Press and with broadcasting services; they help to provide magazines and periodicals with suitable material, and they promote the acquisition of suitable films by the Central Film Library, from which they can be hired for public showing. As noble Lords may know, there is also the Mental Health Exhibition prepared by the Central Office of Information in consultation with the Ministry of Health, for the Ministry of Labour, which has been shown in different parts of the country on the initiative of hospital boards and committees who add local material to it. The showing of that Exhibition has been the occasion for the publication in the 875 provincial Press of many articles on mental health and mental illness.
All these things have two aims: to increase public understanding of the nature of mental health and disorder and of the achievements and problems of our mental health services, and also to stimulate people to take an interest and to give help—a matter which many noble Lords who have spoken consider of very considerable importance. As a result, some young people may become sufficiently interested to think of mental nursing as a career, and many others may be moved to give personal service in other ways. In the last few years there has been a most welcome increase in the number of voluntary workers who are visiting our mental hospitals and mental deficiency hospitals and taking an interest in patients there. In many cases these workers are organised into a League of Friends of the local hospital. There are to-day over one hundred of these. All have been formed since 1948. That number does not include branches of the National Society for Mentally Handicapped Children, who are very active friends to some mental deficiency hospitals. Her Majesty's Government are anxious that every mental and mental deficiency hospital should have its own organisation of Friends and hope that hospital authorities will give every encouragement to the formation of these bodies.
We are also grateful for the activities of the British Red Cross Society, the Women's Voluntary Services, the women's institutes and other bodies who are contributing in a very valuable way to the wellbeing of the patients in our hospitals; and I should like particularly to mention the work of the Boy Scout and Girl Guide movements in helping children and young people in mental deficiency hospitals. Voluntary work is, of course, as welcome in the local health authority services as in the hospital service. Local branches of the National Society for Mentally Handicapped Children now act at many local authority occupation centres in the same way as do parent-teacher associations at our schools; and we believe that that is a most welcome development. Local health authorities are glad to have both their support and their suggestions. The Society itself helps in a number of other ways. It has acquired the first short-stay 876 home for mental defectives, which is situated near Liverpool and is now run on their behalf by the National Association for Mental Health. We have in Scotland a similar home opened by the Association of Parents of Handicapped Children, and in these homes mentally defective children can be looked after for short periods to enable the rest of the family to overcome some temporary problem or to have a holiday.
The noble Lords, Lord Cohen of Birkenhead, and Lord Feversham, and others, have stressed the importance of research, and from that point of view it is interesting to notice that the Society has recently financed a research unit which will undertake at least a three-years' study of the problems of training mentally handicapped children in occupation centres and will seek new and improved methods of training. Unfortunately, it is not so easy for voluntary workers to help the local health authorities by home visiting because, as your Lordships will realise, that needs a good deal of experience of the special difficulties of the mentally ill and the mentally defective.
May I turn now to matters raised in relation to Scotland? We have realised for quite a considerable time the need to revise the mental health laws of that country. As one noble Lord has said, it was as long ago as 1938 that a Committee under the chairmanship of the noble Lord, Lord Russell, was appointed, and it was only due to the war that it was unable to report until 1946. As we were then on the eve of setting up the National Health Service, it was only natural for proposals for legislation to be delayed until the Committee's recommendations could be reviewed against the new administrative arrangements. Then there was the White Paper of 1955, which gave the proposed lines of new Scottish legislation as a basis for discussion; but, unfortunately, again by that time the Royal Commission had been appointed, and although the Commission were not concerned with the law of Scotland, it seemed desirable to await their findings and reconsider the problem in the light of them.
Many of the matters dealt with in the Report of the Royal Commission were not touched upon in the Scottish White Paper, but its main proposals followed 877 the same principles. It proposed to simplify voluntary admission to mental hospitals by doing away with the need to obtain the sanction of the General Board of Control. It is also of interest that in some respects the proposals of the Royal Commission are similar to the present Scottish law. The Royal Corn-mission propose, for example, that there should always be a medical recommendation where compulsory admission is arranged in an emergency; and where there is no emergency or the patient is detained beyond three days, that there should always be two medical recommendations. That, of course, is the existing law in Scotland.
In carrying out a revision of the Scottish law we shall, of course, have full regard to any special circumstances in Scotland. That was a matter on which the noble Lord, Lord Greenhill, laid a good deal of stress. It is for that reason that my right honourable friend the Secretary of State has asked for, and is now receiving, the views of the local authority associations, regional hospital boards and interested professional and other bodies on the application of the Royal Commission's proposals to Scotland, in the light of the White Paper. He has also asked the Scottish Health Services Council for their advice, which he expects to receive within the course of the next few weeks. These consultations are well advanced, but until they are completed we cannot say what Form any new legislation for Scotland w ill take. But the debate that we have had to-day will I am sure make a valuable contribution to the final picture.
§ LORD GREENHILL
My Lords, before the noble Lord passes from that matter, would it be in order for me to refer to the new category of "recommended" class of patient, which is mentioned in the White Paper? My impression is that that is not a favoured title for that particular class.
§ LORD STRATHCLYDE
My Lords, that will he considered as we get the views of the various bodies whom I have mentioned. The noble Lord put to me one further point which I feel I should endeavour to answer. He suggested that the General Board of Control for Scotland should be retained, and in doing so he drew attention to the difference in the composition of the Scottish Board as 878 compared with the English Board. I appreciate the point that the noble Lord has made, but that matter also will be left to be considered with others in consultation with the various bodies whom I have mentioned. What he has said illustrates the sort of difference we have to bear in mind in considering what form Scottish legislation should take.
There was one other point which was made by the noble Lord. He expressed doubt about the wisdom of informal admissions to mental deficiency hospitals, such as those referred to in the recent Ministry of Health circular. The noble Lord himself, however, said that maximum freedom consistent with public safety and the welfare of the patient must be the guiding principle in this matter. And my noble and learned friend has stated that informal admission will be used, except where it is necessary for the hospital to have power to detain the patient. The law of Scotland is different, and we are looking into the matter and hope to make an announcement very shortly. But I can assure the noble Lord that we, too, will be guided by the principle to which I have referred.
The right reverend Prelate (who seemingly has left us) spoke about the situation of the Rampton Hospital. I should like to thank him, on behalf of Her Majesty's Government, for his tribute to the work being done at that hospital, which has recently been subjected to some unjustified and irresponsible criticism. And I would add that my right honourable friend the Minister of Health does, and will do, whatever he can to safeguard the rights and reputation of the staff. The patients in this particular hospital are, in fact, classified according to their mental condition. Whether they have been before the courts before admission seems to be irrelevant in regard to the treatment they receive. My Lords, I have endeavoured to answer, evidently not to the full satisfaction of some noble Lords, the various points which have been raised during the course of the debate. I would now just express thanks to all those who have taken part in it.
§ 6.53 p.m.
THE EARL OF FEVERSHAM
My Lords, may I, in a few words, voice my thanks to those noble Lords who have been so good as to give us, from their experience and knowledge, most valuable 879 views on this Report. The debate has ranged over a wide area, and has covered aspects of mental health and mental disorder which will be of great benefit to all those who work in this field. I am particularly indebted to the noble and learned Viscount the Lord Chancellor for the great courtesy that he has extended in answering so fully the remarks that I made. I am quite sure that when all those engaged in the field of mental disorder have the opportunity of reading the remarks that fell from the noble and learned Viscount they will be encouraged to believe that the Government intend to take action as soon as it may be possible to do so. In any event, we are now assured by the most responsible source of Her Majesty's Government that the recommendations of this Royal Commission have received a most favourable reception, and that it is only a question of convenience and time before the Government bring in what the noble and learned Viscount described as a major Statute.
The noble and learned Viscount, with his precise and logical mind, enabled us, I think, to see more clearly the implications of the legislation that this Report involves. In the same spirit in which I accept his plea in mitigation, I hope that the Government will receive the observations which have been made in this debate. I am sorry that the noble and learned Viscount the Lord Chancellor made no reference in his remarks to my suggestion, and that of the noble Lord, Lord Cottesloe, that there should be an inspectorate to ensure the right development of the mental health services in the future. I cannot help feeling, also, that his reply to my questions about funds for research and in regard to social workers was perhaps a little embarrassed. I hope, in any event, that my right honourable friend the Minister of Health and the noble and learned Viscount, as indeed he has promised, will give further consideration to these points.
§ THE LORD CHANCELLOR
My Lords, I am sorry that I did not mention the inspectorate. It is an interesting and a difficult point, and I shall bring it to the attention of my right honourable friend for consideration. It was my fault that that matter went out of my mind, and I should not like my noble friend 880 to think that I was avoiding his point in any way.
THE EARL OF FEVERSHAM
My Lords, I thank the noble and learned Viscount for saying that the matter will receive consideration.
The noble Lord, Lord Pakenham, was good enough to endorse the gist of my remarks. I am glad to reciprocate and to say that I agree with a great deal that he said—particularly on the point that the classifications and designations under the new terminology require very careful consideration. Secondly, I would say that I was impressed by the emphatic way in which the noble Lord said that the area borderline (as he described it) between sickness and behaviour should be the subject of more research. The noble Lord, Lord Cohen of Birkenhead, clearly held the attention of your Lordships' House to a very marked degree. I am glad that he was able to contribute an expert medical view on this vast problem and, indeed, to tell us something of the advances that have been made and of those that are still desired. I could not agree more, my Lords, when he says that co-operation between the various arms of the mental health service depends on good will. That is the key to the whole question; and I endeavoured to quote examples of this. I feel sure that your Lordships' House will share the opinion with me that this debate on the Report of the Royal Commission headed by the noble Lord, Lord Percy of Newcastle, has fulfilled a very useful purpose, and that good and useful contributions have been made this afternoon which did not appear when the subject was under debate in another place last July. I now beg leave to withdraw my Motion.
§ Motion for Papers, by leave, withdrawn.