§ 4.7 p.m.
§ Report stage resumed.
§ THE LORD CHANCELLOR
My Lords, this is a drafting Amendment consequential on Amendment No. 2. I beg to move.
Page 3, line 7, leave out ("accompanied by") and insert ("including").—(The Lord Chancellor.)
§ On Question, Amendment agreed to.
§ Clause 5 [Informal admission of patients]:964
§ THE LORD CHANCELLOR
My Lords, this is also a drafting Amendment, designed to simplify and clarify the clause. It does not make any change of substance. Unless any noble Lord has any point, I do not think I need occupy any more time. I beg to move.
Page 3, line 16, leave out Clause 5 and insert—
§ Informal admission of patients
§ ("5.—(1) Nothing in this Act shall be construed as preventing a patient who requires treatment for mental disorder from being admitted to any hospital or mental nursing home in pursuance of arrangements made in that behalf and without any application, order or direction rendering him liable to be detained under this Act, or from remaining in any hospital or mental nursing home in pursuance of such arrangements after he has ceased to be so liable to be detained.
§ (2) In the case of an infant who has attained the age of sixteen years and is capable of expressing his own wishes, any such arrangements as are mentioned in the foregoing subsection may be made, carried out and determined notwithstanding any right of custody or control vested by law in his parent or guardian. ").—(The Lord Chancellor.)
§ On Question, Amendment agreed to.
LORD GRENFELL moved, in subsection (2), to add to paragraph (b):
and the provision of adequate numbers of suitably trained and remunerated staff".
The noble Lord said: My Lords, this Amendment was originally put down on Committee stage by my noble friend Lord Pakenham, who unfortunately has found it impossible to be here to-day. I have put it down again because, with all due respect to the noble Earl, Lord Onslow, I was completely unsatisfied with the answer which he gave. In one place, he said [OFFICIAL REPORT, Vol. 217 (No. 88), col. 123]:
It would not be helpful to provide in the Bill that staff should be suitably trained, since this would require some definition and interpretation.
That is precisely what I hope to attain. Teachers in occupation centres for children or adults, whether in hospitals or in local authority institutions, do not come under the Education Acts. The pupils in these centres are technically ineducable. As I interpret this Bill, it is designed at long last to remove the stigma of lunacy and treat all cases as normal illness which every endeavour will be made to cure or alleviate. The whole happiness of a mentally handicapped child is bound up
in the very specialised training the child receives in its early youth. In one letter received from a mother, she said that when the doctor told her that she had a mongol child, he said, "All you can do is to love her very much." That was not only defeatist but the worst possible way to help the mother.
§ We know that almost all mentally handicapped children and adults will respond to good teaching, and all are keen to learn. The training is very specialised and there are special techniques which have proved most helpful in this training, which is quite different from that of a normal child. As the children are classified as ineducable the teachers are not required to have qualifications laid down under the Education Acts, nor do they receive the rates of pay laid down under those Acts. They receive the Whitley Council rates, ranging between £435 to £765, and may get more if they are teaching adults when a special craft qualification is required. These rates are for those who have qualified for a diploma of the National Association of Mental Health. The remainder get less at all stages. Courses run by the Association and some local councils are the only training these people get, and many more could be trained if the courses were enlarged and if more money were available.
At this stage I should like to tell your Lordships that I was delighted to receive a letter today from the National Association saying that as there have been such heavy demands for places in their courses, a third full-time course sited in Bristol will commence in September 16. They go on to say:
In addition, there is an in-service course running in Newcastle, and again, owing to demand, a further course of this nature will commence in London at the end of September.
That course will spread over two years. They go on to say:
It is anticipated that by the end of the current year there will be some 125 students in training. These include to date some new intake, a high proportion of seconded students"—
that is to say, those who are already teaching when they come to the schools.
I should like to return for a moment to the question of pay. Before one can establish scales of pay for a profession it is naturally necessary to establish the fact that the profession concerned does exist. The teachers in the centres are
at present of no official profession; hence their pay, within limits, is established by negotiation with the local authorities, and very little advancement is gained by taking a diploma. Noble Lords will note that this Amendment puts no obligation on the Minister to make training and adequate remuneration a requirement for teachers at these centres, but merely empowers him to authorise or to require the local authorities to provide centres or other facilities for training or occupation, the equipment and maintenance of such centres
and the provision of adequate numbers of suitably trained and remunerated staff.
I feel that the time has come when consideration must be given to this all-important question of training and pay, and I hope that my noble and learned friend will be able either to accept this Amendment or to give us a far better answer than was given on the Committee stage. I beg to move.
Page 4, line 9, after ("centres") insert the said words.—(Lord Grenfell.)
§ 4.14 p.m.
§ LORD STONHAM
My Lords, I wish to support this Amendment moved by the noble Lord, Lord Grenfell, and I want to devote my few remarks to an examination of the reasons which were put forward by the noble Earl, Lord Onslow, for rejecting a similar Amendment during the Committee stage. I would point out, first of all, to the noble and learned Viscount on the Woolsack that the Government have already declined to make these general powers mandatory on local authorities. Therefore, in asking that, if they are required to provide centres, they should be adequately staffed we cannot be accused of rushing things; because if training facilities were not adequate, if it was not possible to provide staffs properly trained, then the Minister would not require local authorities to set up the centres. There is no question here that we are suggesting something that is immediately impracticable, because if it were, it would not be required to be carried out.
We consider it absolutely vital that the centres should be staffed by people who are properly trained and remunerated, and almost every reason given to us in Committee by the noble Earl, Lord Onslow, for not accepting the Amendment which 967 was then moved was, in my view, a reason for accepting it. He asked us not to pursue it on the Committee stage. We know that in this country there is one county that spends as little as 3d. per head, and one county borough which spends as little as 8d. a head, on this branch of local authority service. Yet we were told it was thought unnecessary to single out this particular branch for the direction that they should be adequately staffed. We were told during those discussions—and I believe this to be true—that there is at present no shortage of adequate training facilities, and that if a shortage develops it will be met by the provision of additional facilities. So that there is no excuse for not demanding that we have qualified staff in the centres. As I see it, as the Bill now stands the less enlightened of local authorities could, if they wished, meet this demand by having minders and not teachers. That is why we want to press for the provision of adequately trained and properly paid staff.
In the previous discussion, in one and the same paragraph we were told that the requirement that staff should be properly trained would need definition; that the diploma of the National Association of Mental Health would be too restrictive, and that in any event the Minister could prescribe qualifications under Section 66 of the National Health Service Act, 1946. Since the Minister can do that, and include some other at present non-existent qualification, what is to prevent these words from going into the Bill? As for it being unwise to single out the remuneration paid to particular officers, the noble Earl, Lord Feversham, made it clear that they were not included in the terms of reference of the Young-husband Committee. I should have thought that was a very good reason for our taking care of that point in this Bill.
I believe that these centres, which have been so eloquently and movingly described on previous occasions by the noble Lord, Lord Grenfell, if properly run by adequately trained, contented staff, who come into this service as a career, a life's work, can prove the most effective and at the same time the cheapest way of dealing with mentally retarded people. I think it would be an act of wisdom, and even an act of good faith, for the Govern- 968 ment to accept this Amendment, and then to implement the provisions of this subsection with all the vigour and determination they can command. I hope that they will do so.
THE EARL OF FEVERSHAM
My Lords, I feel that I must speak to this Amendment for two reasons: first, because, as Chairman of the National Association for Mental Health, which is the authorised body for training the supervisors and teachers of the mentally handicapped, I have gone into the present position thoroughly; and, secondly, because I found occasion to interrupt my noble friend Lord Onslow in his reply given on behalf of the Government. It is clear from the previous stage when this Amendment was discussed that I join the movers of the Amendment in supporting the need for trained personnel to be established at the ever-increasing number of centres now provided by local authorities for the mentally handicapped. I have been in touch with my right honourable friend the Minister of Health and I am quite sure that it is his intention at the earliest opportunity to impress upon local health authorities the desirability of appointing trained staff wherever possible He does not feel—and I think with some justification—that we have yet reached a stage when it would be practicable to make the possession of a recognised qualification, whether it be a diploma under my own Association, the National Association of Mental Health, or a teaching qualification, or some other form of appropriate qualification, a necessary condition to employment for all staff at the centres.
We all know that we are now—and I am particularly in a position to know—moving towards the position of having at any rate the senior members of the staff at centres with qualifications. I think there is something in the view expressed by my right honourable friend the Minister of Health that it would not be reasonable at this moment to require that qualifications be possessed by junior staff as well. It is obvious that, when the supply of trained staff justifies it, my right honourable friend the Minister will consider whether he should use his powers which exist under Section 66 of the National Health Service Act to make the possession of a suitable qualification necessary for future appointments.
969 Therefore the issue is that if this Amendment were passed at this stage it might, as I see it, have the opposite effect of the intention of the movers, and that is that there would be a shortage of trained teachers owing to the increased number of centres, particularly for adult mentally handicapped. It would surely be better to have untrained staff as at present in the junior posts than to have no staff at all. Keen as I am to see that the object noble Lords have in mind is fulfilled at the earliest date, I believe it would be better to rely upon the good word that my right honourable friend has personally given to me, as Chairman of the Association, that we are the authorised body to run these courses, rather than to insert it in the Bill at the present time.
§ THE LORD CHANCELLOR
My Lords, I should like to follow my noble friend Lord Feversham and say, first of all, a few words about what we are trying to do in this clause, and then to say some general words about training in order to emphasise again the importance which we attach to it. I would say to all noble Lords who have spoken that we have considered with care what was said in the Committee stage, and with a great deal of sympathy for the intentions expressed.
As to the placing of this Amendment, I think we have been to some extent at cross-purposes because of a misunderstanding of what we are trying to do in Clause 6. Your Lordships will remember that it was one of the basic recommendations of the Royal Commission that the mental health services should be an integral part of the National Health Service, and that proper standards should be secured by the same means as are used in relation to other health services. Special legislation is not needed to secure the provision of mental health services by local health authorities, and we have not attempted in Clause 6 to set out all the functions which they are to exercise in providing community care. The main source of their functions in this regard is Section 28 of the National Health Service Act, 1946, the powers under which may—and, as we have explained, will—be converted into duties by direction of the Minister; so one does cone to the duties there.
970 Noble Lords may well say to me, "What is the purpose of Clause 6?" I should like to develop that matter, and I hope your Lordships will not mind if I take a little time on this, because it is a matter of great interest. The main purpose of Clause 6 is to make clear that these powers include certain functions which in the past have either been in doubt or have been provided under other Acts which are to be repealed under the Bill. Residential accommodation, for example, is specifically mentioned, because some local authorities had doubts about the extent of their Section 28 powers. Training and occupation centres are mentioned because they have been previously provided under Section 30 of the Mental Deficiency Act, 1913, and it is necessary to make clear that after that section has been repealed they may be provided under the general powers under Section 28. There is, however, no need for any additional clarification so far as the staff of these centres are concerned. The power to provide the centres implies the power to start them properly; and, similarly, when the power is converted into a duty by the Minister's direction there will be a duty to staff them properly. The intention of the Amendment is therefore already achieved.
An adequate supply of properly trained and remunerated staff is, of course, needed for every National Health Service function. It is unnecessary to say so in the Act, and it would be quite inappropriate to say so in respect of this category of staff alone. The arrangements for ensuring that local health authority services are adequately staffed are normally covered in the schemes submitted to the Minister under Section 20 of the National Health Service Act. When the Minister issues his direction under Section 28 he will also call for revised proposals under Section 20 in the light of that direction. The submission and approval of these proposals will entail a review of the existing and future staffing of training centres both by the local authorities and by the Minister. So far as remuneration is concerned, that can be dealt with only by negotiation through the established negotiating machinery.
The noble Lord, Lord Stonham, drew attention to-day to the fact that the training centre staff were outside the 971 terms of the reference of the Young-husband Committee, who made a number of recommendations about the remuneration of local authority social workers. Any revision of the remuneration of social workers will be a matter for negotiation, as it will in the case of the training centre staff. That is the position. There is no doubt, in my view, that the duty will exist, although it arises in the way that I have mentioned. That way of arranging matters has its basis in what I consider an important recommendation of the Royal Commission—namely, that the mental health services should be assimilated into the National Health Service. Therefore, I think it is the better way.
I want to make clear, as regards training, that my right honourable and learned friend is very much aware of its importance in this field. At present, as I think my noble friend pointed out during the Committee stage, my right honourable and learned friend gives financial assistance to the National Association for Mental Health, who provide bursaries for staff attending their training course. He also encourages local health authorities to release their staff to attend courses, and he intends at the next convenient opportunity to impress on local health authorities the desirability of appointing trained staff whenever possible. As my noble friend Lord Feversham said, my right honourable and learned friend does not feel that we have yet reached a stage when it would be practicable to make the possession of a recognised qualification—whether the diploma of the National Association for Mental Health or a teaching qualification or some other appropriate qualification—a necessary condition of employment for all staff at the centres. I am glad that my noble friend appreciates the position in that regard. We are moving towards the position of having at any rate the senior staff of centres with qualifications, but it would not yet be reasonable to require qualifications to be possessed by junior staff as well. When the supply of trained staff justifies it, my right honourable friend will consider whether he should use his powers under Section 66 of the National Health Service Act to make the possession of a suitable qualification necessary for future appointments.
972 My Lords, I am conscious that I have been repeating very largely what my noble friend Lord Feversham said, but I think it is perhaps of some importance and value that I should say that to your Lordships, so that it is stated quite clearly in this House that that is the ministerial view. I think one ought to remember that local authorities are responsible bodies, who appoint a great variety of specialist staff, and that in general they are fully competent and are anxious to appoint properly qualified people without being required to do so by the Minister. I say that only because I should not like any words of mine to be taken as a reflection on the attitude of local authorities, because I hope and believe that they share the anxiety which we feel in this House for an improvement of the position. But though I believe that the local authorities fully appreciate the value of the training courses run by the National Association for Mental Health—and that is shown by the increasing pressure on those courses—nevertheless your Lordships are entitled to ask what is the ultimate sanction. The power to make regulations prescribing qualifications is there in the National Health Service Act, for use if necessary, and I do not think it is necessary to put an additional power in the Bill.
The main practical question at present is whether training facilities for the staffs of these centres should be expanded. The National Association for Mental Health is already arranging to provide an additional training course, and the Minister is reviewing the position himself to see what further facilities may be needed. He has asked me to say that he will keep very much in mind the concern which has been expressed in the debate, and your Lordships may take it that the question of training will always he very much in his thoughts. In these circumstances I hope that noble Lords will not feel it necessary to press the Amendment on this occasion; but I am grateful to them for putting it down again, because it has given me the opportunity of stating quite clearly that your Lordship's interest in this matter is generally shared. The matter is not one which we are going to allow to sleep.
My Lords, I should first of all like to thank my noble and learned friend for a very lengthy and very good answer. I think he will 973 agree it is an improvement on the last one we had. With the advice of my noble friend Lord Feversham, and the realisation that both the right honourable gentleman the Minister and my noble and learned friend the Lord Chancellor know how important we feel this matter is, I beg leave to withdraw the Amendment.
§ Amendment, by leave, withdrawn.
§ Clause 10 [Welfare of certain hospital patients]:
§ THE LORD CHANCELLOR
My Lords, I think I can give your Lordships a certain amount of relief in dealing with this Amendment, because it really covers twelve Amendments. If your Lordships will allow me to indicate how it does that I think it may save a little time, without in any way lessening your Lordships' command over our proceedings. This is the first of a series of drafting Amendments, the object of which is to bring together into two new clauses a list of the provisions of the Bill which are to extend outside England and Wales. If your Lordships would be kind enough to look on to the new clause after Clause 148, and the other new clause for insertion after Clause 149, you will see that the former lists the provisions which extend to Scotland and the second those which extend to Northern Ireland. The provisions which are not mentioned in those clauses do not extend outside England and Wales. In this way it is possible to take out a number of references to extension to Scotland and Northern Ireland which are at present scattered through the Bill. The Amendments do not make any change to the extent to which the Bill applies outside England and Wales. The Amendments in the series are Nos. 40 and 42, to which I have just referred, which introduce the new clauses, and the following paving or consequential Amendments which delete existing provisions: Amendments Nos. 6, 7, 23, 24, 30, 32, 33, 34, 35, 38, 39 and 43. There are, as I said, twelve Amendments, and two new clauses. I hope your Lordships will think this is a convenient method of drafting; and I beg to move the first Amendment.
Page 6, line 11, leave out from beginning to ("by").—(The Lord Chancellor.)
§ On Question, Amendment agreed to.974
Page 6, line 42, leave out from ("effect") to end of line 43.—(The Lord Chancellor.)
§ On Question, Amendment agreed to.
§ 4.39 p.m.
§ LORD TAYLOR moved, after Clause 13 to insert the following new clause:
§ Regional Hospital Boards
§ ".—(1) Nothing in Part II of this Act shall be construed as removing from regional hospital boards or hospital management committees any of the functions exercised by them under the National Health Service Act, 1948, in respect of the treatment of patients outside hospital.
§ (2) Local health authorities shall consult with regional hospital boards and hospital management committees in making arrangements for the care and after-care of patients suffering from mental disorder.
§ (3) Joint schemes between local health authorities and regional hospital boards and hospital management committees for the care and after-care of patients suffering from mental disorder may be made, and the cost of such joint schemes may be divided between the authorities in any manner agreed between them, subject to the approval of the Minister.
§ (4) Local health authorities may secure provision for the care and after-care of patients suffering from mental disorder by means of agency arrangements with regional hospital boards and hospital management committees."
§ The noble Lord said: My Lords, I beg to move this Amendment standing in the names of my noble friend and myself. When my noble friend Lord Stonham and I put down a similar but rather longer new clause on the Committee stage, the noble and learned Viscount the Lord Chancellor was good enough to say that he would give full consideration to the speeches of my noble friend and myself. What we were then seeking, and what we are still seeking, is not necessarily that this clause should be accepted by Her Majesty's Government—indeed we shall be perfectly happy if it is not accepted—but that the Government should publicly declare a policy in line with the contents of the clause. I think there was general agreement in your Lordships' House about the contents of the clause, and about its importance, and the noble and learned Viscount the Lord Chancellor has been good enough to send me a copy of Circular 8M/59/46, which the Minister of Health has addressed to Regional Hospital Boards, hospital management committees, and boards of governors.975
This is a most helpful circular. In effect, it endorses subsection (1) of our new clause. It endorses the idea of joint appointments of consulting psychiatrists, psychiatric social workers and mental welfare officers by local health authorities and Regional Hospital Boards so that their salaries can be shared. Moreover, it says—and here I quote:
The Minister hopes that co-operation between hospitals, general practitioners and local authorities will continue and be extended in the ways just described and in any others which are found useful.
I should like to ask the Lord Chancellor three specific questions. Do these words:
co-operation…in any other ways which are found useful
include the following: first, joint committees of hospital management committees and local health authorities, as for example are at present satisfactorily existing at York? We should like to feel sure that such committees can continue under the new arrangements. Secondly, do these words include the use of agency arrangements by local health authorities to discharge their duties? This perhaps is a less important point, but it is an important point because it may happen that a Regional Board can sometimes do the job for a local authority, particularly in these early stages; and one does not see why, if that be so, the local authority should not pay the Regional Board for doing it. Thirdly, do the words include the question of the division of expenses as to premises which are shared, as well as the division of salaries which is expressly stated? Again, such arrangements exist at York. There is a central clinic which is run jointly by the local health authority and the Regional Hospital Board, and I understand that the cost of the premises is shared. If, as I hope, the words in the circular do include arrangements of this type, then the intention of the new clause has been fully met and I should be most happy to withdraw it. I beg to move.
After Clause 13, insert the said new clause.—(Lord Taylor.)
THE EARL OF FEVERSHAM
My Lords, before my noble and learned friend replies, I should like to make this observation. In the first place, the noble Lord, Lord Taylor, in moving a similar 976 Amendment on the Committee stage, made reference to the valuable work that was undertaken by the comprehensive committee of the City of York, with which I am closely connected as it is my home town. I should like to say that I entirely endorse everything that the noble Lord, Lord Taylor, has said as to the advantages of Regional Hospital Boards and local authorities getting together with the expert personnel, both medical and social workers, to effect the underlying purpose contained in this Bill. Therefore, I am one of those who greatly favour the insertion of subsections (1), (2) and (3) of this new clause, on the assumption that not all will read the circular to which the noble Lord, Lord Taylor, referred, directed by my right honourable friend to Regional Hospital Boards, nor will they necessarily read the circular which my right honourable friend sent out, only a short time ago, to local authorities, Circular 9/59, which said very much the same thing except with that emphasis to the local authorities.
I think there is a certain category of person who will pay attention to what is provided by Statute, in a section of a new Act. Your Lordships will all have individual opinions as to how much circulars emanating from Government Departments in fact get read by the officials of committees as well as by the personnel of those committees. I would suggest that although this may be repetition of what my right honourable friend has already sent out in circular form, such repetition does no harm whatsoever.
But I would submit that there should be some hesitation with regard to subsection (4) of the Amendment, which the noble Lord who has moved it has suggested would enable certain valuable undertakings governed by the Regional Hospital Boards to continue in the interim period until the local authorities are sufficiently organised to assume this similar responsibility. The whole intention of the Bill is that in after-care and, indeed, pre-care, the local authorities should be the responsible authority for community care. That is something that all noble Lords who have taken part in the various stages of the Bill have been insistent upon. I think the Amendment provides a loophole for the backward or recalcitrant local authorities not to fulfil their obligation, either under the provisions of 977 the Bill or by the regulation of the Minister, by merely asking the Regional Hospital Board to act as an agency. For that reason, I would strongly suggest that your Lordships should reject subsection (4) of this Amendment, because I think it is contrary to the whole underlying principle of the Bill.
§ LORD STONHAM
My Lords, I am extremely grateful to have the support of the noble Earl, Lord Feversham, for three-quarters of the Amendment, even though he opposes the other quarter. If the noble and learned Viscount is able to give my noble friend the sort of assurance for which he asks, I shall be happy at the withdrawal of the Amendment. But I find it rather strange that we are talking in terms of doing all this by regulation, and yet, at a little later stage of the Bill, we shall be invited to accept an Amendment of the Lord Chancellor which will compel Regional Hospital Boards to designate, as it were, certain hospitals for the reception of emergency patients. I know that that will meet an Amendment which was moved in Committee by the noble Lord, Lord Milverton, and which we on this side support. Here we are putting that into the Bill but not those other considerations. I am a little afraid that Regional Hospital Boards will thereby feel themselves in a state of inferiority in matters of this kind, which I think will be a most unhappy thing.
What I believe will happen in most cases is that there will be a partnership between the hospitals and the local authority. But we wish to do everything in this Bill to encourage this feeling of partnership and not to let there be any feeling that one is more important than the other. The noble and learned Viscount may recall that during the Committee stage I gave details of a mental hospital group that I know very well, and of the most impressive action that they took as long ago as last January. In the short period since we discussed this matter on Committee stage—a week or so—I have had details from them of a most comprehensive and heartening scheme which they have already put forward and which has already had the approval of the Regional Board, wholly and completely designed to secure the co-operation of the local authorities.
They have even got one of the things in it that the noble Earl mentioned— 978 for example, that the medical officer of health and someone else on the local authority should actually sit on the medical advisory council of the hospital, having absolutely complete integration in that way; bringing in the general practitioners; using, as it were, the department of the county medical officer of health as a clearing house or otherwise, in deciding whether patients should or should not go on to mental hospitals, and suggesting fully that they are going to run in conjunction with the local authorities. That is a tremendously heartening initiative coming from the hospital. But as yet, so far as I am aware, there has been no answering response from the local authority, although it may be the case that the local authority is not yet in a position to respond, and may not be in such a position until this Bill becomes an Act, and until they hear from the Minister.
I am sure, not only from this instance, but from what the noble Earl has said, and from other instances, that the initiative, at least in the first place, for this co-operation is coming from the hospitals who are, I think, using the trained staff and getting people to see in this Bill a tremendous opportunity which they need to seize with both hands. I therefore hope that nothing of any kind will be said or done, and that in legislation we shall avoid doing anything to suggest that there is a question of inferiority on the part of the hospitals, because if in any way this initiative were frustrated or stultified we should be doing a great deal of harm to the people we want to help. I am quite sure that the Government's intentions are right in this matter, but I want to emphasise once more that they must have the fullest possible regard for the wealth of experience and enthusiasm which resides in the mental hospitals, and must ensure that no part of their initiative is stultified, but that it is encouraged in every possible way, so that they may work together and live together with the local authorities in this matter.
§ VISCOUNT ASTOR
My Lords, I should like to take up what the noble Lord said about circulars. I know from long experience of the tremendous amount of "double talk" in circulars, which one cannot read quickly. Secondly, they are not circulated to members of 979 hospital committees individually in time so that one can read them before a meeting, however difficult they may be. Thirdly, they always get classed under the category of "any other business", and when that stage is reached after any reasonable hospital management committee meeting the committee are dead tired and mentally incapable of dealing with them and all want to go home. The result is that these circulars do not receive that due care and attention which we should give them. Anything which can make them more simply worded and more widely distributed, and which can give us more chance to consider them, would be very welcome to the ordinary member.
§ 4.52 p.m.
§ THE EARL OF IDDESLEIGH
My Lords, I am a humble member of the Mental Health Association of which the noble Earl, Lord Feversham, is President, but it is not merely out of loyalty to the noble Earl that I beg to support this Amendment. My membership of that Association brings me into contact with a great many social workers in this field, and I have been at pains to inquire from them their opinions of this Bill. They have all stressed their great anxiety about the need for the fullest possible co-operation with the Regional Hospital Boards in this matter and their conviction that unless that co-operation is obtained the Bill will prove unworkable. If for no other reason than to allay the apprehensions of the social workers, I trust that Her Majesty's Government will feel able to accept the first three subsections of this Amendment.
§ THE LORD CHANCELLOR
I am grateful to my noble friend Lord Astor for his acute psychological diagnosis of the working of the minds of hospital committees, and I shall convey to my right honourable and learned friend the Minister the important point which he has developed. I should like also to say to the noble Lord, Lord Stonham, that I am in entire sympathy with the desire he expressed in (if he will allow me to say so) the eloquent last words of his speech, about preventing any stultifying influences of the sort he described.
I know that the noble Lord, Lord Taylor, wants specific answers and I shall be happy to give them. I should like, 980 for reasons which I shall develop in a moment, to take the second of the alternatives—that is, of making the statement—but I want to make quite clear to him that it is my intention to give direct answers and not wrap them up. He first asked me about the joint committees of the York type, and I can say that joint committees of the York type are permitted and encouraged by the Ministry, and that the whole of the working of this Act will continue that permission and encouragement, so long, of course (and I think the noble Lord put it forward on this basis), as they are decided on locally as being an appropriate method of ensuring co-operation in the performance of the respective functions of the hospitals and local authorities. So on his first point concerning joint committees the answer is, "Yes". On his second point, concerning Regional Hospital Boards being the agent for local authorities, the answer is, "No". On the third point, the division of expenses, the answer is, "Yes, according to the functions approved". So the noble Lord has favourable answers on two out of three points. I should like, therefore, to focus my remarks on the one where I have not been able to give him the answer that he wanted.
The question of the Regional Hospital Boards acting as agents for the purpose of local health authority functions has already been mentioned by my noble friend Lord Feversham. I understand that it is not done under the existing joint schemes where the two types of authority collaborate closely but each exercise their own respective functions under the National Health Service Acts. Broadly, it is not desirable to provide that one type of statutory authority should exercise the functions of another. In the York mental health scheme, which the noble Lord, Lord Taylor, described, the costs of the hospital authorities and the local health authorities respectively are carefully allocated according to the estimate of hospital work and local authority work performed. We believe that that is the right way to do it.
If I may deal for a moment with the more technical aspect, subsection (1) of the proposed new clause is unnecessary, because I can assure your Lordships that there is nothing in Part II of the Bill which impinges on the functions of the 981 Regional Hospital Boards or hospital management committees under the National Health Service Act. Similarly, we do not think subsection (2) is necessary, for the reason that local health authorities are required, under Section 20 of the National Health Service Act, to send to Regional Hospital Boards copies of all their proposals for the exercise of their functions under Part III of the National Health Service Act; and the further detailed consultation with the Boards and committees in the carrying out of their approved proposals is, I think, to be achieved by the methods described in the Ministry's circular and, indeed, is already achieved in many areas.
I think I can tell my noble friend Lord Astor that we have good evidence that some people do read the circulars, but I appreciate the seriousness of his point. I think everyone who has been in public life knows the difficulty of selecting from all the material that is sent to one, and I should like to consider that point with my right honourable friend. I hope my noble friend did not think that I was being unduly jocular about it. It is a quite serious point.
§ VISCOUNT ASTOR
My Lords, it was not jocular. It was a serious point that I tried to make as lightly as possible.
§ THE LORD CHANCELLOR
I am sure no one objects to that on July 9, on the fourth day (I think it is) on which your Lordships have been considering this Bill in detail: any jocularity is thankfully received.
Now, my Lords, I want to deal with the point of the insertion of this new clause into the Bill. There is a real difficulty here. It is a sobering thought that, probably, I have been in charge of more Bills, in one House of Parliament or another, than any other living person. That is an unenviable position to reach; but I should not like your Lordships to think that, because of that, I like or enjoy "stone-walling". It has never proved of any use, and I do not enjoy dealing with Amendments in your Lordships' House in that way. The difficulty is that an unnecessary provision in an Act does raise serious difficulties. We have a terrible legal cliché about it, which I have never been sure of: inclusio unius est exclusio alterius—that is, "to put in one thing may mean that another is shut out". But here there 982 would be a danger of raising a doubt as to the sufficiency of the existing powers.
May I give an example to the noble Lord, Lord Taylor? If an express provision of this sort were inserted in the Bill with reference to a joint scheme for services for mental patients, it would immediately raise the question whether other joint schemes—for example, for services for old people—were permissible without a similar express provision. But, as I told your Lordships, in the absence of any express provision it can be assumed—and there is no doubt about it—that joint schemes for mental health services and joint schemes for old people can both be carried on under the existing powers. My Lords, I do not think the noble Lord, Lord Taylor, has done too badly. He has got two out of three, and a general assurance of great sympathy and understanding. I hope that, on that statement, he will, as he 'very kindly suggested he might, not press the Amendment.
§ LORD TAYLOR
My Lords, I consider that we have done very well from the noble and learned Viscount the Lord Chancellor. Sixty-six and two-thirds per cent. seems to me to be a very good dividend indeed. One hopes that we may get some little publicity of the discussion that we have had, so that it reaches the very people the noble Viscount, Lord Astor, mentioned—namely, psychiatric social workers, members of committees who do not read circulars, and so on. Unfortunately, at the moment the medical Press is not finding it very easy to report your Lordships' debates. The circular in question, if I may say so, was, as circulars go, a very good one, though it would be nicer if they were printed in rather larger type and if they were edited a little more tightly. One finds, having drafted circulars oneself, that it is always easier to write a long sentence than a short one; and perhaps a little sub-editorial assistance from the P.R.O.'s Department might improve the quality of the circulars which emanate from the Minister of Health.
I thank the noble and learned Viscount for the assurances that he has given. We are very pleased to have them. I did not expect to get the point he mad-about agencies. It may well be that the noble and learned Viscount is right. I 983 therefore beg your Lordships' leave to withdraw the Amendment.
§ Amendment, by leave, withdrawn.
§ Clause 18 [Continuance of special registration on cancellation or death]:
§ THE LORD CHANCELLOR
My Lords, this is simply an attempt to get more precise wording and to avoid a possible ambiguity in the word "discharged". I beg to move.
Page 11, line 41, leave out ("been transferred or discharged") and insert ("ceased to be so liable").—(The Lord Chancellor.)
§ On Question, Amendment agreed to.
Page 12, line 10, leave out ("been transferred or discharged") and insert ("ceased to be so liable").—(The Lord Chancellor.)
§ On Question, Amendment agreed to
§ 5.5 p.m.
§ LORD TAYLOR moved, after Clause 28 to insert the following new clause:
§ Application to be signed by Justice
§ ". An application for admission for treatment made on the ground that the patient is suffering from psychopathic disorder must be scrutinised, approved and signed by a Justice of the Peace, and the Justice of the Peace shall take such steps as are necessary to satisfy himself that the evidence of psychopathic disorder is such as to bring the patient within the definition set out in this Act."
§ The noble Lord said: My Lords, this is a repetition of the Amendment moved in Committee by my noble friend Lady Wootton of Abinger and myself. We feel that we have taken the Lord Chancellor three-quarters of the way along the road that we have wished to travel with regard to psychopaths, and we are very glad indeed that he has marched with us. We do not altogether expect him to view with complete favour this new clause, because we realise that we are here departing from the proposals of the Royal Commission. In replying to our original suggestions, the noble and learned Viscount the Lord Chancellor said that he doubted the ability of laymen to judge psychopathy on anything more than particular examples of behaviour, and he expressed the fear that we should concentrate on conduct and not on what he termed the "anterior 984 disorder". Our argument was, and still is, that in fact, whatever the law may say, the evidence of psychopathy is to be found in conduct only—"conduct" for this purpose to include the spoken word. I believe that, in fact, the Government recognise this, since psychopaths over 21 and sexual psychopaths under 21 are to be dealt with by the courts—that is to say, by non-medical means, though they will, of course, have the advantage of medical reports. We feel that this is correct. This is the way psychopaths should be dealt with. What we are a little at a loss to understand is why the non-sexual psychopath under 21 is singled out for treatment in this respect.
§ It may be argued that the new definition of psychopath, which we have already accepted earlier in the Bill this afternoon makes the diagnosis of a psychopath more of a medical matter. If that is so, why is the adult psychopath still to be dealt with by the courts, while the psychopath under 21 remains to be dealt with by two doctors? It is very rarely that one complains that the Government have acted too quickly in accepting the recommendations of a Royal Commission—and, taking the Bill as a whole, one is sure that the Royal Commission and the Government have achieved the right answers. But one does have serious doubts whether this matter of psychopathy has received the degree of discussion and consideration in both medical and legal circles which it ought to receive before it is embodied in the law.
§ I would remind your Lordships once again of the importance of that part of the Mental Treatment Act, 1930, dealing with the temporary treatment of patients without volition on the certificate of two doctors without a justice of the peace. This section of the 1930 Act became a dead letter, because the doctors found it so hard to say that any patient other than a completely unconscious one was lacking in volition. I honestly believe that this part of the present Bill, which deals with the detention of psychopaths under twenty-one, will likewise become a dead letter, for the simple reason that the ordinary decent doctor will jib at taking the decision he is called upon to take, with its far-reaching consequences so far as the patients are concerned, without lay support.985
§ We shall not get psychopaths improperly detained but we shall get young psychopaths who should be detained allowed to remain at large because doctors are afraid of making the decision which this clause of the Bill forces upon them. If the Government reject this new clause, I venture to suggest that the simple facts of the situation will force us, in due course, to have an amending Act to restore a non-medical element in the decision of whether or not a patient is a psychopath who should be compulsorily detained on the basis of what is really primarily social evidence. For these reasons, I beg to move the Amendment standing in my name.
After Clause 28, insert the said new clause.—(Lord Taylor.)
§ BARONESS WOOTTON OF ABINGER
My Lords, surely the point that we need to emphasise here is that psychopaths will be an entirely new legal category. There is no parallel for that. As I think I said on Committee stage, the closest parallel is the moral defectives under mental deficiency legislation, but it has never been made clear that they could be persons of normal intelligence. The psychopath can be a person of normal intelligence; indeed, he may well be, and normally is, a person of superior intelligence. His one distinguishing characteristic is his persistently anti-social behaviour. It is true that the Amendment which the noble and learned Viscount the Lord Chancellor has moved this afternoon has emphasised that that behaviour must be due to a disorder or disability of the mind, and that, at least, is a clarification. But, as my noble friend Lord Taylor has said more than once, it remains the practical experience that the mental disability of the psychopath is diagnosed by what is, in effect, a circular process. His behaviour is said to be caused by the mental disorder or disability, and the presence of the mental disorder or disability is actually inferred from his behaviour.
I know that it is the intention, and that it is very likely to be the practice, that this clause should be very narrowly construed. Nevertheless, on paper it is potentially one that has no limit applied to psychopaths and the older, dangerous, persistent; no limit to the antisocial persons who could, on a liberal 986 construction, be brought within its terms. Experience abroad has taught us that, in some circumstances, the definition of what is called anti-social behaviour—or, in the words of the Bill, "aggressive or seriously irresponsible behaviour" is not always objectively made. There have been plenty of examples—I know we say that it cannot happen here—where even a political element has become imported into definitions of this kind. The terms remain wide and the powers which this clause confers are enormously far-reaching. It is for that reason, and for that reason only, that I think it appropriate, on this one occasion, in dealing with this new category of persons, that there should be some independent guarantee that the terms of this clause have been complied with rigidly. That is all the Amendment asks for.
§ 5.15 p.m.
§ LORD COHEN OF BIRKENHEAD
My Lords, although, for reasons which I shall later explain, I cannot support this Amendment, I understand fully the motives which have impelled those who have put it down; because, as the noble Baroness has said, we are dealing with a novel situation, demanding a novel legal requirement. We are dealing with a category of disorder which it is extremely difficult to define. We are also dealing, as the noble Lord, Lord Taylor, mentioned during Committee stage, with a disorder which is extremely difficult of treatment but one for which treatment may nevertheless exist, and we are dealing with a type of individual who may be more than usually hostile to treatment. There are experiments which appear to be yielding fruitful results in the treatment of psychopaths. I do not propose to discuss them at this moment, but we know that considerable attention has been given to research in this field and that more is likely to be given in future.
Four major reasons have been deployed in support of this Amendment. The first, which the noble Lord, Lord Taylor, has just mentioned, is that doctors may be reluctant to implement the Act. They will have some difficulty in knowing exactly the characteristics of the category with which they are to deal. I think that the definition has been enormously strengthened, if I may say so, with great respect and gratitude to the 987 noble and learned Viscount the Lord Chancellor, by the Amendment this afternoon which introduces specifically the words, "disorder or disability of the mind".
Doctors are used to novel situations: we have had to face many within the last decade. And doctors have always been exposed to the appropriate legal remedies which may be taken by those who feel that they have been wrongly certified. In any event, if that be the argument, then the justice of the peace is not there to safeguard the patient but to cover the doctor, to safeguard the doctor. That was not the original conception of the introduction of the justice of the peace. It was to introduce an element of safeguard for the patient, the man or woman whose individual freedom was at stake.
§ LORD TAYLOR
My Lords, will my noble friend permit me to interrupt him? It was always my conception that in the case of psychopaths and the justice of the peace it would be far more important to safeguard the doctor than to safeguard the patient.
§ LORD COHEN OF BIRKENHEAD
My Lords, I am grateful to know that the noble Lord is with me. I am confident that doctors will co-operate unselfishly and conscientiously in the implementation of the Bill.
The second point which was mentioned on Committee stage was that a scheme which does not introduce a justice of the peace strikes at the very basis of the doctor-patient relationship; in other words, the doctor, and not the justice of the peace, becomes the jailer. But which doctor is it at which this Bill strikes, by which the doctor-patient relationship is impaired? There are two types of doctor here concerned. One is the patient's general practitioner, or indeed the psychiatrist under whom he has had treatment for a considerable period of time. And he must be one of the certifying agents, because he is the only person who can say from his own observations that there is a "persistent" disability or disorder of mind. The other is the expert psychiatrist. If, indeed, it be that the second certifying doctor, who is the expert, is the hospital doctor who will have the patient under treatment, then it would surely be possible to have another 988 expert psychiatrist, if necessary from the same hospital, but one who will under the terms of the Bill be approved by the local authority; and it would be thus quite easy to avoid disturbing the doctor-patient relationship and in any way impeding effective treatment. For myself, I have no doubt that it would be possible to introduce an independent second opinion, the expert opinion, if that were desirable in the interests of the doctor-patient relationship.
I will not deal with two points mentioned on the Committee stage because they have not been reiterated today. The first was the "pliable" and accommodating psychiatrist mentioned by the noble Baroness, Lady Wootton of Abinger, and the other was the stigma of a mental hospital which the noble Lord, Lord Stonham, mentioned when he said that the patient might be asked: "Have you ever been in a mental hospital?" But, my Lords, the whole purpose of this Bill is to ensure that that question cannot be asked. All the patient can be asked is: "Have you been in a hospital?" Then the patient may be asked: "From what were you suffering?", and the patient will either say what he was suffering from or will not. But the point is that if this Bill is implemented he will not any longer be able to be asked: "Have you ever had treatment in a mental hospital?"
§ LORD CHESHAM
I am loth to interrupt the noble Lord, but I feel that I must do so in view of the Royal Commission at five-thirty. I do not know whether the noble Lord has many points to make, but I ought to suggest that we adjourn within the next minute or so for the Royal Commission.
§ LORD COHEN OF BIRKENHEAD
Perhaps I can develop my one further point. It is that we have now receded from the position in which psychopathy is not regarded as a mental disorder. It is now incorporated in the Bill. What I am concerned about is that some of these patients, if only a few, have organic disease of the brain which underlies the psychopathic disorder and should be investigated in hospital. They may be resistant to that investigation, but some method should be found to ensure that they are investigated. I believe that this is essentially a doctor's assessment. There are three points for which the doctor's judgment is essential: the "persistency," 989 the exclusion of organic disease and the implementation of the concept that they require or are susceptible to treatment. I therefore hope that the noble Lord and the noble Baroness will not press this Amendment, because I believe it runs counter to the whole philosophy of this Bill.
§ House adjourned during pleasure.
§ House resumed.