MENTAL HEALTH BILL

HL Deb 04 June 1959 vol 216 cc666-768

3.8 p.m.

Order of the Day for the Second Reading read.

THE LORD CHANCELLOR (VISCOUNT KILMUIR)

My Lords, I rise to move the Second Reading of what your Lordships will have observed to be a long and important Bill. It is, in fact, the first fundamental revision of the English mental health laws since 1845, when the two Bills introduced by George Ashley, later the seventh and famous Earl of Shaftesbury, created the system on which all the later additions of the last hundred years have been based. The Bill completely repeals the existing Lunacy and Mental Treatment Acts and the Mental Deficiency Acts. There is, I think, general agreement that a root and branch measure of reform is needed. The existing Acts had many virtues in their day and incorporated several humane and important advances, such as the Mental Treatment Act, 1930. They have however become unduly complex, unnecessarily rigid and it many respects out of phase with contemporary thinking and the medical and social advances of recent years.

The Bill has received the support of all political Parties and the general approbation of the professional and other organisations who are particularly concerned with it. This is due in large measure to the labours of the Royal Commission on Mental Health. Their recommendations derived from a thorough and comprehensive review of the present law and existing services, and provide with only slight modification the foundation for this Bill. I should like to repeat the tributes paid to the Commission when your Lordships debated their Report last year on the motion of my noble friend Lord Feversham. Our only regret—and it is indeed a deep regret—is that Lord Percy of Newcastle has not lived to see his work translated into legislation.

Advances in medical treatment, coupled with the introduction of the National Health Service and other social services, have begun to break down the isolation of mental health from other health and welfare services. It is no longer necessary or appropriate to segregate mental patients in hospitals remote from the community. Increasing numbers of psychiatric beds are already being provided in general hospitals. More treatment is being given in out-patient departments or in day hospitals which patients attend during the day while continuing to live at home. More domiciliary visits are being paid by hospital doctors to patients in their own homes. And the policy of discharging patients back to their homes as early as possible, even though there may be a recurrence of the illness, benefits patients by not separating them from their homes more than is necessary. At the same time it increases the importance of good arrangements for after-care.

These trends in treatment have been accompanied by a much greater readiness on the part of patients to accept treatment voluntarily. Since 1930, when voluntary admissions to mental hospitals began, the proportion of voluntary to certified patients has steadily increased. Between 1949 and 1957 the number of voluntary admissions more than doubled, and it now accounts for more than four-fifths of all admissions. It has also been possible in recent years to de-certify a considerable number of certified patients. In 1958, for example, about 12,500 were regraded to voluntary status.

The Mental Health Bill carries these developments an important stage further. It completes the process of administrative integration of the mental health services into the National Health Service. In particular it abolishes the separate designation of mental hospitals and mental deficiency hospitals, and removes the formalities at present attached to voluntary admissions to mental hospitals.

Under the Acts which the Bill repeals "persons of unsound mind" can be received only into designated mental hospitals, and those hospitals cannot admit patients except through the procedures of the Lunacy and Mental Treatment Acts. Patients dealt with under the Mental Deficiency Acts may be admitted only to other specially designated hospitals. The system of designation thus creates a rigid barrier between hospitals for treatment of mental illness and hospitals for treating mental deficiency. It also limits the types of psychiatric patients who can be received into general hospitals. This system has no counterpart in the Bill. Both psychiatric hospitals and general hospitals will therefore be able to receive any class of mentally disordered patient for whom they can provide appropriate treatment. Specialised psychiatric hospitals will of course still be needed, but psychiatric wards or wings in or attached to general hospitals are likely to became more common, especially for patients who need to stay in hospital only a short time.

The Bill also abolishes the present requirement that voluntary patients entering mental hospitals must sign an application form. This legal formality has meant that some patients have had to be certified because they could not give a valid signature, although their relatives wanted them to be admitted and they themselves did not object. These formalities disappear with the repeal of the existing Acts. The declaratory Clause 5 of the Bill makes clear that patients can be admitted in future quite informally on the same footing as patients suffering from any other forms of illness. We expect that this will further increase the proportion of patients whom it will be unnecessary to subject to the power of compulsory detention and to all the formalities which are necessary when such a power is invoked.

Informal admissions to mental deficiency hospitals (as distinct from mental hospitals for the mentally ill) started in 1958, following a recommendation of the Royal Commission which we were able to implement under the existing law. Over 27,000 of the 60,000 patients in hospital have already been decertified so as to remain in hospital on the same footing as any other hospital patients, and the review and process of decertification is still continuing. About 70 per cent. of the new patients admitted in 1958 entered informally. Under the Bill statutory procedures for admission will be used only for the minority of patients whom it is necessary to compel to enter hospital or guardianship against their own or their relatives' wishes. This will be permitted only when it is necessary in the interests of the patient's health or safety, or for the protection of other people, and also for patients who have come within the ambit of the criminal law.

It is with these matters that the Bill is largely concerned, but before dealing with the compulsory powers, which are contained in Parts IV and V of the Bill, I should say a word about the earlier clauses. Part I contains the clauses repealing the existing law and the declaratory clause about informal admissions to which I have referred. The repeal of the present law also dissolves the Board of Control, whose members are transferred to the staff of the Minister of Health by Clause 2 of the Bill.

The Board has deservedly earned respect for its work over the years in improving the mental health services. It has performed with dedication a number of important functions. These functions will remain as important as ever, but changed circumstances require them to be redistributed to other hands. Some will be performed by the Ministry of Health to which the members of the Board will be transferred; others will be performed by the Mental Health Review Tribunals which are set up under Clause 3 of the Bill and to which I shall refer later.

Clause 4 is an important clause, introducing the terminology used in the Bill for various forms of mental disorder. I am the first to realise, my Lords, that changes of name do not of themselves achieve anything if the underlying attitudes and the situations which have given rise to these attitudes remain unchanged, but the replacement of terms which have acquired misleading or offensive conno- tations can at least contribute to the necessary change of attitude. We have, as the Royal Commission recommended, provided new categories of patients, with new titles to replace the terms used in the Mental Deficiency Acts, and the term which I quoted a moment ago, "person of unsound mind".

The Bill diverges from the Royal Commission here only in two respects. It sub-divides the category to which the Commission applied the term "psychopathic" into two categories, "subnormal" and "psychopathic". This has been necessary because it was clear from the views expressed on the Report, including views expressed in your Lordships' House, that the Commission's wide use of the term "psychopathic" involved so great a departure from the sense in which it is normally used by the medical profession and the public as to be liable to lead to confusion. This is one of the points on which we have been able to meet criticisms of detail made in your Lordships' House and elsewhere. The Bill also departs from the Royal Commission in that it contains definitions of the terms "severe subnormality", "subnormality" and "psychopathic disorder." These conditions, together with mental illness, are the four forms of mental disorder in respect of which compulsory powers may be used under Parts IV and V of the Bill. Unlike "mental illness" these terms are not in general use at present, and we have therefore thought it desirable to define them for the guidance of those applying the compulsory powers.

Parts II and III of the Bill are based on the principle to which I have already referred—namely, that of the integration of the mental health service into the general health and welfare services. The wide powers contained in the National Assistance Act and the Children Act make it no longer necessary to have special statutory authority for the provision of hospital or community services for mental patients. As the Royal Commission pointed out, the necessary provision can and should be made as part of the general health and welfare services. Most mental health services are, in fact, already provided under the National Health Service Acts, but local authorities still derive some of their powers to provide community care from the Mental Deficiency Acts. Clause 6 makes it clear that the local health authorities' general powers under Section 28 of the National Health Service Act are wide enough to cover the services now provided under the Mental Deficiency Acts, and also the provision of residential hostels.

Clauses 8 to 10 follow the same principle. By amendments to the National Assistance Act and the Children Act they allow local authorities greater flexibility in organising services for the mentally disordered within the framework of their general health, welfare or child care services. Clauses 11 to 13 revise the procedures used in relation to children who are unsuitable, because of mental disability, for education at school; provide greater opportunities for the review of such cases, and empower local health authorities to require their attendance at a training centre on the same lines as compulsory school attendance.

Part III of the Bill deals with private homes for mental patients. The effect is to bring the arrangements for inspection and registration within the statutory arrangements for nursing homes and disabled persons homes generally. Instead of the special registration systems of the existing mental health legislation, the general provisions of the Public Health Acts and the National Assistance Act will apply, with suitable modifications.

I come now to Parts IV and V, which deal with compulsory powers and are, in a sense, the core of the Bill. Part IV deals with the compulsory admission to hospital or guardianship of patients other than those who come through the courts or are transferred from penal institutions. Our aim here has been to limit compulsory powers to cases in which it is positively necessary to override the wishes of the patient, either in the interests of his own health or safety or for the protection of others.

There are two basic forms of admission to hospital. The first, under Clause 25, is for observation, with or without other forms of medical treatment, and compulsory detention is normally limited to a period of not more than twenty-eight days. The second, under Clause 26, is not so limited. We attach great importance to the observation procedure. We expect that in many cases it will be possible to give all the treatment which the patient needs during this period. In those cases where a longer period of treatment is necessary many patients will be willing at the end of the observation period to remain in hospital informally. Those who need to be under compulsory detention for a longer period will, we hope, be a diminishing minority. Where, however, compulsion is necessary, for long or short periods, the Bill provides a new system of powers and procedures incorporating safeguards for the liberty of the individual against any misuse of these powers.

There are three main elements in this system of safeguards. First, there are the safeguards provided in the admission procedures themselves and the circumstances in which the Bill allows them to be used. Secondly there are the time limits on the validity of the powers of detention, and the powers of discharge. Thirdly there are the new Mental Health Review Tribunals which the Bill sets up, with powers of discharge, to which patients and their relatives have access on various occasions.

This Part of the Bill is closely modelled on the carefully balanced recommendations of the Royal Commission. It provides better safeguards than the present system, in that it is less complex, more appropriate for use as part of a therapeutic service, and at the same time strong in its safeguards against unjustified encroachments on liberty. The new procedures and the new Tribunals make it possible to dispense with the magistrate's order, which has contributed to the stigma surrounding the present certification procedure without, in practice, providing really effective safeguard.

The Mental Health Review Tribunals, whose constitution is set out in the First Schedule of the Bill, are to consist of members appointed by myself. There will be one Tribunal for each hospital region, and the members in each region will consist of three panels: one of legal members, one of medical members, and one of other members with other relevant experience or qualifications. At least one person from each panel will sit together when applications from individual patients are considered. The regional chairman and the chairman of each group of members considering individual cases must be drawn from the legal panel. The Tribunals will have power to discharge patients or to reclassify them, as provided in Clause 123. Rules to govern their procedure are to be made by me under Clause 124. In making these rules it will be necessary to establish a procedure suitable to the private and personal nature of the matters before the Tribunals, but which at the same time gives proper opportunities for formal, and even, where appropriate, public, hearings where this is desired by the applicant.

The essential feature of these Tribunals is that their decision will be based as much on their own observations and their own assessment of the patient's mental condition and of the need for compulsory detention, as upon the opinions put to them by the patient and the doctors and by other persons and authorities concerned.

My Lords, that brings us to Part V of the Bill, which deals with patients whose conduct has brought them within the ambit of the criminal law. Clause 60 enables the courts of criminal jurisdiction to make a hospital order or guardianship order when a person is convicted of an offence punishable with imprisonment for which the penalty is not fixed by law and is found to be suffering from mental disorder of a nature or degree which warrants detention in hospital or reception into guardianship. Such orders, however, are to be made only when the court is satisfied that this is the most suitable method of disposing of the case, having regard to the nature of the offence and the character and antecedents of the offender and to the other available means of dealing with him.

Clause 61 gives a similar power to juvenile courts in respect of children or young persons found to be in need of care and protection or beyond control. In addition, Clause 65 enables courts of assize or quarter sessions to make an order restricting discharge, in addition to a hospital order, when they consider this necessary for the protection of the public, having regard, again, to the nature of the offence, the antecedents of the offender and, in this case, to the risk of the commission of further offences if he is set at large. Patients subject to restriction orders may not be discharged without the consent of the Home Secretary, and are subject to various other special provisions.

Clauses 71 to 79 deal with the powers of the Secretary of State to direct the transfer of persons suffering from mental disorder from prisons and other penal institutions and approved schools to hospital, and from approved schools to guardianship. These provisions are based on the recommendations of the Royal Commission. To some extent they are a re-enactment, within the framework of the new legislation, of the provisions of the existing law which relate to the mentally disordered who appear before the courts or are found to be mentally disordered while detained in penal institutions or approved schools. They are to that extent changes in form, rather than substance; but whether they relate to persons now subject to the Mental Deficiency Acts or to those now called "Broadmoor patients", they implement the recommendation of the Royal Commission in applying as nearly as maybe the spirit of the Commission's proposals to these classes and by equating them, where possible, with patients detained under Part IV.

The power which the Bill gives to the superior courts to make hospital orders and orders restricting discharge is, however, a change of some substance. The superior courts have power at present to send mental defectives to suitable institutions, but there is no comparable provision in existing legislation by which these courts are enabled to send to hospital a mentally ill offender or a psychopath who does not come within the existing definition of mental defective. It is true that at present if a person makes a successful plea of insanity it is possible to secure his admission to a suitable institution or hospital for treatment; but as your Lordships know, except in murder cases, such a plea is rarely made, and these new provisions fill a gap in the existing powers of the superior courts to deal suitably with mentally disordered persons who have offended against the criminal law.

Part V of the Bill is therefore designed to ensure that mentally disordered persons who have come within the ambit of the criminal law can be dealt with by medical, rather than penal, treatment where the court thinks such a course more suitable. At the same time, it enables the courts to ensure that the public is given a reasonable degree of protection against mentally disordered persons whose criminal propensities are such that they are a danger to the community.

The remaining Parts of the Bill call for only a brief mention at this stage. Part VI deals with the transfer of detained patients from one part of the United Kingdom to another. Part VII transfers from the Board of Control to the Minister of Health the responsibility for managing the State institutions and renames them "special hospitals". These hospitals will be for patients requiring treatment under conditions of special security on account of their dangerous, violent or criminal propensities. Because of the questions of security involved it has been thought appropriate to keep them under the direct control and management of the Central Government, rather than to assimilate them into the Regional Hospital Board system.

Part VIII of the Bill deals with the important problem of the management of the property and affairs of patients. The Royal Commission did not have occasion to deal with this subject, save incidentally, but your Lordships will appreciate that it is of peculiar interest to me, since it deals with matters for which the Lord Chancellor is responsible as a Minister. Although, however, this part of the Bill makes a number of small changes in this branch of the law, and, I am glad to say, recasts it in modern language and in a convenient form, the substantial changes are of such minor importance that I ought not to take up your Lordships' time with them now. Part IX deals with a number of miscellaneous matters, including offences against patients and the powers and procedure of the Mental Health Review Tribunals. It also, together with the Sixth Schedule, contains transitional provisions governing the applications of the new procedure to existing patients.

I should, in conclusion, say a word about the development and improvement of the mental health services as a whole. This depends, in the main, on the action taken by the Minister of Health and the other authorities responsible for treatment, research and community care, rather than on anything in the Bill. It is the Government's intention to press on with developments in all these fields with vigour and determination. As noble Lords will be aware, the Medical Research Council has recently decided to set up two new committees, one on clinical psychiatry and one on the epidemiology of mental disorders. It is also arranging to set up two new research units, one working on epidemiology, and the other on psychiatric genetics.

In the hospital service considerable progress has been made in the uphill task of improving hospital accommodation, reducing overcrowding, developing Outpatient facilities, and increasing the number of medical and nursing staff. We are confident that this progress will continue. By 1961, for example, some 22.000 additional beds in psychiatric hospitals will have been provided since 1948. It is not, however, solely a matter of providing more beds, important as that is it is a question also of making better use of existing buildings by improved methods of treatment and by co-operation with the community services provided by local health authorities.

Local health authority services, especially for defectives, have been considerably increased in recent years, and we contemplate a further large expansion for all categories of mental patients. My right honourable friend the Minister of Health has recently asked local health authorities to review their existing services, and has suggested directions in which development is needed. These include, first, extension of junior training centres, with the provision of residential accommodation where necessary; more adult training centres, and the various types of hostel and residential accommodation recommended by the Royal Commission for patients ready for discharge from hospital but not yet fit enough to live unsupported in the community. A substantial sum towards the development of these services has been included in the general grant from the Exchequer for 1959–61.

These developments do not depend on the Bill, but my right honourable friend the Minister of Health has announced that when the Bill becomes law he will issue a direction under Section 28 of the National Health Service Act converting into duties all local health authorities' mental health functions under that section as clarified by Clause 6 of the Bill. The local authorities will be required to submit revised proposals for carrying out these duties. This will provide a phased programme of development, which will take account both of the practical difficulties involved and of the importance of the social problem with which we are dealing.

There is, in fact, my Lords, a general forward movement all along the line in this important matter of mental health. The Bill is stimulating action and interest well beyond the particular matters actually dealt with in the Bill itself; but the Bill itself makes vital changes without which progress in treatment would be hampered and retarded. It is in this spirit that I commend the Bill to your Lordships and I now beg to move that it be read a second time.

Moved, That the Bill be now read 2^a.—(The Lord Chancellor.)

3.44 p.m.

LORD SILKIN

My Lords, the House will be grateful to the noble and learned Viscount the Lord Chancellor for the clear way in which he has explained the main purposes and the chief provisions of this Bill. I would at the outset join with him in expressing our gratitude to the Royal Commission for the fine and comprehensive work it has done, and our regret that the Chairman of that Commission has not survived to see the outcome of the Report. May I also take the unusual course of congratulating Her Majesty's Government on the speed with which they have implemented this Report? The other day, during a debate on charities, the noble Viscount, Lord Samuel, said that the average time taken to implement the Report of a Royal Commission by any Government was (I think he said) fifteen years. I thought that was a bit high as an average; but certainly the period of about a year and a half from the date of the presentation of this Report to Parliament to the date when this Bill was introduced in another place will greatly reduce the average.

May I say at once that we—and, I am sure, noble Lords in all parts of the House—welcome this Bill as an important, far-reaching and progressive measure. In another place it was received with great cordiality from all parts of the House. It was never regarded as a Party measure. All Parties claimed credit for it, and all Parties participated indiscriminately in such criticism of the Bill as was made during its progress. During the Committee and other stages it was very greatly improved; and on the Third Reading the Minister of Health received unanimous praise for the way in which he had conducted himself during the progress of the Bill, and for the improvements that had been made. I want to say at once, however, that while we in this House are glad of such improvements, many of us feel that when the Bill received its Third Reading in another place not all the improvements possible had been made and we very much hope that, during its passage through this House, we shall be able to make still further improvements.

May I just say this also? While I yield to nobody in my praise of the Government and of the Minister in charge for introducing this Bill, and for the many improvements that have been made in the course of its progress, I still think that there are quite a number of matters which require the most careful consideration of this House, and I propose to make a number of critical observations, which I hope will be without prejudice to my general appreciation of the Bill.

This is a very important subject. At the present time no fewer than a quarter of a million of our citizens are occupying hospital beds as mental patients, and that is out of a total of something like 550,000—a very high proportion. As the noble and learned Viscount the Lord Chancellor has said, about 80 per cent. of these mental patients are voluntary patients. The stress and the strain and the hustle and the bustle of modern civilisation. the noise and the speed of life, television and aeroplanes and all the rest of it—all the paraphernalia of progress and civilisation—have indeed made great inroads into the nerves of our people; and to-day there are more people, and an increasing number of people, suffering from mental trouble than there have ever been. Side by side with that, I would say that the improvement in scientific knowledge has not kept pace with the increase in the strain on our people. I see, for instance, that something like 40 per cent. of the people who have been discharged as cured of mental trouble have to be re-admitted to hospital. As I hope to make clear in the course of my speech, we have still a great deal to learn in the treatment of mental disorders.

The major alteration this Bill brings about is a new approach to mental disease. There is a complete revision of the law, as the noble and learned Viscount has informed us. There are to be no more mental hospitals, so designated, although the hospitals themselves will remain. Later on, I should like to ask what is to happen to them. So many of them are very old and, in my view, quite unsuited for the reception and treatment of mental patients. I want to say at this stage that my knowledge of this subject is extremely limited and I speak with no authority whatever, and therefore with some diffidence. In the past, I have visited a number of mental hospitals and even before the war I regarded these hospitals as being quite unsuitable for their purpose. They are still there and still receiving patients in large numbers. One extraordinary thing about mental hospitals is that they are all very large. I wonder whether it is intended that these hospitals should remain in their present form, even though not designated, and still used for the treatment of patients.

There is to be no certification, but there will still be compulsory detention. I wonder whether that is very different. I wonder whether the effect on the patient is going to be similar to the old certification. The care and after-care of mental patients, and mental welfare, are being brought within the scope of the National Health Service Act, and, of course, that is a great improvement; but a great number of local authorities have already been carrying out these duties, even without complete authority, and it certainly is not a new thing.

I do not propose to go right through the Bill, but there are one or two aspects which caused me and a number of my noble friends some apprehension. We are all still concerned with the liberty of the subject. This Bill imposes certain restrictions and limitations on that liberty. Of course, they are not new, but in certain respects the safeguards have been removed. I refer first to compulsory detention. Under the Bill, except in the case of emergency, as the noble and learned Viscount said, two doctors have to certify that the patient is a proper subject for removal for his own health, for his own safety and for the safety of other persons. I am not so convinced that it is right compulsorily to detain a person simply on the ground of his own health; yet it is possible under the Bill that that should happen. To do so for his own safety and for the safety of others, I understand, but merely for his own health, I am not sure. The Bill removes the requirement of authorisation by a justice of the peace—that is, by the civilian element—the lay element—and a patient can be compulsorily detained on the certification of two doctors alone.

I recognise that the Bill has gone some way to provide safeguards, on the assumption that there are to be two doctors responsible. I think that most of us would feel that in a case of the restriction of freedom, the civilian element should come into the picture. I know it has been said that a justice of the peace is no real safeguard. I do not accept that. He is a safeguard, even if he is only a psychological safeguard. The public feel that here is a layman who has some experience in these matters and who is there to look after the liberty of the subject, and if the doctors, in their enthusiasm, think it desirable that a patient should be detained, the justice of the peace is there to ensure that they do not overstep the mark. Although I freely admit that in many cases justices of the peace act as rubber stamps, and do not feel that they can reject the advice of the doctors, nevertheless, even if only in the minds of the patients and their relatives, he is a safeguard. And I do not accept that in the majority of cases the justice of the peace is a rubber stamp. I know a considerable number of justices who take their duties very seriously and who make it their business to see the patient themselves and form a judgment, and examine carefully the evidence upon which it is proposed to detain a patient. And if only a limited number of patients have been saved from detention, I should have thought that the retention of the civilian element was worth while.

I want to go a stage further. In this Bill certain requirements are laid down—what should be contained in the certificate, the periods in which people should be seen, the evidence upon which detention is being carried out—and I should have thought that it is essential that there should be somebody who should say that he is satisfied that the legal requirements have been carried out, or that on the evidence submitted he does not think that the case has been made for detention. I hope the removal of a civilian check has not been accepted as final and that it will be possible to look at this point again.

I am well aware that the Royal Commission recommended that the function of the justice of the peace should be done away with, and to that extent the Government have acted within their rights. But they have not accepted all the recommendations of the Royal Commission; and I would say that this is one at which they might look again. If there is any doubt about whether a justice of the peace is the best person to carry out these duties, I would suggest that we might think of some alternative. One might be that there should be a panel drawn up of legal persons with, say, ten years' experience, who might act in the capacity of a civilian check. I imagine there would be no difficulty in getting a panel of that kind, and I put that forward in all seriousness in the hope that it will receive proper consideration.

My next point is on the psychopath. He enters into the field of legislation for the first time and he has had to be defined. I observe that in this respect the Government have not entirely accepted the recommendation of the Royal Commission. I would invite noble Lords to look at the definition of a psychopath which is contained in Clause 4 of the Bill, where it says: In this Act 'pschopathic disorder' means a disorder of personality (whether or not accompanied by subnormality of intelligence) which results in abnormally aggressive or seriously irresponsible conduct on the part of the patient, and requires or is susceptible to medical treatment. If one looks at that definition carefully, one sees that the governing factor is the behaviour of the patient. He is a person of "aggressive or seriously irresponsible conduct". Under the Bill it is possible to take such a person, provided he is under the age of twenty-one, and compulsorily detain him until the age of twenty-five, subject, of course, to his right to make applications for release. The test, I repeat, is that he is of abnormally agressive or seriously irresponsible conduct, whether or not that is accompanied by subnormality of intelligence. In fact, large numbers of people of the highest intelligence are abnormally aggressive—which only means argumentative and difficult—and capable of irresponsible conduct. I do not want to say anything invidious, but we can all think of people in either House of Parliament who might fit into that definition.

I would suggest that this definition is far too wide, particularly in view of the fact that the civilian element has disappeared. It leaves too much to the medical profession to say that, in their opinion, this person is of this character and requires or is susceptible to medical treatment. We have all at some time said about an inconvenient relative that he could do with treatment, but I hope that we never intended that that should be taken literally.

What will happen to this young person under twenty-one is that he will be faced with a psychiatrist, who as a rule knows nothing about him, and he will presumably be asked questions; but lie will know the purpose for which he is being interviewed. The young person will react in the way that young people do, and will become even more aggressive and argumentative, and this will confirm the opinion of the psychiatrist who will regard him as abnormally aggressive. In the normal course of events people put up with their young folk and take them for better or for worse; but let us not disguise the fact that there will be cases where the young person is a nuisance in the home. One or other of the parents may have remarried, and he may have a stepfather or stepmother who will not show him the same generosity and charity that a real parent might. He might even be a disturbing element in the home. So away he goes until lie is twenty-five. I beg those who are responsible for this Bill to look at that definition again and to see that this kind of thing is impossible; and I think one of the ways in which it would be made impossible would be if there had to be the additional safeguard of civilian control.

Now I want to say a word or two about observation and treatment. Those two terms are used in the Bill and it seems to me that they are, to a great extent, interchangeable: sometimes the expression "observation" is used alone sometimes it is "observation or treatment" and sometimes "observation and treatment". I should like to have a clear statement as to what is meant by "observation". What do you do when you observe a patient who has been forcibly detained? He is obviously not going to behave normally, even if he is a normal person. The very fact of compulsory detention will make him behave in an unusual way, especially if he is a psychopath. I should be grateful if we could be informed as to what is meant by "observation of the patient" where observation is the only thing that is to happen to the patient. He is going to be observed in some cases for twenty-eight days.

I now come to Part II of the Bill, which is that part dealing with conferring upon local authorities certain duties, such as the provision of aftercare, welfare and so on. In another place there was considerable discussion as to whether, as is the case in this Bill, these functions should be optional or mandatory. I have no doubt that they ought to be mandatory. I think the Minister went a long way in making it mandatory without actually saying so in the Bill. I wonder why he is not prepared to say so in the Bill. If, in fact, the device—and it is a device —of issuing a direction, and so on, to the local authorities is effective, why need you have a device at all? Why cannot it be said straight out that this is the duty of the local authorities. I hesitate to use the word "wangle", but to issue a direction and then to require local authorities to do it under a direction when it could equally well be done under the Bill itself seems to me to be a rather circumlocutory way of doing it. Furthermore—no doubt the noble and learned Viscount can give me the answer—I wonder whether it is valid to issue a direction under this Bill requiring a local authority to do something it is not required to do. Suppose the local authority refuses, and says, "You say that I may do this under this Bill. Now you are compelling me to do it." What is the remedy? Whether that be so or not, I suggest that a much more effective way would be to make the Bill mandatory in its terms.

Next, I want to say a word about the admission of patients. There is no doubt that under the old law once a patient requires to be given accommodation in a hospital he gets it. There is no argument about whether they have room or not—they take him. But under this Bill it will be open to any hospital to refuse permission for the patient to be entered. It would be a fatal thing if, a detention order having been made, patients were hawked around from one hospital to another. I do not imagine that this will be very common, but 1 should think the more difficult a patient—the more of a psychopath; the more crockery he has broken—the less likely a hospital would be to take him if they had a choice. The Bill itself puts no responsibility upon anybody to ensure that the patient is received into a hospital. I should like to see some responsibility put upon somebody—for instance, the Regional Board or some other body—to see that once a patient is genuinely and truly in need of admission to a hospital he can gain admission.

The Bill does away with certification and the stigma of certification, and I should like to ask—and I am genuinely seeking information on this point—whether there will not be an equal stigma after a time if a compulsory detention order has been made against a patient. Will it not be recorded against the patient? It may be inevitable, but I am very much against humbug and pretence, and so I say, if we are doing away with certification in the interests of the patient, let us do away with it; but let us not re-create the thing under the name of compulsory detention. I wonder whether that is what we are doing? I should be grateful to have a reply on that point.

There are two other points I wish to raise, and one is the censorship of correspondence. Under Clause 36 of the Bill, incoming and outgoing correspondence of patients is liable to be censored. Under Clause 133 this power is extended even to voluntary patients. A person goes in as a voluntary patient, and somebody will examine all letters he writes or receives. That seems an unwarrantable interference with the liberty of the subject. I know that some patients can write awkward letters, and I realise that in the Bill provision is made to enable them to write awkward letters to Members of Parliament and people whose duty it is to receive them. But why cannot the patient be free to write to anybody he likes? I know that this may make a bit of trouble here and there, but I regard the evil of censorship as even greater than the possible danger of a patient occasionally breaking out and writing offensive letters. Moreover, this censorship is not likely to be really effective, because most patients can get out at times, or find other ways of sending off letters—though I admit that it is a little more difficult in the case of incoming letters. But those are not the things that are important. The danger that is sought to be guarded against in the Bill is of outgoing letters and, as I say, the power will not be really effective, because if a patient really wants to send a letter out he will find ways and means of doing so. In the meantime, it is infringing the liberty of the subject, and it is involving the hospital in a great deal of administration when it could use its time to better advantage.

The final point I wish to raise is the rather delicate question of Members of the other House who become insane. Provision is made so that in due course they are not allowed to function. I wonder why this House is privileged. Is it because we are not likely to get insane people? Perhaps we are not overworked like the other place. But I feel that some provision, if only for parity of treatment, should be introduced into the Bill so that if a Member of this House should become incapable of carrying out his duties he could be prevented from doing so. Perhaps the noble and learned Viscount will look at that.

LORD WINSTER

Will the noble Lord allow me to intervene? I believe that there was a case of a Peer who was declared incapable of managing his own affairs but there was nothing to stop him from coming to your Lordships' House to sit and vote.

LORD STONHAM

My Lords, my noble friend is, of course, aware that we also have parity with the patients in mental hospitals, because we share with them the disability of not being able to vote.

LORD SILKIN

The fact is that this Peer was declared to be incapable of managing his own affairs, and yet was quite free to manage the affairs of the nation.

I have made a number of criticisms of the Bill, or raised a number of questions and I do that in no unfriendly spirit. I still think that the Bill has the makings of a good Bill. I say that because everything depends upon the way in which it is implemented. If nothing were done under this Bill it could become a dead letter—a series of pious aspirations. But I am quite sure that everybody would wish this Bill to mark the beginning of a big step forward in the treatment and care of mental disorder. There is a great deal to he done, and this Bill is only the first step. A great deal of money has to be spent. We shall want new buildings. Our doctors, who, it is agreed on all sides, generally speaking have but a lamentable knowledge of mental disorder, must have incorporated in their curriculum a great deal more about this subject. There must be far more research, and generally we must take active steps before we can congratulate ourselves on having made progress in this matter. But I believe that, with good will on all sides—and I think that does exist—and a genuine desire to deal with mental disorder in the way in which we have dealt with many other diseases in the past, which have to-day been almost eradicated, we can go forward and make substantial inroads into this terrible and cruel disease.

4.20 p.m.

LORD AMULREE

My Lords, I should like to join with the noble Lord who has just sat down in thanking the noble and learned Viscount for the extremely clear exposition he has made of this not altogether uncomplicated measure. The Bill, I think, has a great deal of good in it, and it is one to which I am sure your Lordships will give a warm welcome. It follows to a great extent the recommendations of the Royal Commission, and one thing which makes it popular in the country is the fact that people do feel that a considerable number of people have been detained in mental hospitals in these buildings for long periods of time when they have committed no particular crime but have been merely sick. These provisions will make it more possible for them to come back into the world, and I think that that will make the Bill a very popular one when it becomes an Act of Parliament.

One of the things which makes it simpler for the Bill to be put into force now is the great increase in the knowledge that we have of mental disease and the great advances made in its treatment. I trust that under the Bill it will be possible to do a great deal more research into the causes and treatment of such diseases. It is found that fewer people are going to be dangerous to the public than was thought in the past. In the past it was thought that anybody showing any signs of mental illness should immediately be locked up, and kept locked up for a long time, because he was dangerous. We do not hold that view so much now. Therefore it is far simpler to bring in a Bill of this nature.

With regard to compulsory powers of removal, I think that probably some kind of powers must remain, for the protection of the public. Nevertheless, I share Lord Silkin's anxiety that in this respect the powers of the justices of the peace have been taken away from them. As the noble and learned Viscount knows, I have a great respect for the law—probably because I was brought up in a legal family myself—and it has always seemed to me that that requirement did give a certain protection to patients who might be put away by too enthusiastic doctors. I know that a great many members of my profession feel rather worried that they have such enormous power in their hands for the curtailment of civil liberty. I share the apprenhensions of the noble Lord, Lord Silkin, that the civil power is no longer required in the case of compulsory removal. I quite understand that in some cases the order of a justice of the peace was a "rubber stamp" order, and that it made the removal a formal affair; but to some extent I regret the passing away of that requirement. One thing which in my view is a great improvement is that it will be simpler to obtain a person's discharge by means of the Mental Health Review Tribunals, which seem to me a very good thing it will give great protection against such things as have occurred.

Clauses 25 and 26 refer to the compulsory detention of people in mental hospitals, and one reason given is for the sake of the public: that these people must be removed if public safety is involved. But, like the noble Lord, Lord Silkin, I am a little doubtful whether they should be too freely removed for their own sake. I trust that when this Bill becomes law the very great powers conferred here will be used in the very sparing way in which the powers of the National Assistance Act. Section 47, are used now. Under that section, a person can be removed to an institution if he is thought to be dangerous to the neighbours or, in the second place, if it is thought to be of benefit to the person concerned. These powers have to exist, but they must be used extremely carefully. If people wish to remain by themselves in their own room, apartment or lodging, and are not going to be a danger to the public, they should not be bustled away into some institution.

The mental hospitals I know at the present time are far too large; they were built a very long time ago, and they are very uncomfortable. But it is amazing what can be done if you get a new atmosphere appearing. That occurred with the passing of the National Health Service Act in 1948, when a large number of what were the old Poor Law infirmaries, which were in most uncomfortable inconvenient buildings, were modernised. The doors were opened; the buildings were redecorated, and a good deal of modernisation done, thus saving a good deal of money at the time. One would like to renew them all, but one has to be realistic about the cost. I am sure, however, that a great deal can bed one by imaginative repairs and redecoration to make some of these places far more reasonable and comfortable than they are at present.

The whole of the success of this measure appears to me to rest on the local authorities, with the transfer to them of the mental powers under Section 28 of the National Health Service Act. One knows a good deal about the way that section has worked. Where there is a good interested local authority it works extremely well; but in other cases it does not work so well. I share the regret that local authorities were not given more obligatory power instead of a merely permissive power. One has seen that the first-class local authorities do very well indeed, but that the bad ones do not really try at all: they may not be interested in that particular subject; they may want to spend money on other matters. So I feel that the absence of compulsion, although I do not agree with compulsion as a general rule, is not a good thing; I think that obligatory powers are sometimes a good thing for local authorities.

There is a further point. Who will be the people who are going to carry out much of the work under the Bill? There is a person called the mental welfare officer. Is that to be the same man who is now called "the duly authorised officer", who is responsible for bringing people in under emergency orders? If they are to be given wider powers they will need a great deal more training, because they will have very great responsibilities in this matter. I do not myself come across mental illness a great deal, but I have come across a certain number of these duly authorised officers. Some are excellent; but some are not, because they have not had the necessary training and not enough experience in the work they are doing. If they are going to be given more powers they have to be properly trained. Then the greater services provided for the mentally sick patient will mean more work for the psychiatric social workers, and the patients will need to be taken care of much more in their homes and in the out-patient departments. That is a point which came to my notice the other day.

I had a letter from a man I happened to know something about four or five years ago. He had been kept in a mental hospital for the last four years but had just been discharged, and he wanted to resume his original job as a waiter. That seemed to be a very good thing to do. He rang me up and asked where he could get £15, because he wanted to buy a dress suit and two white shirts, and needed his railway fare to the South Coast where there was more chance of getting employment. All that seemed very sensible, and my advice to him was to apply to the hospital for a loan to buy the dinner jacket and to apply to the National Assistance Board to get the railway fare. He did this, but he got only £5 towards the cost of the dinner jacket, although the Assistance Board did offer to pay the railway fare. One cannot do a lot with £5 to buy a dinner jacket and two shirts.

It seems to me that part of the rehabilitation of patients, and particularly mental patients, is in seeing that they get back to work and are not merely discharged from hospital. I should have thought it should be possible for a patient, up to a point, to borrow money from the hospital service for that kind of thing. The hospital would have far more chance of getting their money repaid than a private person like myself would, because they can keep a check on where the person is. If it is not made simple for a man to get work, it will merely lead to his having a further relapse and going back to hospital.

There is another point in regard to after-care. If you come down to the other end of the scale, there you have mentally defective children. There is going to be a need for a much greater number of schools for these children throughout the country. The situation is fairly good in London where there are good and numerous enough schools for the mentally defective; but in the country areas certainly it is not so. That is a most important thing to be looked at if we are to get some of these mentally defective people out again into the world; we must have educational facilities for them to go to. Those are two points that I should like Her Majesty's Government to think about when the matter is being considered further.

Another important point is the training of medical students and young doctors. As always, it is the general practitioner who is going to bear the brunt of this work. I do not think you are wise to keep a large number of beds in mental hospitals attached to medical teaching schools. What you want is a large number of facilities, such as out-patient departments and observation wards, where the student can see the person who is being treated before that person gets to the stage of requiring admission to the hospital. In that way the student can see the mental side of the illness before the patient comes into the hospital. I hope that that suggestion will be considered by the Ministry of Health when the Bill comes into force. I am sure that that is going to be a most important need in the training of medical students and doctors. It has been mentioned that mental beds should be attached to teaching schools. I do not think that that is necessary or that it is a very good idea.

I take it that one thing which will occur under this Bill is that it will be possible now for the senile and elderly, confused patients to be treated in a much more "general hospital way" rather than be almost forced into mental hospitals because there is nowhere else for them to go. They do not need the skill of the mental hospital; they need much more general care and attention, and not the skill of the trained mental nurse or doctor. Again, that seems to be a point about which it is well worth doing something. It would ease much of the burden on the mental hospital, and it would make it easier for these unfortunate people to be looked after in a reasonably comfortable way.

There is one other point to which I think the noble Lord, Lord Silkin, referred—namely, in regard to Clauses 29 and 54, where the mental welfare officer or somebody else has to obtain admission of the patient to hospital. The noble Lord, Lord Silkin, put that point very well: that at the present time it is possible to get these people into a mental hospital. If this Bill becomes law we have to see that that facility still remains, because one of the sad things that occurred when the Poor Law finally vanished in 1948 was that the statutory bed for the sick and old person vanished with it. I admit that it was not a very good bed, nor a comfortable one, but it provided somewhere where there was food and rest and a limited amount of care. In the old days under the Poor Law these people would go into the hospital, under some compulsory powers. When this excellent Bill becomes law I hope that that power will not be lost, and that it will be possible to get these people in.

It might appear that I have made some rather carping references to this Bill. I do not really mean to be unkind to it. It seems to me to be a real step towards a better future in regard to the mental health of the people of this country. We must look forward; we must not stop at this Bill, because there are more things to do in the future.

4.35 p.m.

THE EARL OF FEVERSHAM

My Lords, the noble and learned Viscount the Lord Chancellor has presented this Bill to your Lordships' House in the lucid and intelligible way which we have come to expect from him when he has the onerous task of explaining to us the legal and complicated measures that come before us. May I join with the noble Lords, Lord Silkin and Lord Amulree, in paying my tribute to the noble and learned Viscount by expressing my grateful thanks for his analysis of the 151 clauses and eight Schedules of this most important and far-reaching Bill.

The noble Lords, Lord Silkin and Lord Amulree, have spoken with great knowledge and good intent on this Bill, and have given to your Lordships' House an indication of the generous welcome and the warmth of the interest on this Bill that exists on both sides of the House. As one who has been concerned for over twenty-five years in the mental health field, I should like to salute the arrival of this Bill, which, to some extent, marks the fulfilment of the hopes embodied in the pre-war Report of the Committee on the Mental Health Services of which I had the honour to be Chairman in the years 1936 to 1939. More than this, the Bill clears away the legislative undergrowth which is the result of the piecemeal attacks on the problems of mental disorder which have gone on for a great number of years. As such, it recognises the advances both in public attitudes and in medical knowledge which, as the noble and learned Viscount has said, have revolutionised thinking in this generation.

I think that here it is not inappropriate for me to honour the names of those earlier pioneers, by quoting a paragraph in the recently published Younghusband Report which says: Much of the credit for changing public attitudes towards mental disorder is due to voluntary effort, which pioneered new forms of care and after-care for both the mentally ill and defective, and help to bring about a more general recognition of the significance of stress and emotional causes in neurotic symptoms and mental breakdown. In the progress of this Bill in another place the National Association of Mental Health, of which I have the honour to be Chairman, has taken an active part, and we have had the satisfaction of seeing a great number of our Amendments taken up and incorporated into the Bill. I should like to pay tribute to all those, in and out of Parliament, who have worked so hard and so effectively to achieve this end, and I should personally like to thank the noble and learned Viscount the Lord Chancellor for the courteous way in which he has paid attention to various points I raised in the debate on this subject to which he made reference this afternoon. It is most gratifying to be told by the noble and learned Viscount that the important point concerning research has been taken up and that the Medical Research Council has inaugurated two new research units and two new committees to advise on matters relating to this subject. I understand that the noble Lord, Lord Cohen of Birkenhead is going to intervene in this debate, and I am sure that we shall have the advantage from his intervention of learning more on these research problems. Also, the references I made in your Lordships' House at that time are again implied in the decision to set up an investigation of the three State institutions at Rampton, Broadmoor and Moss Side.

I do not propose to follow the noble Lord, Lord Silkin, in the discussion that he initiated on the possible deprivation of the individual of his personal liberty, by the provision in this Bill of certification by two doctors rather than by a justice of the peace. I feel that others are more qualified than myself to speak on that subject, and particularly we in your Lordships' House have the advantage of receiving the opinion of two eminent men of the medical field by the remarks that will fall from the noble Lords, Lord Taylor and Lord Cohen of Birkenhead. Nor do I mean to follow the noble Lord, Lord Silkin, in his comments on the definition of psychopaths. A great deal of the time taken up in discussion of this Bill in another place was concerned with that definition, and I know that there are those who are going to refer to it to-day. It is an important question and one on which the noble Baroness opposite, Lady Wootton of Abinger, is eminently qualified to express an opinion.

I feel that perhaps the best and most useful contribution I can make to-day is to amplify the essential requirements which are indispensable if the underlying principles of this Bill are to be brought into successful operation. Let me say at once that all our enthusiasm for the Bill, which deals almost exclusively with the legal aspects of mental disorder, must not blind us to the fact that it is only a beginning. As the noble Lord, Lord Silkin, has already indicated, it will not give us better buildings in our mental hospitals; it will not in itself give us the extensive research for which the services crave; and it will do nothing to provide trained staff. Without these three, the development of any health service must be crippled. But these limitations, which, as the noble and learned Viscount clearly brought to our attention, were properly left out of the scope of the Bill, can be overcome if we have the right attitudes in our future thinking; and it is with the influencing of those attitudes that I am principally concerned.

The Bill provides a legislative background for doctors working in hospitals to carry out treatment under the best possible conditions: this is to confirm the hospitals in their good work. I have felt, however, ever since the Bill was published, that it is little more than a half-hearted attempt at promoting the preventive services where, to my mind, the future of this whole subject lies. The noble and learned Viscount has told us again to-day that the development of the community services is not written into the Bill itself as a mandatory direction and both the noble Lords, Lord Silkin and Lord Amulree, have made observations on that point. The Association that I represent has also made representations on this point to my right honourable friend the Minister, and I know that he has given the most sympathetic attention to the question.

It may be that the public pressure which has been brought to bear on my right honourable friend has led him to consider this question more deeply than he might otherwise have done, and he has given us the undertaking that, though he will not write any direction into the Bill, he will lay upon local authorities a duty to develop their preventive and after-care services by direction under the section which has already been referred to, Section 28 of the National Health Service Act. I am grateful to the Minister for having gone thus far, but I still have my own reservations about this decision and while I respect the intention of the Minister I shall be one of those who await with the keenest critical interest the effect of his actions. And I reserve the right to raise the question of amending the Bill if, after due time, it is found that the regulations which the Minister proposes do not have the desired effect.

I claim to speak with some knowledge on this question, for during and just after the war the National Association of Mental Health had a preventive and aftercare service, on a national scale, whose success has never been questioned. In many regions, however, when this service was taken over by the local authorities in 1948, it simply ceased to exist. It is true that the Minister has indicated in another place that he intends to act under Section 28 of the National Health Service Act in a way which he has never seen fit to act before; but I should be glad if the noble and learned Viscount could tell the House what kind of lead my right honourable friend the Minister proposes to take in ensuring that local authorities do carry out the duties he proposes to lay upon them. We have not been told hitherto whether the default powers which exist under Section 57 of the National Health Service Act have ever been used. Does my right honourable friend the Minister believe that these powers, and the similar powers contained in Clause 141 of the present Bill, will give him a real weapon in his campaign for better services?

The second point which the National Association for Mental Health have emphasised throughout the debates on the Bill in another place arises out of these considerations. I refer to the need for increasing the prestige and numbers of those employed by local authorities to deal with their new responsibilities under this Bill. It is, I think, very appropriate, when your Lordships are considering the Mental Health Bill, that you should have in your hands the Report of the Younghusband Committee on the Recruitment and Training of Social Workers in the Local Authority Health and Welfare Services. There are sections of this Report which are basic to the proper development of the local authority mental health services. I have pressed in this House on previous occasions for proper training for mental welfare workers—apoint reinforced to-day by the noble Lord, Lord Amulree—and I have pressed for the expansion of psychiatric social work services. My contentions in the past are amply confirmed by the findings of the Younghusband Committee. With your Lordships' permission I should like to quote paragraph 450 of that Report. It says: The Mental Health Service has thus an increasing importance in the community and must play an appropriate part, both in prevention and aftercare of mental disorder and in assisting with other social problems such as absenteeism in industry, the voluntarily unemployed, delinquency and marital or family difficulties of various kinds. I recommend that the Mental Health Service must be comprehensive.

The need for expanded social work is not confined to one service. I am glad to see that my right honourable friend the Minister, in the circulars to which the noble and learned Viscount referred, which are the Minister's first instructions to Regional Hospital Boards and local authorities, asks for joint operation of community services by both local authorities and Regional Boards so clearly both should use the same comprehensive team of trained experts. A key category in this team is, of course, the psychiatrists and, as many of your Lordships are no doubt aware, there is to-day an acute shortage of psychiatrists in the hospital service. At present there is virtually no possibility of increasing the number available to staff the community care services. The best arrangement would certainly be the joint employment of psychiatrists by Regional Hospital Boards and local authorities, but I am told that many hospital authorities complain that there is insufficient staff available for them even to consider such an arrangement.

The Royal Medico Psychological Association tell me that the demands of the Health Service on doctors in this category are increasing much faster than the number of new trainees available to meet them. They say that if an adequate service is to be developed in the next ten years it will require a fivefold to sevenfold increase in medical manpower in mental hospitals. The Younghusband Committee refer to other members of this comprehensive team. The Committee say that they estimate that to provide adequate mental health services, including services in Scotland, would require an increase in the number of psychiatric social workers in the employment of local authorities from the present surprisingly low figure of 31 to a total of 325. They also recommend an increase from 625 to 2,200 in the number of mental welfare officers. These figures indicate conclusively that the existing service is hopelessly understaffed.

As the noble and learned Viscount indicated in the presentation of this Bill to your Lordships, it must be sensible to urge under the principles of this Bill that the maximum attention should be given to keeping people out of hospital, rather than trying to deal with them in overcrowded conditions. This, my Lords, means good social work in the local authorities, and it also means the maximum co-operation with other welfare services, and particularly with general practitioners. I was very glad to note that the noble Lord, Lord Amulree. Paid attention in a great part of his speech to the importance and the position of general practitioners. With your Lordships' permission I will again refer to the Report of the Younghusband Committee, which makes the remarkable statement (it appears in paragraph 235) that in any one year there is a total of 2 million patients suffering from mental disturbance who are under the care of general practitioners.

To-day "G.P.s" everywhere should be familiar with the workings of these teams in comprehensive mental health services. They should be able to take their part in the discussions of case-work committees and should be qualified sufficiently by training to diagnose kinds and degrees of mental illness. It is appalling that so few general practitioners have any training in psychiatry. Few of them need undergo, in their final examinations, a test of knowledge in this subject, and I believe that only in a few medical schools is the subject being adequately taught. Therefore I would urge my noble and learned friend to persuade the Government to insist that this comprehensive idea of community mental health service is universally adopted.

It is good to know from my noble and learned friend that the Government mean to press on with vigour and determination in this field, and I only hope they will succeed. As my right honourable friend the Minister said in another place, and as he has emphasised in the circulars he has already sent out, local authorities must weigh up the priorities. My Lords, priorities are never so difficult as when finance is involved.

Your Lordships will remember that the Royal Commission hoped that the Mental Health Service would in future get a fair share of the nation's resources. Certainly the mental hospitals have had capital grants in the last few years, but those of your Lordships who know about, and visit, mental hospitals cannot but doubt that there is a despondency about their present progress. Certainly more money has been made available for the running of mental hospitals, but a glance at the statistics shows the vast disparity between general and mental hospitals. On feeding patients, general hospitals spend three times as much per patient as do mental hospitals; on treating patients, general hospitals spend nine times more on doctor attention than do mental hospitals. In the case of local authorities, it is disturbing to find that only 6½per cent. of the money they spend is devoted to preventive and after-care services such as I have been describing, while 93½per cent. goes on services imposed upon them by Statute.

It has been said in another place that expenditure on mental health services by the local authorities will be increased next year by £900,000 and the following year by £1,750,000. I should like to ask the noble and learned Viscount what proportion of this extra money the Minister thinks will be spent on expanding the preventive and after-care services. Are the Government happy in the belief that the figure of 6½per cent. which I have quoted will be increased in the direction I have indicated? It seems that without pressure from the centre the right financial road will not be taken.

My Lords, I said at the beginning of my remarks that this Bill is the result of a tremendous change in the attitude of the public towards mental health. Although the Bill deals only, with the mentally afflicted, I am glad that its title is "Mental Health", because I should like to see a more informed opinion in the nation towards positive mental health. On the mental health of every individual depends personal happiness, the welfare of the family and the stability of the community. To-day, because of rapid development in science and technology, and because of the changes in the conditions of living, it is infinitely more important than ever before in our history for the individual to maintain mental stability and rational judgment. Is it not right that man's motives, the reasons why he acts and thinks as he does, should be a study of supreme urgency and importance? Is it not right that mental health should be investigated and explored, without prejudice and without fear, but with clarity and with reason? This Bill lays open the way to our next Mental Health Bill, which must surely be based on the experience to be gained in pioneering real mental health services which are primarily preventive and which have as their aim the happiness of the community and the wholeness of man. This Bill provides the greatest opportunity for the public health services, and this is the hope of the mental health movement.

5.0 p.m.

LORD TAYLOR

My Lords, when I was a junior medical officer in a mental hospital there used to be a distant, but very powerful, figure to whom patients always had the right to address their letters. That was the Lord Chancellor: his Visitors in Lunacy were people whom one never saw but of whom one stood in a great deal of awe. I still stand in a great deal of awe of the noble and learned Viscount the Lord Chancellor, but I should like to join with all the noble Lords who have paid tribute to the clear and sincere way in which he has presented this Bill to your Lordships' House. In particular, he has not claimed for the Bill matters which can be dealt with only by administration. The Bill is a part of the story only, but an important part.

The Bill does one very important thing: it recognises that, in the eyes of the law, there is no valid distinction between illnesses of the mind and the brain and illnesses of the rest of the body. Now this was first positively shown in medicine about forty years ago by a doctod named Wagner von Jauregg, in Vienna, who made a most remarkable discovery. He discovered that if patients who were suffering from a severe form of mental illness, general paralysis of the insane, were deliberately given malaria, one-third of them recovered, in one-third of them the disease ceased to progress, and in the remainder no success was achieved. Until then, every case of paralysis of the insane was quite hopeless. Here was a physical remedy which produced a physical cure of a mental illness. During the early part of the war, I served as a psychiatrist in the Navy, and we were called neuro-psychiatrists just to emphasise that very point—to emphasise that the mind and brain are at one with the rest of the body.

This Bill enables those with illnesses of the mind to be treated in just the same way as those with illnesses of the body, with two important exceptions. The first exception has already been mentioned by my noble friend Lord Silkin, and that is in the matter of censorship of letters. This is dealt with by two clauses in the Bill. So far as it concerns the censorship of letters of patients who are compulsorily detained, I think it is Clause 36: and so far as concerns the letters of patients who are ordinary patients in a mental hospital, it is Clause 133. I must say that censorship of letters is a very distasteful business. I worked during the latter part of the war under the noble Lord, Lord Radcliffe, in the Ministry of Information, where he was responsible for the postal censorship, and I can remember how he adjured us not to make use of the information obtained by postal censorship. It is a very distasteful business.

I am probably the only Member of your Lordships' House who has had to censor letters in a mental hospital, and I must say that I got the impression that the patients in fact wrote the letters for the censors. They wrote them so that they could be read by us and one got precisely the sort of letters that one expected. Now, as I understand it, censorship of letters has been given up by two-thirds of the hospitals in this country. If that is so, there is no earthly reason whatsoever why it should be continued by the remainder, at any rate as regards patients who are not compulsorily detained in hospital. I sincerely hope that we shall put that matter right during the course of the Bill through your Lordships' House.

The second way in which the treatment of patients under this Bill differs from the treatment of patients in ordinary wards is in the matter of compulsory detention where this is socially necessary—for, in the last analysis, it is a social decision rather than a medical decision. When I was a medical student in 1930 I remember Parliament passing the Act to which the noble Viscount referred, the Mental Treatment Act. It was a very important Act, and it was welcomed widely by those who taught us psychiatry. They had great hopes of it. Some of those hopes have been justified, but some of them have been frustrated by what one can only describe as the realities of the situation and, as I hope I shall shortly show, there is a risk that some parts of this Bill may also be frustrated in exactly the same way and that history may be going to repeat itself.

That Mental Treatment Act did two things. First of all, it made possible the voluntary admission of patients to mental hospitals instead of its being by certificate. By and large, that has worked very well, but it has taken an extraordinary long time to get going; and it has been extremely patchy in its application. The second thing it did was to make possible the admission for temporary treatment of patients, without certification, on the recommendation of two doctors. That procedure, the procedure for temporary treatment under the Mental Treatment Act, 1930, is very like the procedure for compulsory detention for all those who need it which is proposed in the new Bill. But under the temporary treatment provisions of the 1930 Act, which could operate for two years, it was provided that the patient had to lack volition—that is to say, the capacity to make up his own mind. In fact, very few mental patients do lack volition and the power of self-expression so, for practical purposes, it could be applied only to patients who were in a state of stupor or semi-unconsciousness. The non-certificated temporary treatment of patients under the 1930 Act therefore became a dead letter. It was hardly ever used. I have never seen a patient admitted under that particular procedure. In this Bill the same method of detention is provided, but the provision about volition is omittted; and I see no reason at all why it should not work in what we hope will be the limited number of cases where detention is required.

It is worth looking for a moment to see how often detention is likely to be required. This depends not upon the Bill but upon the facilities available. I know one area where there is still a very unsatisfactory mental hospital and where about five out of every ten patients admitted still have to be certified. That hospital is a dreaded and a hated place. I know another area wher nine out of ten patients go in willingly as voluntary patients. That is why the voluntary patient scheme has been patchy. With good facilities, it is possible to get the rate for compulsory detention right down. If we have really good facilities everywhere, we could get the number of cases of compulsory detention down to about one case in fifty admissions, and it would then be a very small problem indeed.

My Lords, it is worth looking also in a little more detail at why some areas have a high rate of voluntary patients and some a comparatively high rate of certification. The first reason has been the problem of getting old people into hospital it has been a sad necessity that, in order to get old people beds, it has sometimes been necessary to certify them. They have been confused; they have in fact been mentally ill; but it has been only a part of their general deterioration. There were no geriatric beds and no proper home-care available, and the hospitals would not take the patients unless they were certified. That has been one way in which the certification rate has been kept up, because of lack of alternative facil ties. The second has been the public attitude towards bad hospitals and hospitals with bad reputations—and some of those reputations have been richly deserved, because hospitals are still grossly overcrowded and in many cases are in shockingly old buildings, for which the only treatment is to pull them down. The third has been inadequate staff—inadequate in number and inadequate in quality; inadequate numbers of psychiatrists, psychiatric social workers and nurses.

The easy way out has always been to certify the difficult patient rather than arrange for the more complicated domiciliary visits and the operation of persuasion. I think that there is something to be said for making compulsory detention a difficult procedure, to encourage the medical profession to exercise every possible persuasive power before they have recourse to the easy way. My noble friend Lord Silkin looked upon a lay magistrate as a safeguard in another direction. I think some form of lay authority is desirable, so as to encourage the doctors and the authorities concerned to take every possible way of persuading the patient to have voluntary treatment. I do not like dictatorships, and I am a little afraid of a medical dictatorship. Finally, if this is going to be a rare occurrence, the lay magistrate or my noble friend's panel, which has many attractions for me, should be able to develop the necessary experience, so as to be able to do it, not as a rubber stamp but as a serious decision on a social basis, which is what it must be.

When the Royal Commission was appointed, one felt that perhaps it had been given the wrong terms of reference—or, at least, that there ought to have been a second Royal Commission set up alongside. What we need is not only a reform of the law but, even more essentially, as the noble Earl, Lord Feversham, has said, a reform of the Mental Health Service. Good law cannot make up for bad administration or for State parsi- mony. Reform of the law is a comparatively cheap form of reform, but reform of the Mental Health Service is going to be a very costly business. It need not be a very prolonged business, if we decide to give it the high priority which it deserves.

Furthermore, the means chosen to implement this Bill are in many respects either non-existent or in embryo existence only. The instruments chosen to work part of it are not provided with the financial means and, as again the noble Earl, Lord Feversham, has indicated, they appear often to be lacking in the capacity to do so. May I illustrate this by two examples. The first is the case of psychopaths. Those who have had experience of psychopaths know how difficult they are to deal with. They are a problem when they are taken to any mental hospital, and everybody tries to get rid of them. There is only one way in which psychopaths can be treated—that is, in special institutions. So far as I know, there is only one such institution in this country—Dr. Maxwell Jones's unit at Belmont. If the provisions of this Bill are to be implemented, we shall need one unit for psychopaths in every Regional Hospital Board area.

My second example is the work placed on local authorities. Local authorities have had power under the National Health Service Act to do much of what they are supposed to do under this new Bill, but I know of only five of them which have done anything substantial at all. They are Oldham, York, Nottingham, Croydon and Worthing. I do not share the view that by either directing or ordering a local authority to take a certain action, that action will necessarily be performed or performed well. One experienced so much of this when the health services were in local authority hands, when there seemed to be so little of the necessary enthusiasm and drive, and when there was also a measure of local parsimony, which seemed to hold things up. The wonderful changes which have happened in our mental hospitals since the coming in of the National Health Service Act have been due entirely to the Regional Hospital Boards.

I think that we ought to scrutinise the provisions of this Bill carefully, to make sure that we do not take away from the Regional Hospital Boards the power to continue what they are already doing in the field of after-care, and that we do not prevent them from providing after-care when the local authority fails to provide it. We all hope that the local authorities will respond; but if they do not do so, I think that the Regional Boards should be in a position to do so.

There have been wonderful changes in mental care over the past twenty-five years, since I had my first job as a doctor in the Brighton Mental Hospital, where I had charge of 350 patients. No patient at all was receiving any treatment, and the average duration of stay was a couple of years. Today, I am sorry to say, there are still hospitals where there is only one doctor for 350 patients, but the rate of recovery, the duration of illness, is now more like two months than two years. This revolution has not come about as the result of the processes of law, but as the result of advances in medical treatment. There have been a staggering series of advances in physical treatment, and I have no doubt that those advances will continue. They have been matched by advances in the sphere of social psychiatry and by social change in the hospital itself—the opening and unlocking of doors, the socialisation of the hospital and its relation to the community. The best example I know is Warlingham Park Hospital, where remarkable results have been achieved by Dr. T. P. Rees, who was a member of the Royal Commission. At first when he opened the doors of his wards the nurses did not let the patients come out they did not realise that the idea was to liberate the patients. Yet in the end the results were dramatic and successful.

We now have the knowledge necessary to treat patients with mental illness properly, but we have not the facilities. We have not the buildings, the doctors, the nurses and the psychiatric social workers; and without these, changes in the law will have limited importance only. We need a large number of acute psychiatric units—long-stay units for psycho-geriatrics and separate units for psychopaths. We must develop the after-care service; and I confess that I am not very optimistic that we shall see hostels built very rapidly by local authorities. All these will cost a great deal of money.

There are several minor but important changes which the Bill makes. It gets rid of the statutory responsibility of the medical superintendent; he ceases to be the statutory head of a mental hospital. I think this is all to the good. The Minister has said that he may introduce regulations to reintroduce the medical superintendent. I hope that he will think again, and that we shall run our mental hospitals as our general hospitals are run, with medical committees though I see no reason why the chairman of a medical committee should not function as the medical superintendent, and should not change from time to time. In my view administration is best done by laymen and not by doctors, who ought to be doing their doctoring.

Then there is the position of the patient who is up before a Mental Review Tribunal, with a view to discharge, when the relatives are not really in a position to receive him again. This is happening increasingly as a result of the use of the drug chlorpromazine, which gets back into circulation patients who have been in hospital for twenty years or more. Time and again it happens that there is nowhere for them to go. It is a great problem. The taking into a family of such a patient after twenty years may have disastrous effects on the family. There is no easy solution to this problem, but one wonders whether it would be possible for the Review Tribunals, pending the provision of local authority hostels, to hear about the position of the family as well.

Finally, there is the question of urgent admissions under the twenty-eight day procedure. At present it is easy to get an urgency order through the duly authorised officer. Some general practitioners are anxious about what will happen in the really urgent cases. As one sees it, it will be necessary to get hold of a consulting psychiatrist. The difficulty is that there is a great shortage of consulting psychiatrists for domiciliary visits, and at the present time it is often necessary to wait two or three days before one can be obtained. This point will have to be looked at. If we had enough consulting psychiatrists, that would be an ideal method; but I am not sure that it will work quite as expected.

Dr. Denis Leigh, who is the physician at the Bethlem Royal Hospital and the Maudsley Hospital, said this of the Bill: There is a real possibility that the provisions of the Bill seek to make psychiatry run before it can walk, with a consequent lowering of standards. That is the risk, but I think it is a risk well worth taking. However, unless to-day's legislative action is matched by an expenditure of many more millions of pounds on existing mental hospitals and on acute psychiatric units, long-stay units, on hospitals for psychopaths and, above all, on psychiatrists, psychiatric social workers and other staff, and on research, the possibilities which this Bill opens for the mentally ill will not have been realised.

5.24 p.m.

LORD COHEN OF BIRKENHEAD

My Lords, I would at the outset join with other noble Lords who have spoken in paying tribute to the noble and learned Viscount the Lord Chancellor for the masterly, clear and concise way in which he has expounded the Bill. In the debate on the Report of the Royal Commission which we held in this House some fifteen months ago, I ventured to remind your Lordships of two earlier Commissions. The Radnor Commission, some fifty years ago, reviewed psychiatry and its responsibilities at that time. It made wise and prescient recommendations, none of which were implemented. Then the Commission which sat some thirty years ago under the chairmanship of Lord Macmillan made recommendations which were wholly consonant with our modern concept of mental illness, but again they were not implemented. Both the Reports suffered the fate of being relegated to official oblivion. When my noble and learned friend Lord Shaw-cross wrote yesterday, in the journal which perhaps it is indiscreet and almost imprudent to mention since last Monday, the following words about the Reports of Royal Commissions and Government Committees, I felt perhaps that it applied to those earlier Reports. He wrote: Too often, alas, it has happened that when such Reports have eventually been made, Governments have professed themselves unable to find time to debate, still less to implement, the recommendations made. History, fortunately, does not always repeat itself, and historical situations do not always recur. To-day we all welcome, whatever our criticisms, this invaluable Bill, this tremendous incentive for the betterment of our mental health services, which so speedily and so substantially implements the recommendations of the Report of the Royal Commission. It is right that we should offer our admiration and our gratitude to all who have been responsible for that. To most of us it would have seemed wellnigh impossible, when the Royal Commission reported two years ago, that within this short space of time a Bill would be produced with 150 clauses and eight Schedules, which repealed in part or in whole 54 Acts of Parliament which certainly, whatever merit they may have had in the past, resemble the description Cromwell uttered of the laws of England: that they were "a tortuous and ungodly jumble", a mêlée which I think all of us who have to work these Acts recognise. We now have in this Bill something which replaces a patchwork quilt of chaotic design by a tapestry of a clear plan which is wellnigh universally accepted in its major recommendations.

We all recognise that the National Health Service has made an enormous difference to the welfare of patients in mental hospitals, and indeed to the structure of mental hospitals themselves. We all recognise, also, that if we can improve the mental health services in the way in which this Bill suggests we shall have made a contribution which, even in the simplest terms, will be a significant economic gain to this community. But what is perhaps more important is that in terms of human happiness and human welfare the gain will be almost incalculable.

I, too, should like to express my deep regret that the noble Lord who chaired this Commission, the late Lord Percy of Newcastle, is not here to witness the fruits of his labours. I do so perhaps with greater personal sorrow, because a few months before his death I succeeded him as President of the Royal Society of Health, and I then learned for the first time what weighty contributions he had made to the provision of many progressive health measures.

Here I fully concur in what the noble Lord, Lord Taylor, has expressed to your Lordships. In the first exultant flush of joy we must not overlook the fact that this Bill of itself achieves but little. It provides a tool and an incentive which were hitherto lacking to do this job properly. But if it is to be done, then legislation of itself is not enough. We need men, and we need money. I shall revert to that in a moment. We also need (and this is fundamental, and has not yet been mentioned to your Lordships) the closest co-operation and goodwill between all the agencies—the local authorities, the hospital boards, general practitioners and professional organisations—which have a contribution to make to the working of the schemes which this Bill seeks to promote.

We need also a public attitude which no longer regards as it did compulsory detention—call it what you will; and here I agree with the noble Lord, Lord Silkin, that there are too many who to-day "surrender judgment to the fascination of the name" and still regard mental illness as a stigma. I am at any rate helped in this consideration by the fact that, call it "certification" or call it "compulsory detention", the significance is little different. When I last spoke in your Lordships' House on this question I mentioned that in a hospital at Nottingham on March 1, 1957, there were over 1,000 patients of whom only one was certified. I believe that that is the trend which we now see in all our mental hospitals. But it is the public who must understand, and it is our duty to try to ensure that they do understand.

Despite the debate in your Lordships' House yesterday, I believe that both channels of television have made a contribution to the public understanding of the significance of mental illness and the methods of its cure. But it does mean education. We also need education in overcoming the stresses and strains of life which lead to mental illness, but we still have to remember that that is possible only by the amelioration of social and economic conditions which increase mental stress and strain in the vast majority of cases which we meet, and certain factors over which we have little control, such as the marital discords at which the noble Earl, Lord Feversham, hinted. It is these which make a contribution to the mental illness of those who are often genetically predisposed to a mental disturbance. These are the triggers, the detonators, of overt mental illness, and we need relentlessly to pursue our investigations into the causes of mental illness—I do not mean the specific and necessary causes, but many of the environmental factors, because unless these are unmasked then our efforts at prevention will be virtually negligible.

We mislead ourselves and others if we believe that over-night, when Royal Assent has been given to this Bill, with any Amendments which may later be made, all the necessary services will be immediately available. There is—and it must be freely recognised—a wide gap between what we need and what we have. New hospitals cannot rise between dawn and sunset. As has been said earlier in this debate, the barracks-like buildings of so many of our mental hospitals will not encourage the free interchange of the medically and physically ill, such as is envisaged in this Bill. There may be little alteration needed in most of our general hospitals to accommodate the mentally sick, but few of the present mental hospitals would be suited to accommodate the physically ill patients, and they lack the necessary physical and diagnostic facilities. Perhaps this is another reason why we should seek in our future hospital building to ensure a flexibility of design to meet the varying needs.

Again, the shifting of the weight of responsibility over to community care, to the local authorities, will create great needs, as my right honourable friend the Minister of Health pointed out in his recent memorandum. There are to-day, as the noble Lord, Lord Taylor, has mentioned, few of the desirable hostels and residential homes, and yet these in abundance will be necessary, for there are three groups of patients for whom this form of treatment is not only desirable but, indeed, indispensable. There is the group, for example, of the educationally subnormal or maladjusted young people who are in some employment but who need—it may be only temporarily—care and guidance which they cannot be given in their own homes.

Also, it must be recognised that the sudden transition from a hospital to their own homes is an extremely difficult step to be taken by most mentally ill patients and, indeed, is not infrequently a cause of relapse. These hostels should be available as a kind of halfway house for those who are discharged from hospital and who need a period of adjustment during their transition to their restored life in the community. Also, they are needed for the elderly who are mentally infirm but who do not need hospital treatment, and yet who today are occupying a large number of our mental hospital beds. In the past ten years there has been a vast and commendable increase in the provision of occupation and training centres for mentally subnormal children up to the age of sixteen. Indeed, 80 per cent. of those regarded as suitable for training are receiving treatment. But because of the lack of facilities, only 50 per cent. of adults are receiving this instruction.

Frankness also demands that we should take note of what the noble Earl, Lord Feversham, said of the shortage of all forms of trained workers in this field—psychiatrists, psychiatric social workers, those who will be mental welfare officers, nurses, occupational therapists and the like. It may be that this Bill, which gives the incentive and the Minister's promise of finance, will help to make good in some degree that deficiency.

The Government may well have to give urgent consideration to the Younghusband Report quoted by my noble friend Lord Feversham, but I think it must be remembered—and this we sometimes forget—that there is only a limited pool of manpower and of finance in the country, and it has to be used for a large number of purposes. There are more professions than medicine, and certainly more than psychiatry. There are teachers and nurses; technologists and technicians; those who have to carry out the humdrum duties of everyday life those who have to accept managerial posts. It may well be that, sooner or later, we shall have to try to decide what we should do properly to utilise this pool of manpower and resources in order that the most vocal will not receive the highest share. Although the Minister has shown that he recognises these increasing needs, and he has significantly increased the block grant to local authorities, or intends to do so, there are many of us who would have preferred what the Royal Commission recommends—namely, that a special grant should be made to local authorities, particularly to relieve the burden of capital expenditure in the initial development of community mental health services.

It is a well-established practice of Government wishing to initiate a new service, or to stimulate the development of an old service, to do so by offering a percentage grant directly related to each local authority's needs and expenditure. Education, housing, tuberculosis, maternity and child welfare, are well-known precedents; and these grants have been made and earmarked for special services, even though a block grant was in operation at the same time. When the services are firmly established the cost of them has subsequently been merged in the block grant. That is happening this year, for example, in relation to education. It seems to me that the implementation of the provisions of this Bill would have been particularly appropriate for an earmarked grant. The Minister will approve local authority schemes. If sufficient money is to be available for their development, it seems that this would be achieved more readily by a specific grant for this purpose, rather than by increasing the block grant, the disposal of which is entirely at the discretion of various local authorities.

My Lords, I need not reiterate what I said in the last debate of the amazing and spectacularly dramatic advances in mental treatment which have developed during the last two or three decades. I will not subject you to yet another clinical lecture. But I think perhaps in one field I may be permitted to quote what has happened in relation to some defectives. Only this year, in the Lancet of January 31, Dr. Croft reported on a ten-year follow-up of 315 ex-defectives. Five years after their discharge from hospital, 78 per cent. were in employment and 51 per cent. had had continuous employment for over five years;29 per cent. of those were happily married;91 per cent. have committed no further police offence.

Now advances in this field demand research. We are all gratified to hear of the two new Committees which have been set up by the Medical Research Council. But it must be stressed that Committees do not conduct research. They can initiate research; they can direct research; they can assess research. But if research is to be conducted, money is wanted, and men with ideas are wanted. I hope that there will be sufficient money to support the right men with promising and fruitful ideas and provide facilities to develop them.

It is perhaps right that I should tell your Lordships that in some respects there is not unqualified approval from the medical profession for all the provisions of this Bill. Some have felt aggrieved, as the noble Lord, Lord Taylor, has already mentioned, about the status of the medical superintendent, now a feature of most large mental institutions. No one, however, defends or hopes to see perpetuated the type of superintendent who ruled with an authoritarian autocracy, though it was sometimes sweetened by a patriarchal benevolence. What we really need to ensure, perhaps on the lines the noble Lord, Lord Taylor suggested, possibly on other lines, is that there is central responsibility for administration—and this, of course, is possible within the provisions of the Bill. Some have questioned the clause which has been criticised by the noble Lord, Lord Silkin, on a different basis—namely, that it is two doctors who certify a patient. They have felt that this interferes with the normal doctor-patient relationship, particularly if the patient is to be under the care of one of the doctors who has certified him. I confess that I am not greatly disturbed by that fear. Whilst I share in some measure the apprehensions expressed by the noble Lord, Lord Silkin, about the need for a civil authority to be interpolated, as it were, between the doctor and the hospital, I would say this: I have spoken to many of my doctor colleagues and they can, if it be necessary to assure your Lordships, be trusted in this matter. I believe they recognise that no Bill can defend liberty without the integrity of those who implement it, and they will play their part as loyally and justly as anyone.

Again, there has been some question on the validity of the definition of the psychopathic personality—a point raised this afternoon. It is a task from which the Royal Commission recoiled. The Government have attempted it, and I shall refrain from any seraphic analogies. It is only fair to say that if we question the psychiatrists on the definition of a psycopath, we find added support for the truth of quot homines tot sententiae. Those who have doubts will, I think, do well to remember that no definitions are written on tablets of stone. They can be reviewed in the light of experience, for however prescient, however far-sighted draftsmen may be, all the implications of a definition cannot be foreseen.

There are many other non-medical topics on which I share some of the anxieties which have been raised by others, but those are matters which have been fully debated in another place and they might well be reopened later in your Lordships' House. But I am satisfied, as indeed every noble Lord who has spoken has emphasised, that those who nurture these misgivings readily concede the overwhelming merits of the Bill. There is, however, one specific point to which I had not intended to draw attention, but on which the noble Lord, Lord Silkin, has drawn me. He spoke of the "lamentable knowledge" of practitioners. Well, I have trained, and I meet thousands of doctors; and I think it is doing them an injustice to say that their knowledge of mental illness is "lamentable". We have not yet emerged, indeed, from a state in which a psychiatrist practising one form of psychiatry may well say to another that his knowledge is "lamentable". Here, we are indeed still confused by the numerous schools in this particular field.

It is suggested that medical students should have additional training in mental disease. This claim is made for every single subject in the medical curriculum. It is true that in 1858 the Medical Act prescribed that, on qualification, a doctor should in effect be efficient in the practice of medicine. surgery and midwifery. That was repeated in the Medical Act of 1886. But we have long grown beyond the stage at which any human mind can encompass in its lifetime, let alone in the few years of the medical curriculum, the whole corpus of medical knowledge. I should like to assure your Lordships that in every medical school with which I am familiar students are given, during their undergraduate career, the basic knowledge of mental disease which enables them to appreciate the nature and the scope of mental disease, the potentialities as to treatment and the responsibilities of a doctor in regard to mental disease; and it is on that basic knowledge that their subsequent experience is developed. I am sure that the noble Lord, Lord Silkin will agree that there are a few pages of Halsbury's Laws of England which are unfamiliar to him. But it is also true that the noble Lord has the knowledge whereby, if he so desires, he can find any additional information he requires and from basic principles he can interpret what he reads. The same is true of a medical student when he passes his final examination.

LORD SILKIN

My Lords, may I put my difficulty to the noble Lord? I fully agree with everything he has said, but I am never asked to put people in compulsory detention on the basis of something that I can look up in certain pages of Halsbury's Laws of England. What I am worried about is that that is the position of a considerable number of medical practitioners.

LORD COHEN OF BIRKENHEAD

But, with great respect, that is not the position. Is not the position—and here I am prepared to be corrected—that there must be two medical recommendations, and that one of the medical recommendations should he by a practitioner who has special knowledge in this field?

LORD SILKIN

And the other need not.

LORD COHEN OF BIRKENHEAD

Certainly; but he is guided by the one who has. No doctor alone can put a patient into compulsory detention, except in the one instance of which the noble Lord is well aware. But I did not wish it to go out from this House that it would be possible in the future for a doctor who was completely ignorant of the basic principles of mental illness to incarcerate a patient against his will. That is not the case.

My Lords, I fear that I have spoken rather longer than I had anticipated, and therefore I must come to my final point, which is one which has not yet been made this afternoon. It is that this Bill does not abolish the need for a continuing contribution by voluntary organisations to the welfare of the mentally ill. It can do so particularly, I think, in social clubs, social centres, in public education and in helping the once mentally ill patient to be restored to a full community life. A great challenge is also a great opportunity. Such an opportunity is now presented to us—to this country, the local authorities, the hospital boards, the medical profession and the public, to revolutionise and to place on a rational basis the treatment of the mentally ill and to ensure their rightful place in the community. I earnestly believe that not the least of the yardsticks by which our stature will be measured by future generations is the enthusiasm and energy with which we seek to ensure that this great measure of social reform is translated into a full reality.

5.56 p.m.

BARONESS WOOTTON OF ABINGER

My Lords, I rise as one more grateful pupil deeply in the debt of the noble and learned Viscount for the masterly exposition that he gave us of this long and complicated Bill. I wish, no less, to associate myself with the many tributes that have been paid to the progress that this Bill marks in our treatment and our conception of mental disorder. I think particularly that we welcome the new flexibility and the abolition of labels—and labels, after all, as the noble and learned Viscount suggested, have their importance—and we welcome the provision that treatment may be given wherever it is most appropriate, without having to segregate particular categories of patients in particular types of hospitals. It is indeed against this background of appreciation and admiration that I hope any small criticisms that I have to offer of the provisions of the Bill as it now stands may be read.

I must at the outset associate myself with the observations that have been made by several noble Lords about the abolition of the magistrates' consent for compulsory treatment. Perhaps I ought at this stage to declare an interest, although I, with other magistrates, would say that this is perhaps one of the most unpalatable tasks that we are ever called upon to perform. My interest is not so strong that I would demand that it must be the magistrates whose consent is required. I would certainly associate myself with the noble Lords who have suggested that some other lay element might be equally or even more appropriate. I do not wish to cover the ground that has already been traversed on this topic, but I should just like to say that when the noble and learned Viscount touched upon this theme, I could not help feeling that he dismissed rather lightly the safeguards which he said the Bill contained.

May we pause for a moment to consider what those safeguards are? First there are the relatives. We all know that in some cases of mental disorder the relatives are as likely to come down on one side as they are on the other, and there are many unfortunate people whose relatives are not available to help them. Second, there is the Mental Health Review Tribunal. But, as is apparent from the Bill, the Tribunal comes in after the decision for compulsory treatment has been taken. There is the world of difference between opening a door that has been closed and refusing, to give permission for it to be shut. The question which the mentally disordered person will have to ask is, not, "Am I really in such a state that I must be put away against my will?" but, "How do I get out of this place?" That is a very much more difficult question for that person to get taken seriously.

It is true also that the number of admissions under compulsory detention orders is likely to be small, certainly in relation to mental illness. Certifications are already much fewer than they were, and they are steadily diminishing, but the number is not so small in the case of severe abnormality—as we are in future to call it. Even if, as the noble Lord, Lord Taylor, has suggested, the numbers are likely to become very minute, it has always been a principle of English law that wrongful detention was not a matter of numbers. It is a matter of principle, and on this principle many debates have taken place through history in this House and many cases have been brought before the courts concerning single individuals, cases which have occupied a great deal of public attention and caused a great deal of public concern.

Moreover, it is true that doctors, on the whole, do not want to detain and that hospitals do not want to receive mentally disordered patients, but there are cases—and these are the ones to which I should like to call special attention—where the pressure to transfer from one institution to an institution for the treatment of mental disorders may be strong. There are, for instance, people in prison who make themselves a nuisance to the prison authorities and the prison medical officers. The medical officer, along with other prison authorities, must sometimes be under great stress; and I have seen this situation. Under that great stress he must sometimes be tempted to think "How nice it would be if So-and-so could be transferred to a hospital for mental treatment and if my responsibility for him could be ended!" The same is true of young persons in the care of the local authorities. There, again, there may be considerable pressure upon a medical officer who is sometimes pestered by refractory children to exercise his discretion to get compulsory medical treatment substituted for local authority care.

I do not suggest that the medical profession does not and will not take very seriously its duty in this matter and discharge it honourably, but I am concerned with cases where doctors are busy. When doctors have too much to do there is, after all, the same risk as there is with the rest of us that not all that they do may be as well done as could be wished; and I do know that sometimes certifications, as they are at present, in cases of mental deficiency, have to be done by doctors who are under great pressure and cannot give much time and attention to each individual patient. Indeed, I have occasionally wondered whether those cases of remarkably encouraging follow-ups such as were quoted by the noble Lord, Lord Cohen of Birkenhead, may not sometimes be explained by the fact that the subjects of those inquiries were not, after all, quite so mentally lacking as had originally been thought.

Perhaps there is to-day a tendency to endow the medical man with some of the attributes that arc elsewhere supposed to inhere in the medicine man. For reasons into which I need not go, the medical profession carries a very high prestige in the world to-day, and there may be a tendency to attribute to persons who are learned in medicine a wisdom in all spheres which they would be the first to disown. This temptation to exalt the medical profession is entirely intelligible, particularly in this House this afternoon after the speeches that we have heard from the noble Lords, Lord Amulree, Lord Taylor and Lord Cohen of Birkenhead; but I think it does sometimes place doctors in an invidious position and sometimes possibly lays them open to the exercise of powers which the public would regard as arbitrary in other connections.

I wish now to turn for a few moments to the other aspect of the Bill on which there has been a good deal of comment this afternoon: I refer to the creation of this new and very important category of psychopathic persons. Here I must confess that I speak with a mind divided, though not I hope divided in such a sense as to lay me open to procedures under Clause 26 in this Bill. I see the creation of this new category of psychopaths as one stage in a very important social development which seems to me characteristic of our age; that is, the encroachment of the science of medicine into the province which was formerly reserved for morals. This encroachment first made itself felt in our law two years ago in the Homicide Act, 1957, when diminished responsibility became a defence in charges of murder, making it possible in those cases for the charge to be reduced to one of manslaughter. It is now, I think, carried a very significant stage further in the present Bill, inasmuch as the psychopath is not so much given a legal defence on the ground of his psychopathy as enabled to by-pass the courts altogether.

May we consider for a moment in a little more detail the definition of psychopathy which the Bill at present contains? First, there must be a persistent disorder of the personality. That need not be accompanied by subnormal intelligence. Indeed, it need not be accompanied by anything else except the behaviour which forms the second part of the definition and in the current use of the term "psychopath" it is very unlikely to be accompanied by any noticeable symptoms other than those of persistently anti-social or otherwise aggressive behaviour. The psychopath, in fact, is diagnosed by his anti-social behaviour and his failure to respond to the normal stimuli of punishment and reward. There must, therefore, be a persistent condition of that kind.

Secondly, as has been said, there must be abnormally aggressive or seriously irresponsible behaviour. A persistent condition of abnormally aggressive or seriously irresponsible behaviour, which is all the definition we have so far, is an admirable description of the recidivist with whom we are very familiar in the courts. I believe that that definition would cover practically the whole of the recidivist population. And do not let us forget that this definition goes potentially even wider. The only forms of anti-social behaviour that are specifically excluded are promiscuity and other immoral conduct. Presumably in that context the term "immoral" is to be read as confined to sexual immorality, but there is nothing specific in the Bill to say so, and one can foresee some remarkable legal arguments developing as to the line between immoral conduct, which does not constitute a factor in psychopathy, and abnormally aggressive and seriously irresponsible behaviour, which does.

I know that it has been emphatically stated in another place that it is not intended to construe this definition widely; and I know, too, that the stereotype of the psychopath is well known and indeed recognisable not only to the medical profession but, I suppose, to all those who have experience in the courts. We know what this definition is intended to stand for. But we cannot necessarily take these disclaimers at their face value for all time. Experience teaches us that there is no guarantee that what the Minister says to-day the courts will do to-morrow; or, if not to-morrow, the year after next. As the noble Lord, Lord Cohen of Birkenhead, has said, no definitions are written on stone; they are exceedingly flexible—perhaps all too flexible.

May I remind your Lordships of what has happened in other countries? It is, I think, significant that in a standard textbook on social pathology, written and widely used in the United States, one of the chapter headings is concerned with radicals and radicalism, and the other chapter headings deal with criminals, prostitutes, alcoholics and such-like. I think it is not less significant that a distinguished German criminologist—and this may be a sign of the times—has specified among psychopaths persons who refuse military service and persons who are incurably litigious. Both these categories might be brought within the definitions in our Bill as they now stand.

There is, I know, one other restriction, apart from the restriction of age, to which I will come in a moment. The other restriction is that this condition must require or be susceptible to medical treatment. I think it is to be noted that the linking word is "or", not "and". It is easy to say of any condition that it requires medical treatment, particularly when, as is the case with psychopathy, it has been subjected to other treatment which has been a notorious failure.

This category of persons then, my Lords, are liable to be detained without any judicial process; or, alternatively, they are liable under the Bill, after conviction for an offence, to be again indeterminately detained for mental treatment. The noble and learned Viscount has mentioned in passing that a defence of insanity is seldom used at present except in cases of murder. But he did not refer to a possible explanation of that fact, the obvious explanation being that, while an indeterminate period of detention as a person of unsound mind is much to be preferred to a capital sentence, it is not usually to be preferred to a determinate sentence of imprisonment, and it is therefore not put forward in cases in which a determinate sentence of imprisonment is the possibility. So, on the one side, it seems that the psychopaths, as at present defined, are exposed to very considerable risks; on the other side, they enjoy an extraordinarily privileged position, for they are in effect exempted from taking the consequences, the normal consequences, of their antisocial actions. They are not to be brought to trial because they are held to be persons suffering from a form of mental disorder and not persons who are responsibly guilty of anti-social conduct.

Thinking this over, my Lords, it occurs to me that we are now looking forward, if we take a long view, to a time when perhaps the courts will be left to deal with only the following classes of offence or offenders. They will be left to deal with only the trivial offender among the young, the person whose conduct is only mildly irresponsible, and with the occasional offender—that is, with the person who does not have a persistent disorder of personality—since, under the present provisions of the Bill, the psychopath cannot be detained after the age of 25 unless he is dangerous to himself or others. The Courts will also be able to deal, among the older population, with tiresome and persistent offenders so long as they are not dangerous.

My Lords, that would create a very profound revolution in our judicial appeal procedure, not to mention the possible unemployment it would create amongst Her Majesty's judges. If we are coming to a time when all serious and persistent anti-social conduct is recognised as, or thought to be, a medical problem, and only occasional or less serious anti-social conduct is thought to be a matter for penal treatment, we get first a very odd selection of cases in the courts and, secondly, some very strange consequences; for those who are only occasionally or mildly anti-social may well begin to question why they retain their responsibility when others whose conduct is more glaringly anti-social are, by definition, relieved. They may begin to draw the moral that it is better to do wrong in a big way rather than in a small way, since if you do wrong in a small way you are punished for it, but if you do it in a big way you are petted for it.

LORD TAYLOR

My Lords, will the noble Baroness forgive my intervening? Surely you are indeterminately detained for it, which is even worse than being punished for it.

BARONESS WOOTTON OF ABINGER

Only in cases where you are under the age of 25, and it may be that a very subtle calculation will have to be made as to the time at which it is desirable to do wrong in a big way. There is also a possibility of diverse opinions as to the merits of indeterminate detention and imprisonment, although I know that indeterminate detention is generally unpopular.

Finally, if we follow this course—that the grave offenders are, by definition, irresponsible, and that the moderate offenders are, by definition, responsible—I find myself wondering what becomes of the argument that the noble and learned Viscount himself put so forcibly last night, that basically the problem of criminology is a moral problem. If we follow this line to its logical conclusion, the moral area consistently contracts as the medical area expands. As I have said, I am in two minds about this question. I think there is much to be said for this development. Penal treatment in the courts has not been such a success that we have no cause to try something else. But I feel that it is important to call attention to the fact—and here I am profoundly serious—that the creation of this category of psychopaths in this Bill is not just a little trimming of our present legal and judicial procedure; it is the herald of a very profound and far-reaching revolution. I feel that if we are going to embark upon this road—and I, for one, am quite prepared to do so—it behoves us to consider very seriously before we do so what is likely to be the ultimate destination to which the signpost points.

6.20 p.m.

LORD GRENFELL

My Lords, as everybody who has spoken in this House to-day, I rise to welcome this Bill with all my heart, and to thank the noble and learned Viscount who sits on the Woolsack for the wonderful way in which he has explained it to us. I welcome the Bill, not because I think it is going all the way to assist the mentally handicapped, but because in no uncertain way it is bringing before the public the whole question of mental health which has in the past been talked of in whispers as an embarrassing subject. I venture to address your Lordships to-night on that portion of the Bill which deals with children, and, in particular, the mongol child—the biggest single class of mentally handicapped children. One child in 700 is born a mongol, and my wife and I are among the many thousands of parents who have a child of this nature, with all the problems attached to it. I feel, therefore, that if I talk a certain amount about my daughter, it is in no way in a feeling of self pity, but merely that my very personal knowledge of this subject may be of assistance in consideration of the clauses in this Bill which refer to the young.

Many of your Lordships will have seen an excellent television programme on May 15 which dealt with the subject of the mongol child, and heard of the wonderful discovery of Professor Penrose which, we pray, may lead to great things in the elimination of this sad waste of human life. But we must remember that we still have to consider the future of all those alive to-day, and of those who may be born in the near future. I have found so great an ignorance of this subject that, with your Lordships' permission, I will say a few words in general about these children, in the hope that some of my words may infiltrate to the general public.

The birth of a mongol child into a family is in no way hereditary. It might happen to any one of us at any time. The name derives from the strange Eastern features at birth, which remain at varying degrees throughout the life of the child. The mental deficiency shows itself in extreme backwardness, as in the case of my small daughter, now in her tenth year, who does not yet speak. She did not sit up until she was eighteen months old, or walk until she was five, and it appears unlikely that she will ever read or write. There is one great joy about these children, and that is that in almost every case they are charming, in no way vicious, and, for some unknown reason, very musical. They are full of loving kindness to each other and to all who are kind to them. They thrive on love, and live in a happy little world of their own, especially when they are together with children of their own mentality but they would obviously be left far behind if educated with children of normal ability.

I have already said that this type of child is of a naturally happy disposition: hence the birth of a mongol child into a family is, to my mind, far more a parent's problem than a child's problem; and in dealing with this Bill this aspect must be kept very much in mind. Many doctors have advised parents to put the newly-born mongol child into a home immediately—and certainly the reactions of the parents to the child, and the conditions of their particular home, must be very carefully studied. But I believe that these children, if accepted by the parents, do far better in their early days, within the love of the family, rather than the more impersonal—but, my Lords, dedicated—atmosphere of a children's home.

In past years many of these children died at an early age; but now, with the marvels of modern medicine, life has been prolonged, and we must keep in mind that many more handicapped children will grow to adolescence—in fact, to old age—than was the case some years ago. As the child grows up the difficulties of the parents increase. Long after the normal child has learned to feed or dress himself or herself and to perform the natural functions of life in a normal manner, these children will need constant attention day and night, and infinite patience. During this period the assistance and friendship of a mental health visitor, whether from the voluntary services or the local council, is invaluable—and especially to those families who have limited accommodation and where there may be a large family of normal children.

The Middlesex County Council, assisted greatly financially by the Enfield Parents' Association, are setting up a special care unit attached to the special training school in that town, where mothers can bring their children during the day, and hence not only be relieved of a heavy burden but also assisted in the early education of the child—so essential to its happiness in after life. That is for the child of pre-school age. I do trust, my Lords, that other councils will follow Middlesex in this concept. It is not necessary for the unit to be big and very expensive; and I feel sure that parents' associations, if in being, will assist in the financing of such units by holding jumble sales and other forms of entertainment.

We now come to the stage when the normal child will be going to school and the mongol child is growing in body and strength but not in mind. It is at this stage that the State must assist and take over from the education point of view. May I mention one matter which has given me concern in this Bill? Clause 12 (1) of the Bill deals with the power to compel attendance at training centres; and the Second Schedule, paragraph 57, on page 101, deals with the requirement for a medical examination at the age of two or over if there is reason to believe that the child is mentally retarded. In both these parts of the Bill it is stated that notice will be given to the parents in writing about matters which must be complied with—the matters are not important in this context. But I would point out that it is always possible that a mongol child may not be "spotted" at birth, and, if the parents are not highly educated, it may happen that this notice will be the first intimation of mental disability in their child. I fully realise that in most cases it is extremely unlikely, but we know how forms are apt to go out under a signature, with little thought, and I would ask the noble and learned Viscount whether it would not be possible to put some such words as "after a visit from a health visitor to explain the circumstances" after the words "notice in writing to the parents". It can be a dreadful mental strain to be suddenly told by something in writing, and if this other method were adopted I think it would be of great assistance to many parents.

May I return to the education of these children? At first my daughter went to a small voluntary school for chronic handicapped children. They did wonders for her. She played with the other children, but it was soon obvious that she was being left behind mentally. Last summer she went to a special training school in Enfield under the auspices of the Middlesex County Council. It would be hard to put into words our gratitude, and I am sure the gratitude of all parents in that area, for the splendid work done by the teachers and those who form a flourishing parents' association. Many councils throughout the country have done wonderful work, but I know that my wife and I have been blessed by living in Middlesex.

Where a real lead is given by the county council, the parents get together and form associations which do untold good, not only in raising money for special purposes but also in defeating that tragic feeling of loneliness that is so deeply felt by parents living in isolated areas where little or nothing is done for them. I read the other day a letter in which one paragraph brought out this feeling. It said Can you do something to help? I am so terribly tired and I am afraid that my marriage is not going very well. I think that that brings out the point. Everyone must help, and not least the church. One vicar has special services for mongol children and their parents. I attended one such service and shall always remember it. Voluntary societies have done wonderful work. My noble friend Lord Feversham has done splendid work and my noble friend Lord Pakenham is chairman of the National Society for Mentally Handicapped Children, of which I have just become honorary secretary. They do a wonderful job of work. But the people in the immediate vicinity can also assist parents greatly by giving them their comradeship and providing some respite for mothers from a job which, after all, is twenty-four hours a day, all the year round. I would especially ask noble Lords who are in any way connected with the local councils to do all they can to get these bodies to press forward schemes, to find out where these children are and do all they can for their parents.

My daughter has now gone to a training school and is living with a foster parent, as she is too far away to go there daily. She comes home for the holidays and lives with us the life of a child who is normal. These special training centres are undoubtedly the real answer to the problem of mentally handicapped children of school age. In some cases the children are picked up by bus, either from their homes or from their foster mothers, if the parents live too far away. Parents need have no fear of putting their children in the homes of foster mothers recommended by a council. The children settle down very happily and there is no question that they live in that little world of their own quite happily if their bodily comfort is cared for and they have friendship and love. But they do not forget their parents, and we are always received with open arms when my daughter comes home. I am glad to say that I shall be fetching her home to-morrow for the week-end.

The Bill as it is drafted has not made it obligatory for councils to set up these schools, and there is a great lack of them. I am delighted to hear that the Minister is going to make regulations, for I would join with other noble Lords in saying that we shall all be happier if we can have this incorporated in the Bill. To my mind, it is vitally important that it should be in the Bill. I would ask the noble and learned Viscount, to whom I have given notice of this question, the number of these schools at present.

May I turn for one moment to the staff problem, which has been mentioned by most noble Lords? Mental health teaching, especially of children, is very exacting and highly specialised. So far >as I understand, there are plenty of volunteers, hut finance for training is limited and the courses few. I know that my noble friend Lord Pakenham will enlarge on this matter later. A visit to a special training centre is an education in itself. In a normal school the masters and mistresses have the reward of seeing some of their pupils winning diplomas and passing examinations. There are no examinations in these schools; but I can assure your Lordships that the joy when one pupil advances a stage and gains a star is not only thrilling but very touching. It may be that the child has distinguished one colour from another or taken a part in a percussion band. These children long to learn, and so do these dedicated teachers, and finance must be found to give them the training and to have their pay brought up to a figure comparable with that of other teachers.

The situation regarding adult mongols is also causing concern. One practical training centre has lately been set up which will give practical training—I mean for the female, how to wash clothes and sew and do all those small things which are essential in life, and for the man, how to do small jobs which will get him into industry. There is also need for hostels and, if possible in the future—and I know that this is going well into the future—sheltered factories where they can not only do useful work but enjoy the fullness of life by the companionship to which we are all entitled. I must stress that companionship amongst themselves; if they get together in their own little mental lives they will be so much happier.

Finally, may I make a plea to industry to make it possible to use these handicapped people, who in many cases can do simple jobs, and also to the generalpublic not to complain if a training centre is put near their homes? We all realise the difficulties, but it is hoped that through this Bill mental illness will be treated as a perfectly normal form of illness and the assistance of all will be forthcoming in making the life of the children and parents easier than it has been in the years gone by. I stand here representing something like 16,000 parents, and if I could send a message to them I would say reverently, in the words of the first Chapter of the Book of Joshua: Be strong and of a good courage…. And when this Bill reaches the Statute Book, I hope and believe that one could paraphrase the words in the ninth verse of that Chapter: Be strong and of a good courage, as we, the nation, will be with thee whithersoever thou goest.

6.40 p.m.

LORD WINSTER

My Lords, by an odd coincidence I spent three hours of my time this morning on the bench dealing with a most distressing case where, following the birth of a child, there had been a psychological breakdown on the part of the mother and a subsequent history of periodic sojourn in a mental home. What struck me forcibly about the case was that all concerned wanted to do the best they could in the matter. Although it involved the break-up of what had been a very happy home, there was no recrimination, and not a harsh or unkind word was spoken by anybody. I am bound to say that my fellow magistrates and I were for the time being absolutely at a loss to know what could be done, and we were reduced to adjourning the case for a considerable period to give those concerned time for reflection—and, I may add, to give the magistrates time for reflection, too. This case, coming this morning, impressed upon me all over again that in this Bill we are dealing with one of the most cruel of the afflictions to which mankind is subject, and one about which the public is not now so much hostile as so terribly misinformed.

The commonest remark that one hears from people who have been, or are, confined in mental hospital is: "If only People knew what it is like to be mentally ill if; only they could understand." I have heard those remarks made by people in this condition. A woman who has been afflicted in this way, but who has recovered, said: "It is a slow and insidious process. One passes into another sphere. It is like living in a nightmare. There are voices and visions, It is common to believe that you are possessed of a devil. A battle is going on inside your head night and day. You reach a point where you just cannot cope. You feel alone, different from everyone else." The point is brought out by an unfortunate boy of eighteen who said: "I began having hallucinations: people in my mind telling me to go and drown—a terrible feeling; and I felt as though insects were crawling all over me." Then the pathetic part: "I feel safer in hospital than outside. I am trying to get better. I do so hope to get on in this world." How tragic to know that you are not as other people are, and that you long to be!

Until I became a magistrate, now many years ago, I used to think of mental illness as something which happened only to other people and could never happen to me. But in fact this mental illness is possibly the largest single health problem confronting us to-day. To me the figures are quite extraordinary. One in twenty of the people in Britain will at one time or another be in a mental hospital one family in five has someone in a mental hospital nearly half the total of hospital beds is occupied by mental patients. A matter which is of some importance on the economic side, but is frequently overlooked when discussing this subject, is that nearly one-third of all absence from work is caused by mental illness or psychological trouble. In a typical year some 480,000 in-patients or out-patients are treated for mental illness. In 1957, 8½ million working days were lost through strikes—too much perhaps—but 70 million working days were lost through mental trouble.

I heard a professor of psychiatry say this: "We all have a kind of private conspiracy not to talk about things that frighten us. So long as there is ignorance about mental illness there will be fear and unwillingness to talk about it. Poliomyelitis gets a lot of support because it is dramatic: a lot of mental illness is not dramatic." There is this ignorance which we have to fight and struggle against with all the means in our power. It is commonly believed, I find, that there is a distinction between mental illness and insanity. I find that the man in the street is apt to think of the mentally ill as being just mildly ill with something that will pass, but that an insane person is incurable. I think I am right in saying—the noble and learned Viscount on the Woolsack will know—that "insanity" is a lawyer's term and not a doctor's term. All the same, I think that knowledge about mental illness has grown among the public and that to-day the attitude towards the sufferers is much more humane.

The noble Lord, Lord Silkin, said at the end of his speech that we can now go forward. But we have been going forward for centuries. In the bad old days, insanity was believed to be incurable; it was thought that all that could be clone with the insane, who were divinely afflicted, was to lock them out of sight. Think of those revolting prints and pictures throughout the ages which depict the ignorance and bestial cruelty of their treatment in the old days! By comparison, the mentally ill to-day are fortunate. And this Bill, again, effects another complete revolution in the treatment of the mentally sick.

No longer is the idea to lock them away in Bedlams and prevent their escape. Mechanical restraint, padded rooms and so on, are hardly employed at all, except in oases of quite dire necessity where it is a compulsion. Now, the effort is to get the menially sick out of hospitals, to treat them and to restore them to the current of normal life—to care for them in the community instead of in hospital. The staff in mental hospitals, or these old Bedlams, were allowed to treat the patient worse than they would have treated animals. But to-day these staffs are trained to think of patients as 100 per cent. human beings with a life of their own: people with whom they have to establish a good and understanding liaison.

As has already been said this afternoon, mental hospitals now admit mental patients without certification. There is to be no more filling up of forms. A more common sense point of view is replacing the old sense of shame at having an afflicted relative. As an instance of modern common sense which has crept in already in these matters, I was most interested to read something by a patient who had been restored to her home from a mental hospital. She said she had discarded all the genetic phrases which are so favoured. She said, "I prefer 'nut-house' 'loony bin' and 'dotty'. They are more homely and comforting. Friends were taken aback at first, bat they have got used to it, and now I think it is a relief to people. Sanity is something which you can learn." I think that is a very agreeable and pleasant point of view, illustrating the common sense which now finds its way in. This woman had found no sense of stigma; she had not encountered that, and is now married. Another ex-patient said: "Why should not my poor head be ill just as your poor head, or your poor leg, or your poor anything else." That is a hopeful attitude for the future.

I think it is a wonderful thing that we are to abolish the distinction between mental and physical illness, and that any hospital will be able to treat a mental patient as readily as it treats a physical patient. That is perhaps the greatest step forward which is being effected. Treatment without compulsion, except in very abnormal cases, which are provided for in the Bill, will in future be normal. Psychiatry, as we have heard repeatedly this afternoon, is becoming a more important subject; and so is training in the care and handling of the mentally sick, which is now recognised as being of the greatest importance, and the realisation that what was once called insanity is only another illness and is to be treated on that footing. As has been emphasised by many speakers, I hope that sufficient money will be spent on medical health research in this sphere.

There is one point in the Bill about which perhaps the noble and learned Viscount will be kind enough to take note that I have spoken. Part V of the Bill deals with the powers of the court to order admission and detention of a person in hospital. I understand that magistrates' courts may do this in the case of offences punishable by imprisonment, provided that two doctors also certify that the offender is suffering from mental disorder to a degree rendering detention in a hospital desirable. This seems to me in some sense to involve a conflict in the Bill.

Clause 61 requires that where a young person is brought before a juvenile court as needing care and protection or as being beyond control—provided that certain requirements are satisfied—the court shall have power to make a hospital order; and the provisions of Clause 59 apply the necessary modifications. But Clause 61 (2) provides that a court shall not make such an order in respect of a young person beyond control—as opposed to one convicted on an offence—unless satisfied that the parent or guardian understands the implication of the order and consents to its being made. It seems to me, however, that under this clause a juvenile court has power to make a hospital order without the consent of the parent or guardian if the young person is convicted of an offence of the type provided for in Clause 60 or, in the case of a young person brought before the court under Section 62 of the Children and Young Persons' Act, 1933, is considered to be in need of care and protection. I think that possibly this may call for an Amendment to the Bill.

It seems to me that that could be easily done by deleting the words "consents to its being made" and making the clause read, A juvenile court shall not make a hospital order or guardianship order unless the court is satisfied that the parent or guardian understands the results which will follow from the order, but it shall not be necessary to obtain the consent of the parent or guardian to the order. It seems to me anomalous that a juvenile court may, on the evidence of two doc- tors, make an order in the case of a young person found guilty of stealing 5s., or who is brought before the court by an authorised person as being in need of care and protection under Section 62 of the 1933 Act, but that if a parent or guardian brings a child up as being beyond control under Section 64 of the Act the court, although satisfied that the child is mentally disordered, cannot make an order unless the parent or guardian consents. I feel that between now and the Committee stage that matter deserves some examination.

I can see two possible objections to what I propose. The first is that parents or guardians, if satisfied that the young person needs hospital treatment, would not refuse consent. Anybody who holds that view about parents knows little about them, as is common knowledge to both doctors and magistrates. Unfortunately, there are a large number indeed of parents who are thoroughly unreasonable. And the second objection is that the liberty of the subject ought to be protected and treatment should not be given without the consent of the parent or guardian; but the order can be made without consent only in a case of theft however small, or if the charge is one of being in need of care and protection. It does seem to me, therefore, that perhaps there is an anomaly involved here and it deserves some examination.

I say, in conclusion, that training in this matter is all important and it is essential that it be tackled with urgency. Too many mental welfare officers have had no training. Of about 12,500 adults over 16 suitable for training only 6,000 are receiving any training, and we want ten times as many psychiatrists and social workers as we have at the present moment. There is one other thing to which I think it is well worth while calling attention, and that is the difficulty of obtaining employment by a recovered mental patient. In law no special disabilities attach to anybody who has once been certified, but in practice what happens is very different. There is great difficulty in obtaining employment by one of these unfortunate people. Employers do not like to give a job to someone if they find out that there is a record of mental ill health; and if by some chance they happen to have given such a job and the person is found to be doing it perfectly satisfactorily and well, yet if the fact is found out the employer is very likely indeed to find some cause for getting rid of such a person.

That difficulty of getting employment, the search for employment and the being turned down because of this old history, leads to the setting up of a state of strain which is very likely indeed to result in the person finding his or her way back to the mental home from which he or she came. And the fact of his return makes the cure far more difficult than ever it was in the first place. I hope employers may be generous in this matter and make it their custom to give such people at any rate a chance.

I have one last thing I want to say to my noble friend Lord Pakenham. We have heard a great deal to-day about the definition of "psychiatrist" and "psychology", and so on. I never worry very much myself about definitions, because I think that on important matters they are extremely difficult to arrive at. I believe there are upwards of forty definitions of "socialism" for instance. Here I feel that Lord Pakenham can help me. Has a definition of a Christian ever been arrived at? It seems to me very difficult, because such a definition would have to cover the Pope of Rome, the General of the Salvation Army and such a man as the late Lord Balfour. I should think it is very difficult indeed to define a Christian. But what matters is that we all know a Christian when we happen to have the good luck to meet one; there is no doubt about that. We do not require any definition on that occasion.

The noble Lord, Lord Silkin, asked the noble and learned Viscount the Lord Chancellor to reconsider the removal of the justices of the peace from the chain of events which affects a mental subject. I have only this to say: I do not want to beat the drum for the magistrates, and you know, my Lords, that I should be the last person to say a derogatory word about doctors, to whom I owe a debt that I can never repay, but there is a great suspicion among the uneducated to-day about doctors, and especially where mental disease is concerned. There is this phrase "Put away", and there is always the feeling about the mentally afflicted that they "get put away". It dates from the time of which I have been talking. I feel that on that account people have a sort of confidence in a magistrate to see that, as they would say in their language, no "hankey-pankey" is done about it; and I believe that the magistrate is still a very valuable link indeed in the chain of events dealing with the mentally sick.

7.7 p.m.

LORD AUCKLAND

My Lords, due to business commitments I was not able to be present when the noble and learned Viscount the Lord Chancellor moved the Second Reading of this Bill. I conveyed my apologies to him yesterday and I do so again in your Lordships' House now.

My wife worked for three months as secretary to one of the doctors in a large mental hospital near where I live, and I am closely connected with this hospital myself. I also serve on the board of childrens' hospitals. Therefore I feel that I am at least partly qualified to participate in this debate. I have always had a great interest in this problem of mental health. As has been stressed before, it is one of the greatest problems of our age, but with the progress of science it is gradually being modified into something which can be tackled.

I feel that this Bill is a landmark in the mental history of this country. It is not a perfect Bill but it does cover every conceivable sphere of mental health. It was perhaps fortuitous that in your Lordships' House yesterday the subject of television was debated, because through the medium of television much of the fear of the stigma which has been applied to mental hospitals has been removed. Only a few days ago I saw a most movingly presented programme on the problem of child mongolism, which the noble Lord, Lord Grenfell, so expertly mentioned, and it was the kind of programme which only the medium of television could put over in a really convincing form. While this Bill does not attempt to cover that problem, it is one which is ever evident in our lives to-day.

The Bill itself includes one or two matters which need to be raised, and one of the most important clauses, I think, is Clause 4 of Part I, which deals with the informal admission of patients. In the particular hospital in Epsom in which I am interested, this practice has been going on for a good many years, and most successfully. But there are two snags connected with this problem. The first is the provision in Clause 132 of Part IX of the Bill, in regard to pocket money for patients. I am informed—perhaps the noble and learned Viscount the Lord Chancellor will correct me if I am wrong—that only in-patients can draw on financial help and that other patients do not get that assistance. It seems to me that this ruling will discourage people who normally would take themselves in for voluntary treatment. Perhaps some explanation or clarification can be given on this point.

Then, connected with the same problem is the clause on the local authorities' service in Part II—I think it is Clause 40. This is perhaps one of the most vital clauses of the whole Bill, because it enables the patient, particularly the younger type of patient who is reasonably able bodied, to get work locally, thus making room for the older and infirm patients who are not employable. But, taking my own area of Epsom, which has a population in the town of about 20,000, we find that there are eight mental hospitals with some 7,000 or 8,000 patients. The problem is going to be how these matters are to be financed, because most of the patients who enter these hospitals come from the area of South-West London. I do not know whether the local authorities in the London area will contribute as well as the Surrey local authorities. From the point of view of the ratepayers, that seems to me to be quite an important point.

Another matter arises in regard to Part IV of the Bill. Clause 59, at line 35, describes a responsible medical officer in charge of a patient. Again referring to the hospital in which I have an interest, I would mention that there was a case of a young girl who was given permission to attend a dance. That permission was given by one of the junior doctors—the registrar, I think the term is—and the girl claimed that at this dance she had been assaulted. Naturally, there was an inquiry. The parents came down. Fortunately, it was proved that the story was not in fact true. But there seems to be a danger here that a junior doctor can, without the authority of his senior counterpart, give authority on very responsible matters. On the Committee stage of the Bill perhaps a clearer definition of who is a responsible medical officer may be inserted. Obviously, he must be somebody of high rank to give permission in matters of this nature.

There is one other point which I should like to mention—namely, the fact that in the Epsom group there is not one electro-encephalogram for use in those hospitals. I am informed that contact has to be made with Belmont, which is several miles outside the town, for the use of this most vital piece of equipment, and that transportation costs for getting patients to the centre and bringing them back, and for getting the equipment to and from the centre, are very high. I mention this one instance—no doubt the problem is nation-wide—for it seems to me that equipment of this nature should always be on hand, within reason, when needed. Obviously, an area which has eight hospitals in close proximity should have this equipment available at very short notice, because it can save much time and possibly much distress.

Particularly do I welcome the statement in another place by the Minister of Health that the estimated expenditure in the year 1958–59 on the mental health services is to be £4,100,000—an increase of over £500,000 on expenditure in the previous year. That, I think, proves that Her Majesty's Government are far from complacent about the importance of this problem. I commend this Bill to your Lordships. It is a Bill which, as I say, will make our mental health services most impressive, and I think that the Minister and all who are in charge of these services and who have a very difficult task before them deserve the highest commendation.

7.19 p.m.

LORD STONHAM

My Lords, I join in the warm welcome which I think has been accorded to this Bill, because it seeks to acknowledge, and indeed to enhance, the tremendous improvement which has been effected in the treatment of mental illness and the near revolution which has taken place in the attitude of the public towards mental illness in the last few years. Even thirty years ago, the words "Abandon hope all ye who enter here" would not have been entirely misplaced if placed over the entrance of a mental hospital. Even in 1950, just over nine years ago, when I became chairman of the mental health committee of a Regional Hospital Board it was still the case that the mentally sick were mentioned in terms of shame and fear. To-day, people are at last beginning to realise that sickness of the mind is an illness like any other, and just as susceptible to treatment and cure.

But, warmly as we welcome the Bill, I think it is only right that we should not overlook two great dangers: first, that if the Bill is not implemented with speed, energy and full provision of finance, we shall merely have raised people's hopes only to dash them again in disaster; and secondly, that if mental hospital patients are thrust on to the public before there is adequate provision of all kinds, we shall do cruel and irreparable harm to people who are helpless and depend upon us.

Do not let us pretend that we are anything like ready. There is not a single local authority in the whole of the country which in twelve months' time could carry out its responsibilities under this Bill. Nor, I think, have the general public been sufficiently educated to absorb willingly and with understanding a considerable number of mentally disordered people in their midst. We do not yet know when the Bill will begin to operate. At best, in my view, it will take at least two years for local authority schemes to be submitted, approved and set in motion; and then we shall need the trained staff to which frequent reference has been made this afternoon. I would recall the article by Professor Titmuss in The Times recently which showed how woefully the Government's arrangements for trained staff have fallen short of what is needed. According to another estimate, it will take ten years to train the necessary 300 psychiatric social workers; and even this long-term target will be achieved only if there is a combined financial and other effort.

I believe it is only too unhappily true to say that the sums of money so far mentioned in this regard by the right honourable gentleman the Minister are derisory in relation to the need. In my view, a ten years' wait is quite unnecessary. The Minister should ask not for local authority schemes to be submitted but for joint schemes from Regional Hospital Boards and local authorities, because it is only in our mental hospitals and mental deficiency institutions that there is any reservoir of trained staff; and most of them are dedicated or they would not be there. If patients are to be treated in the community, then some psychiatrists and trained mental nurses can be relieved of hospital duties; and they will be the key workers providing the nucleus of the staff we need for field work. They will know about the patients they now have in hospital, and they can be relied upon not to turn them into the world until the domiciliary conditions and services permit a fair chance of success.

There is absolutely no room for parochialism in this job. From the first day, and always, the local authority health officers and the hospitals will need to work together on almost every case, and therefore I urge Her Majesty's Government, in the first instance, to make not the local authority but the hospitals, the Regional Hospital Boards, and the mental hospitals and mental deficiency institutions under those Boards, the prime movers in the development of this matter; and to make the hospitals joint partners in every scheme which is submitted when this Bill becomes an Act. I want the mentally sick to be as free as possible, as soon as possible, as safely as possible—three objectives which are sometimes in conflict; but in all of them this Bill falls short of what is desirable, particularly in regard to the mentally handicapped and mentally deficient.

I find it somewhat remarkable that when a high proportion—something like 40 per cent.—of all the afflicted people who are dealt with by this Bill are mentally deficient, so little reference has been made to them during this debate, apart from the moving speech by the noble Lord, Lord Grenfell. I speak from experience, and I feel it cannot be over-emphasised that when we are dealing with what we call the "mentally deficient" we are dealing with people who, subject to sonic exceptions, will be children all their lives.

The noble Lord said that his daughter, aged ten, could not yet speak. It has been my experience to walk into a room containing fifty men, not one of whom could speak. It meant that although they were fully clothed, walked about and were doing simple handicrafts, and although they suffered no physical disability, not one could speak because their mental age was that of a baby. But, my Lords, they were happy. As the noble Lord emphasised—and I was very glad he did so—they are really happy, so long as they can be protected and loved. They are perhaps among the happiest people in this world, because they live in the perpetual happiness of childhood and love; and it is vitally important that they should be cared for by those who can see beyond the external, who can see the happiness they have inside and experience the great joy of having that love and trust returned, and who realise that the rewards of that service are greater than almost any other.

I regret, therefore, that this Bill pays comparatively little attention to mental deficiency, and I would refer the noble and learned Viscount on the Woolsack to what I regard as a fundamental defect—namely, that we are asked in this Bill to deal with mental deficiency on the same basis as mental illness or psychosis, though it presents an entirely different set of problems. We cannot really deal with the two in the same way. It is in the field of mental deficiency that the Bill makes the greatest changes, and it is a pity that only one member of the Royal Commission had had considerable day-to-day experience of mental deficiency practice, and an even greater pity that the right honourable gentleman the Minister of Health, when he was approached to receive a deputation of medical superintendents from mental deficiency institutions, felt it inadvisable to do so.

There is a curious element of class distinction—and it has arisen in a curious way—between our treatment of people who suffer mental ill-health and people who are backward or mentally deficient. It arises in this way. Anyone who is mentally ill must be cared for in a hospital or a mental home, but if a child of middle-class parents is mentally deficient it is usually looked after in the home and is not sent to an institution. Consequently, most mental deficients in institutions—and I would mention to the noble Lord who shakes his head that for some five years I was responsible for 17,000 of them—come from the working class, and as they are perhaps more used to having things done to or for them they have been less vocal about the clauses in this Bill. It behoves us, therefore, to look at those proposals all the more carefully.

The Bill sweeps away the Mental Deficiency Act and the Board of Control, but in some respects they are only discarded for new entrants, not the others already in the hospital. For example (and I hope the noble and learned Viscount on the Woolsack will deal with this point), the Bill lays down that the subnormal patient must be released at the age of 25 unless he is likely to be dangerous to himself or to others; but if he is already in the hospital he can be denied release at the age of 25 on the three additional grounds that he is liable to be exposed to danger or serious exploitation by other persons, is likely to resort to crime or is incapable of caring for himself and there is no suitable place to put him. In my submission and experience all those safeguards are necessary. Whether they are or not, there can be no possible justification for different treatment of persons of the same age and the same mental standards in the same hospital; and I hope we shall put that right in Committee.

Then again, although I am in favour of a demarcation line, and perhaps the age of 25 is as reasonable as we shall find, we should not act as if a subnormal was magically cured on his 25th birthday. Many sub-normal patients can be trained for life in the community. Some become completely independent; others need constant guidance to maintain their place in the world; and there are some who, having been put out on licence, having been given a chance, are found unsuitable and have to return to hospital. All who have had experience know that this is true. But under this Bill, if a patient of twenty-one is working out on licence or leave he cannot be recalled after six months. This is a totally inadequate period if we are to be reasonably sure, not of the public safety but of the safety of the patient. I hope that this can be amended so that, if necessary, the six months can be extended for further periods of six months, subject always to the right of appeal to the Tribunal. I have always been opposed to long periods on licence and I have made it a rule in my hospitals that after two years the medical superintendent must show cause why a patient should not be recommended for discharge from order.

I had the terrible experience of a man of twenty-nine coming to my house. He said that he had escaped from a mental deficiency institution, and he came to my house because he believed that once he got there he would be safe. I discovered that what this lad told me was true. He had been working on licence since he was seventeen, for twelve years. He told me what would happen to him when he went back, as I insisted he should go back, and what he told me was true. I had an inquiry made and within two months he was discharged, as he should have been years previously. But after the age of twenty-one, to be out on licence, out on trial, for six months is not enough; and if it is not altered the danger is that the medical superintendent may feel obliged, in the interests of the patient, to deny the chance of licence and keep the patient in until he is twenty-five.

Medical superintendents' whole attitude has changed enormously, unbelievably, in the last few years, and particularly in the last twelve months since the Ministry's Circular 58/5 of January, 1958. One of my friends who is a medical superintendent in Bedford wrote to me only last week asking me to go up to the parents' association, which the noble Lord mentioned, which is doing such wonderful work and which was unheard of a few years ago in connection with mental hospitals. Out of 67 new entrants last year only two were subject to order in a mental institution—only two subject to any kind of order out of 67. But we must protect those two. We must ensure that conditions are such that those two cannot he thrown out into the world to be exploited in a manner which we know does happen. I have seen too many parents, unfortunately—I regret to say it—whose only interest in their children began to arise when there was a chance that they might earn some money. Those children have to be protected in this way and we must have some reserve powers and not destroy anything.

We should also make provision in special circumstances for compulsory admissions of sub-normal patients who are over twenty-one. I know a working-class family, that of one of my foremen living in the country, with a son living at home whom I see frequently. The boy is thirty, but his mental age is about eight or nine, and when he is bad or his mother is sick he has to go into a mental-deficiency hospital for a few months. Under the Bill as it stands that would no longer be possible, and without his consent he could not be cared for in an institution when, as will inevitably happen, his parents cannot look after him. We must make provision for such cases in Committee, and for instances of deterioration in later life.

So far I have pleaded for more safety provisions in the interests of the patient. I now wish to give some examples of where further Amendments are needed in the interests of freedom. The first is this abominable proposal—I think it is abominable—to legalise illegal detentions. It is known that, despite a large number of releases, there are still some 2,700 persons detained under orders which are illegal under the High Court judgment in the Rutty case; that is, the people who were detained because they were "found neglected" when they were not so found, and were therefore illegally detained. Clause 147 of the Bill proposes that all these orders should be deemed valid if the Board of Control have considered them and decided that the patient is not fit to be discharged. The right honourable gentleman the Minister of Health has admitted that some would he discharged but for the fact that they have nowhere to go, so we are being asked to legalise the illegal detention of people who are not suffering from mental disorder. I would suggest that that is wholly intolerable and indefensible. If they have nowhere to go it is up to us to make provision so that they can be employed either at the hospital or in some other place and looked after.

I think that another considerable and dangerous restriction of the essential liberty of the subject lies in the proposals for compulsory detention without the right of appeal, a matter which was so ably dealt with by my noble friend Lord Silkin. There is, of course, the appeal to the Tribunal after six months, but that is when the damage is done. The Tribunal can get a patient out but they cannot stop his going in. The fact that a person has had mental treatment is a handicap for the rest of his life. It is harder for him to get a job or to take out certain insurances and he cannot emigrate to the Dominions. It is the fact that he has had treatment which counts. If the patient is really suffering from mental disorder, then he must, unfortunately, suffer also the attendant consequences but we should make absolutely sure first.

I think there should be, or there could be (and I hope this point can be dealt with), provision for compulsory detention for observation—not for treatment but for observation—which would not involve diagnosis and then compulsory treatment. The patient should then have the right of appeal to the Tribunal against any proposal for compulsory detention before the end of the observation period. If it was confirmed we could not help it, but there will be cases where during the observation period it can be shown that detention is not necessary; and therefore there should be the right of appeal during that period. I hope that when this Bill finally leaves us we shall be able to say that we do not agree and we will not allow a person to be deprived of his liberty without some form of judicial sanction—what my noble friend Lord Silkin called a civilian check. I think it is necessary and generally desired by the medical profession.

I hope that the noble and learned Viscount the Lord Chancellor will be able to tell us that the regulations for the conduct of Tribunals will permit an appellant to be represented or accompanied by a friend, and that he will be kept fully informed in advance of the nature of the evidence put forward in support of the demand for compulsory detention—something on the lines of the pensions and appeals tribunal. I think that that machinery is admirable and works well.

Finally, I would support the plea advanced by my noble friends Lord Silkin and Lord Taylor for complete freedom in the matter of patients' correspondence. At present there is no legal power to intercept letters from patients in mental hospitals, but the Bill gives a medical officer the legal right to open and censor both incoming and outgoing correspondence. I know that there is something to be said for protecting a mentally afflicted person from the letters of inconsiderate, ignorant or selfish relatives who may try to interfere with or curtail treatment. But there can be no possible justification for stopping outgoing letters from patients. This was certainly the view of the Royal Commission, whose only reservation was that individual addressees could ask that letters addressed to them might be scrutinised or withheld, which can be done without censorship because you have only to read the addresses. It can be done without this whole ugly business of censorship.

The whole object of this Bill is to stop treating patients like prisoners, and to make them feel like patients. What makes the thing particularly intolerable (and I do not think it is generally realised) is that Clause 133 makes it clear that this censorship will apply to both those patients who are subject to detention and informal patients who are not, which is surely quite unbelievable. The basic purpose of this Bill is to persuade people that mental health is just a sickness, like any other physical illness. We want people to come forward for treatment with confidence. It is intended that some of them, perhaps many of them, will be treated in general hospitals. Yet at the outset we shall sap their confidence and prove that it is a special illness by revealing that their letters will be opened and read, and perhaps withheld.

In a group of general hospitals in London of which I am Chairman I see every complaint. They are fortunately very few, but they are sufficient to indicate that scurrility, slander, libel, sex obsession, baseless accusation, and general foulness, are not confined to letters from patients of mental hospitals. Yet no one would dream of suggesting that letters from patients in the general surgical and medical wards of hospitals should be censored. The powers proposed in the Bill are administratively burdensome and easy to evade; but, above all, they are unfair, and they will discourage and damage the very people we wish to help. I hope that at a later stage the Government will delete them.

My Lords, we have all welcomed this Bill. It is inevitable that in a Bill of this nature, running to nearly 150 pages, there are many points of controversy, but I know that the noble and learned Viscount the Lord Chancellor will agree that it is better for us to express our approval and then to deal with the points with which we disapprove rather than to make it just one continuous hymn of praise. It is a good Bill, and I think it is the chance of a new deal for tens of thousands of afflicted people who have suffered too much and too long. If, when it becomes an Act, everyone—doctors, nurses, patients, relatives; in fact, the whole community—will unite in implementing its provisions, then it may well prove the outstanding achievement of this Parliament.

7.43 p.m.

LORD CRAIGMYLE

My Lords, at the risk of vain repetition, I also venture to welcome this Bill. The change of attitude, and terminology of the Bill on the subject is demonstrated very clearly even from the Short Titles of the Acts about which we have been speaking this evening. It goes chronologically: from lunacy to mental deficiency; then mental treatment; and, this year, mental health. It may be, as the noble Lady opposite has so shrewdly pointed out, that we are now getting to the stage when we must seriously watch out for the danger that all criminals may be categorised as mental patients, thus destroying the basic concept of moral responsibility. I eagerly look forward to the reply of the noble and learned Viscount the Lord Chancellor on that all-important point. However, that is riot the point which I wish to raise.

This Bill alters a great many arrangements, and sets up new arrangements. But before we abolish all the old arrangements, we must be quite certain that in every important respect those things which were good in the old arrangements are retained. As I see it, there is one important respect in which something that was good under the old scheme is not provided for in this Bill—I refer to the chaplaincy services which were insisted on under the Lunacy Act of 1890. And with that I would couple the provisions in the Mental Deficiency Act, 1913, which were designed to ensure that patients would be treated in an atmosphere which accorded well with their home religious background. I shall venture to quote briefly from both those Acts in a few minutes.

The necessity of chaplaincy services, my Lords, is well recognised in this country—in the Armed Forces, in the prisons, in the hospitals, and in every walk of life; certainly in Parliament. It seems to me, therefore, that it would be a great pity if, where specific provision has been made in past Acts, the matter should, under the new procedure, be left merely to be treated according to custom. It is certain that the good will of Her Majesty's Government will always ensure, even though no specific provision is made, that adequate chaplaincy services are available to mental patients, but I should like to see such a provision written into the Bill. On different points several other noble Lords have made the same remark: that they would like to see provisions written into the Bill, rather than just left as permissive to the Minister.

The reference in the 1890 Act to chaplaincy services is in Section 276 and Section 277, under the heading "Officers of Asylums". The Act says: The visiting committee of every asylum shall appoint"— and, my Lords, notice the order in which the officers are mentioned—

1. "(a) a chaplain who shall be in priests orders and shall be licensed by the Bishop of the Diocese;
2. (b) a medical officer", etc.

That, my Lords, was the sense of proportion of our Parliamentary predecessors in 1890—(a) a chaplain, and (b) a medical officer. Section 277 lays down in considerable detail the chaplain's duties, and also provides for chaplaincy services to patients who are not members of the Established Church. There is a further section in that Act which I will briefly mention. That is Section 47, which governs the right of the patient's friends to be admitted, and others also, which could presumably include ministers of religion.

Turning now to the general provisions for religious compatibility between patients and their surroundings. I believe that this point arises particularly under the guardianship provisions. There are quite careful provisions in the Bill for the selection of suitable people as guardians under the guardianship orders, but none of those provisions specifically instructs the local authority to see that the patient is under the guardianship of someone of his own religious persuasion. It might be that this would only comparatively seldom be a stumbling block, but both in the question of guardianship and, even more, in the question of training centres there might on some occasions be, between the home and the training centre. or between the original home background and the guardianship, a difference in religious approach which might set up a tension to the detriment of the patient.

It seems to me that this point is sufficiently illustrated in Clauses 12 and 13, where it is provided that the parents of a child which is being sent to a training centre are bound to send the child there, or allow it to be sent there, as a resident. Among the reasons which are recorded in the exceptions as being legitimate reasons why they should refuse is inconvenience and sickness; but apparently there is no right on the part of the parents to object on grounds of conscience. It is difficult enough for parents of healthy children to see their children going to schools where there is a different religious background from that of the family. How much more does tension arise with a mentally retarded child, such as that of whom the noble Lord, Lord Grenfell, has spoken!

LORD GRENFELL

My Lords, at the moment these training schools are not boarding schools but day schools, and there is no doubt that any form of religious teaching is most carefully looked after. I feel convinced about that, and I have no fears at all that there is going to be any difficulty there.

LORD CRAIGMYLE

My Lords, I am glad to have that reassurance from the noble Lord, from his experience. My point is not that the danger is actual but that specific protection could be, and should be, written into the Bill.

In conclusion, may I say—although I may be accused of irreverence—that if "man does not live by bread alone" it is equally true to say that a sick man is not cured by medicine alone. The advances in science since 1890 have shown us how close is the relationship between body and mind and between mind and spirit, and how intricate and difficult it is to sort out the inter-actions between one part of the human personality and the other. Yet here we have our comparatively ignorant grandfathers providing specifically for the spiritual welfare of the people they called lunatics while we ourselves are apparently making no such specific provision for those whom we now regard merely as sick.

7.52 p.m.

LORD PAKENHAM

My Lords, I should like to support the burden of what has fallen from the last speaker, the noble Lord, Lord Craigmyle, but he will forgive me if I do not follow him further to-night, although it may well be that when we reach Committee stage there will be a good deal more to say about this aspect.

We have listened to a very expert debate, as always in your Lordships House. We have had almost every kind of expert knowledge brought to bear, except actual experience inside a mental home. If that has been enjoyed by any of the speakers it has not been revealed. If my noble friend, Lord Silkin, has his way in regard to membership in your Lordships' House, it will be more or less likely that we shall have that happening; but no doubt that will be settled in the case of every one of us by a psychiatrist and another doctor or by a psychiatrist and a magistrate. Certainly if I were going to fall into the hands of a psychiatrist, I should prefer to have a neuro-psychiatrist, just as I should rather he treated by a physiotherapist than by a masseur, by a pharmaceutist than by a chemist. On that and on other grounds, particularly after listening to the deeply experienced, wise and impressive speech of my noble friend Lord Taylor, I can assure him that, if we have to be examined in the way suggested by my noble friend Lord Silkin, I will come to him for his diagnosis and classification. If morality is to be brought into this matter, I should gladly turn to the noble Baroness, Lady Wootton of Ahinger, except that she has shown herself so strict a moralist that I am afraid I should be frightened of her inevitable censure.

I should like to say how deeply impressed I was by the various speeches that came from the Benches behind me, and by that of my noble friend Lard Silkin, whom most speakers have paid the compliment of imitating in greater or less degree, and also by that of my noble friend, Lord Stonham, who dealt so effectively and movingly with the mentally sub-normal. As my noble friend, Lord Grenfell, has said, I have recently become the chairman of the National Society for Mentally Handicapped Children. The noble Lord, Lord Grenfell, has spoken about that whole question far better than I can, so that I do not intend to say anything like so much as I would otherwise have said. We shall all long remember the noble Lord's speech. We in the National Society welcome the Bill. We welcome it because of the change of atmosphere that the Bill is bound to bring about. No longer will the mentally sub-normal and the handicapped. these fellow human beings of ours, be treated as despised and rejected, as people to be tucked away. I would have referred earlier to the speech of my noble friend, Lord Feversham, who speaks with such great authority on this matter, and I hope he will forgive me—he was out of the Chamber.

We welcome the tremendous psychological advance held out to us in this Bill, and certainly the Society of which I have the honour to be Chairman welcome it cordially from that point of view. But, as several speakers have said, I must draw attention to the vital measures of reform which are fundamental to the effects of working out the good intentions evident in the Bill. These come under three main headings: first of all, research; then, teaching and training, and then better conditions in mental deficiency hospitals.

We know that the scientists want to do research into mental deficiency, but at present there is fantastically little money allocated, as my noble friends, Lord Feversham and Lord Grenfell, have said, to provide for research work in this field; and naturally the research is simply not done. It has been known for same time, but perhaps not to the public, that with suitable training many sub-normal people can become partly self supporting. Far too little is done to provide for the training of teachers in this work, and the status of the occupation centre teacher at present compares so unfavourably with that of any other category of teacher that it is difficult to recruit people with a vocational interest in the educational problems of the mentally defective who may also be able to experiment in methods of training these children and exploring the limits, at present ill understood, within which qualities such as manual dexterity and motor co-ordination are capable of improvement.

Finally, the conditions in some mental deficiency hospitals, as my noble friend Lord Silkin observed, are shocking. They are a serious factor in the reluctance of parents to part with a child whose condition may be so severe that he needs hospital care. I think we all agree with my noble friend Lord Grenfell that the health and social services must increasingly get together and support the parents who are caring for these children at home. There are many other aspects of these provisions for the mentally handicapped that I hope, as no doubt many other noble Lords will wish to do, to raise on Committee stage, but the hour is late and we are anxious to hear the noble and learned Viscount the Lord Chancellor, though I appreciate that he may be reserving a good deal of what he wishes to say until the Committee stage is reached.

I think it is very hard to stand up and say whether this Bill is a matter for unmitigated congratulation or a matter for praise and regret. What is good in it is undoubtedly very good. My noble friend Lord Silkin and other noble Lords have raised doubts, which will be further explored. What the noble Baroness, Lady Wootton of Abinger, said about the psychopath touches on a very delicate and profound point of moral philosophy, which it is certainly vital to raise and about which we shall no doubt hear much more. When all is said and done, it is difficult to know, before this Bill passes from your Lordships' House and becomes an Act, what will be the arrangements made. It will be perhaps difficult for some time after that, but I think we all, or most of us, feel that much can still be accomplished to improve 'the Bill before it leaves this House. Speaking for myself, that is my attitude to the Committee discussions that lie ahead of us. Therefore it does not become me now to try to pass some final comment on the Bill as it might become some of us when it reaches the Statute Book.

There are these masses of our fellow citizens to whom we are holding out a new message of hope. Some years ago remember reading a book by that famous Scots lawyer, well known to the Lord Chancellor, Lord Haldane, The Pathway to Reality. The real question here is whether we can make this a pathway to decency. That is, in my opinion, still an open question, but I go away to-night hopeful, although at the same time anxious, as most of us are, that this Bill, good though it is at the moment, shall be a much better one before we finally send it away from your Lordships' House.

8.1 p.m.

THE LORD CHANCELLOR

My Lords, it is no mere figure of speech when I say how grateful I am to noble Lords for the reception which they have given to this Bill and for their personal kindness to myself. With regard to the concluding words of the noble Lord, Lord Pakenham, I have been a Minister of the Crown for only eleven years, but I suppose I have put as many Bills before one House of Parliament or the other as any living person. If the day ever comes when someone says that a Bill that I put before the House cannot be greatly improved I shall be exactly like the donkey in Fred Oliver's Endless Adventure. Your Lordships will remember that he said that a politician is like a donkey who is so continually beaten behind that if the beating ever terminated the politician himself would stop out of sheer astonishment. I have very little beating, comparatively, to deal with to-day, but I have a far more difficult problem. I have listened with great pleasure to a number of expert and thoughtful speeches, from the time when I sat down, at a quarter to four, until now, five minutes past eight. If I were to answer adequately all the points raised in those speeches your Lordships would have some chance of rising at twenty-past twelve. Therefore I hope your Lordships will forgive me if I deal with what seem to be the most important points. If I do not cover every point that has been made, I shall be glad to look into those omitted; and if any noble Lord would like a special communication on any point I should be glad to write to him.

The first point raised by the noble Lord, Lord Silkin, was on the question of buildings. I think it was my noble friend Lord Feversham who indicated that it was most important that we should not waste even the less excellent buildings that we have. I would tell the noble Lord, Lord Silkin, that there has been considerable development recently. There has, for example, been a substantial increase in out-patient clinics for mental illness, and clinics are now provided in most areas of England and Wales.

Perhaps, without going into detail, I might give the noble Lord one or two facts with regard to day hospitals, which, as I indicated, is an important matter. They are a recent development and still largely experimental. There are about 35 special day hospital units, but more are planned; and several other hospitals take day patients who join in-patients for the day. But going to the figures during the period 1948 to March, 1958, we find that out of some £86 million spent by Regional Hospital Boards on capital development, just over £13 million was spent on mental hospitals, and nearly £9 million on mental deficiency hospitals. In 1957–58 Regional Hospital Boards devoted 30–8 per cent. of their capital expenditure to these hospitals, and this money has been spent partly on modernising and improving existing buildings and partly on new building. By March, 1961 (I think I said this earlier, but it is worth repeating), it is expected that about 22,000 additional psychiatric beds will have been provided, including the new mental deficiency hospitals at Balderton and Greaves Hall.

With regard to staffing, I agree, as I think everyone has said, that this is a problem to which there is no simple answer. As my noble friend Lord Feversham indicated, while underlining its importance, it involves questions of medical education, as well as the provision of satisfying careers in psychiatry; and that, in turn, as was stressed to us by my noble friend Lord Cohen of Birkenhead, is connected with progress made in basic knowledge and methods of treatment. But the number of consultant psychiatrists working in the National Health Service increased by 52 per cent. between 1949 and 1958, compared with an increase of 32 per cent. for consultants in all specialties; and the intake of new senior registrars into training-plan posts in psychiatry in 1956–57 was greater than the intake into any other specialty.

The noble Lord, Lord Pakenham, mentioned the question of research. He will remember that my noble friend Lord Cohen of Birkenhead and I dealt with that matter in our last debate. I could give him additional figures and bring him up to date, but perhaps he would excuse me this time. If he would like the information on the Committee stage, and will so indicate to me, I will see that he has it.

LORD PAKENHAM

I am grateful to the Lord Chancellor. I quite appreciate the reasons for leaving it until the Committee stage.

THE LORD CHANCELLOR

I am grateful to the noble Lord. The next point made by the noble Lord, Lord Silkin, really included his doubts as to compulsory admissions from the point of view of the liberty of the subject, and especially the doing away with the magistrate. I think it is not only logical but gets the matter into the proper proportion first of all to look at the conditions of compulsory admission. The doctors making the recommendation for compulsory admission under Clause 26 are required by subsection (3) to record the grounds for their opinion that these conditions are fulfilled and, in particular, to state whether alternative methods of dealing with the patient are available, and, if so, why they are not appropriate. That is intended to exclude the use of these compulsory procedures if the patient could equally well be treated as an outpatient or admitted as an in-patient informally without the use of compulsion. But, as I stressed when I addressed your Lordships last, in each case, in addition to the presence of mental disorder, it must be necessary in the interests of the patient's health or safety, or for the protection of others, that he be admitted or detained.

The noble Lord, Lord Silkin, had some doubts about "the patient's health or safety." That phrase was substituted in another place for the phrase "in the interests of the patient", which was used by the Royal Commission and appeared in the Bill as it was originally introduced. I think it would be wrong to restrict it further to the interests of the patient's safety alone, as has been suggested. I think the noble Lord had that in mind as a possible method of dealing with the problem. But that would limit the application of the clause to persons who were dangerous to themselves or to others, or in danger from others. I believe that that would he a retrograde step. Very few mental patients are dangerous, but many others who can be cured refuse treatment because their illness itself makes them incapable of appreciating the need for treatment.

The Royal Commission emphasised at paragraphs 314 to 317 that mental disorder has long been accepted as requiring or justifying a restriction of personal liberty in special ways. They accepted as one of the main justifications for these special powers of compulsion that: When an illness or disability itself affects the patient's power of judgment and appreciation of his own condition, there is a specially strong argument for saying that his own interests demand that the decision whether or not to accept medical examination, care or treatment should not be left entirely to his own distorted or defective judgment. They go on to say that admission to hospital may be the only way of providing the treatment or training which may restore his health and enable him to take his place as a self-supporting member of society. Therefore, although under the Bill every effort will be made to persuade patients to accept treatment informally without compulsion, I suggest that the Royal Commission are right—and it is the general opinion of those who have experience of patients suffering from severe mental illness, especially their relatives and others with their welfare at heart—that they would strongly deprecate the restriction of compulsory action to cases where the patient is actually dangerous.

There must be—and I tried to give all the emphasis I could to this when I was making my opening speech, but I say it again and I could not feel more strongly about it—safeguards against possible misuse of the powers. That is the reason why this elaborate system of checks and cross-checks provided by the provisions of Part IV of the Bill are in several respects stronger than those provided under the present law—for example, the wider powers of discharge, the requirements for more frequent reviews of longstay patients, the new Mental Health Review Tribunals and the age limits for the detention of sub-normal and psychopathic patients.

Now we come to the second of the points raised by the noble Lord, Lord Silkin, in this regard—the specific point that we should maintain the provision in the present Act which requires an order from a justice of the peace or other judicial body if the patients are compulsorily taken to and detained in hospital. Of course, the most commonly used procedure under the Lunacy Act requires a certificate from only one doctor, who may be any medical practitioner. The Royal Commission put the view that the magistrate's order is not an effective safeguard against misuse of powers of compulsion. The noble Lord, Lord Silkin, and I have sat on both sides of the House, and we have heard this discussed in many contexts. Of course, I do not say that a Government are bound by the findings of a Royal Commission, but they have, as we say, a high persuasive authority, and I ask your Lordships attention to the grounds on which they advance it.

The first is that in their view the magistrate cannot reach any sound independent opinion on the patient's mental condition, and, secondly, the judicial order has the disadvantage of linking certification with the courts and the punishment of crime. They recommended that the judicial orders should be replaced by a procedure by which there were two medical recommendations, one given by a doctor with special experience of mental disorder and one, if possible, by a doctor who already knows the patient. They recommended power to discharge the patient at any time by the hospital doctor and the managers of a hospital and, except during the twenty-eight days' observation, by the patient or his nearest relative or other person appointed by the court to act in his place. Of course, although I agree that this is at a later stage, there is access to the Mental Health Review Tribunal. That was part of their general recommendation.

I think it is important at this relatively late stage in the Bill—important, though, of course, not conclusive—to point out that in general the proposed abolition of the judicial order has been welcomed since the Report was published. As my noble friend Lord Cohen of Birkenhead mentioned in his most interesting speech, some voices have been raised for its retention by a minority of the medical profession who feel that it may damage the relationship between them and their patients if the main responsibility for recommending detention in hospital is clearly seen to fall upon them. My information is—we try to take an objective view of these matters—that this is not the opinion of the medical profession as a whole and that the assessment of the patient's mental condition and his need for treatment which is the essential basis for action is a matter of medical judgment. To put it bluntly, it is no advantage to the patient and little to the doctor if the doctor shelters behind the magistrate. A far greater safeguard to the patient, and one which, according to our information, most of the medical profession accept, is the need for the double recommendation of the doctor with special psychiatric experience, and the doctor who is acquainted with the man himself. That is our justification on that point.

I now come to the difficult question of the definition of psychopaths, which the noble Lord, Lord Silkin, was the first to raise; and I think the noble Baroness, Lady Wootton, said that she was in some difficulty on that point. It is not at all an easy point. I think it is one that it is worth considering for a moment. If your Lordships will look at the definition in the Bill, you will see that it contains elements which were not all quoted by the respective noble Lords who dealt with it. It says: 'psychopathic disorder' means a persistent disorder of personality (whether or not accompanied by sub-normality of intelligence) which results in abnormally aggressive or seriously irresponsible conduct on the part of the patient. and requires or is susceptible to medical treatment. There is, I suggest, considerable importance in those last words, and I ask your Lordships to bear them in mind with the other matters which your Lordships have considered. There is one point as to the exactitude of the definition and the other as to the treatment. I should just like your Lordships to consider the three different points. The essential elements are, first, a persistent disorder of personality. That means that there must be signs that the disorder has existed over a considerable period of time —that follows from "persistent"—before the diagnosis of psychopathic disorder may be made. Then that the disorder results in abnormally aggressive or seriously irresponsible conduct. That is a much more stringent criterion than anything in the definition of subnormality in subsection (3). Thirdly, the disorder must require or be susceptible to medical treatment. That is defined in Clause 146 as including nursing and care and training under medical supervision. It also includes any treatment given by a medical practitioner, whether in hospital or elsewhere, and no patient is to be diagnosed as psychopathic for the purposes of compulsory treatment or guardianship unless treatment is considered necessary.

I should have said that that was the answer to Lord Silkin's somewhat pessimistic view that you cannot go along a street without seeing some aggressive personality and you cannot enter either House of Parliament without the same experience. I think that if you add the criterion I have just stressed, that distinguishes psychopathic persons from other persons as aggressive or irresponsible, even if due to a disorder of personality, if it is not considered to be susceptible to or require medical treatment. I think also that the noble Lord, Lord Silkin, will agree with what I said in my earlier speech: that the division we have made accords much more clearly with the general view of these terms than the division already suggested by the Royal Commission, in which we made a subdivision.

The next point on which the noble Lord, Lord Silkin, had doubts was a very important one, and I hope I shall be able to dispel his doubts. That was on the conversion of powers into duties. He faintly questioned the legality. I do not think he was taking up a position but just asking me to clear it up. Section 28 of the National Health Service Act, 1946, reads: A local health authority may with the approval of the Minister and, to such extent as the Minister may direct, shall make arrangements…. Clause 6, as I said quite shortly earlier, brings within the ambit of Section 28 of the National Health Service Act services which is has hitherto been the duty of the local health authorities to provide under Section 30 of the Mental Deficiency Act, 1913. Those include the provision of training and occupation of mental defectives. But the clause also makes it clear that other specified services may be provided under Section 28. They include residential accommodation for patients who do not need hospital care.

I think that, taking it generally, much of the early criticism of the Bill was based one the assumption that the local health authority services for the mentally disordered would be permissive and not mandatory, as was recommended by the Royal Commission. My right honourable friend has made it clear that he intends to make these services mandatory by using the machinery which I have just quoted from the 1946 Act. Until the Section 28 direction and the proposals in Section 20 come into effect, the transitional provisions of the Sixth Schedule will continue the duty.

Several noble Lords asked me—the noble Lord, Lord Silkin, my noble friend, Lord Feversham, and I think the noble Lord, Lord Grenfell, had the same point in mind—"If that is what you are going to do, why don't you put it in the Bill?" There are two advantages I should like your Lordships to consider of proceeding by the issue of directions under the National Health Service Act. First of all, it fits with the pattern of the National Health Service Act; you take up the powers which are given in Section 28. And it is consistent with the policy of The Bill which I mentioned several times when I was commending it to your Lordships; that is, of integrating the mental health services into the National Health Service. That is not only our idea; it is the method recommended by the Royal Commission in paragraph 715 of the Report. The other advantage is that it gives greater flexibility and permits of a phased programme of development which can take into account factors such as the availability of staff, on which the expansion of the service must depend.

I do not take as pessimistic a view as the noble Lord, Lord Stonham, but he put to us some views that expressed, and expressed quite frankly—and I take no exception to that—his own opinions and appreciation of the difficulties. Even they are not nearly so great as the most pessimistic views which the noble Lord quoted to us. There is still obviously a need for flexibility and transitional arrangements. I hope that I have consistently justified the use of regulation powers in general on that basis. It so happened that in the war-time Government I was Chairman of the Parliamentary Sub-Committee of the Machinery of Government Committee. That is a long time ago, but I had the advantage of working then with, among others, Lord Schuster (Sir Claud Schuster, as he then was), who was one of the survivors of the old insurance problems of 1911 at the time of Lloyd George. From having heard the very beginning of it, and from having a considerable number of years of experience myself, I think that the need to have flexibility at a time of initiation and transition is a good argument. It is one that I have consistently used and therefore I venture to commend it to the attention of your Lordships.

There was one other point in which again Lord Silkin was only the precursor of other noble Lords, and that was the question of correspondence. Nobody wants to do away with correspondence from a sadistic pleasure in destroying letters: we are not approaching the matter in that way. The position is that Clauses 36 and 136 of the Bill are, I suppose, halfway between the present law and the recommendations of the Royal Commission; but the aim has been to reduce the present restrictions on patients' correspondence to the minimum, consistent with the patients' own interests and the protection of the public. I ask your Lordships to note that the powers conferred by these two clauses are permissive and not mandatory. They will certainly not result in all patients' correspondence being scrutinised. They will, however, allow a doctor responsible for a patient's treatment to arrange for the letters of individual patients to be controlled to the limited extent permitted by the Bill in cases where, from his knowledge of the patient's mental condition, he considers this is necessary.

These clauses were discussed at length in another place. I think it is permissible to say that Clause 36 (2) was amended, on an Opposition suggestion, accepted by the Government, to give wider powers to withhold the outgoing letters of detained patients. Then another Amendment to delete the whole of Clause 136 was defeated. But my right honourable friend the Minister of Health announced that the Government would move Amendments in your Lordships' House to delete from Clause 136 the reference to patients in local authority residential accommodation, thus restricting the clause to hospital patients. That will be done. I think it was Lord Stonham who raised that point.

LORD STONHAM

I hesitate to interrupt the Lord Chancellor, but he has three times mentioned Clause 136. Is he not referring to Clause 133, at page 89 of the Bill?

THE LORD CHANCELLOR

Yes; I am sorry. There has been a change in the numbers. I am grateful to the noble Lord. He knows the difficulty which occurs when numbers of clauses change at each stage. I am sorry that I should have made that mistake and I am grateful for the correction. But it does not affect my point. I think it is important because it was either the noble Lord or one of his noble friends sitting near him who mentioned specifically the position of people in local authority residential accommodation. We are going to move Amendments to cover that point, so that it will be restricted to cases where a doctor considers it in the interests of the patient that the letters should not be sent. That is the point to which your Lordships have to direct your minds.

LORD TAYLOR

My Lords, in this matter there is a wide variation of practice in existing mental hospitals. We are informed that about two-thirds of the mental hospitals have given up this practice altogether. I wonder whether the Government would look at this matter again to see whether that is in fact so. I understand that it is rather the old-fashioned medical superintendent who wishes to retain the power, rather than the majority of the hospitals.

THE LORD CHANCELLOR

I shall be delighted to look at the point again, as I shall at all the points that have been raised in this debate. But I just wanted to make it quite clear that that is the limit which we are enforcing. We will certainly consider what the noble Lord, Lord Taylor has said. The noble Lord, Lord Amulree, asked me about the position of the mental welfare officer. His duties will include those now performed by duly authorised officers, as well as general social work for mental patients.

On the question of training, my noble friend Lord Feversham dealt at some length with the Younghusband Report, but not at too much length for such art important document. If I take it quite shortly at the moment, I am sure that your Lordships will not think that I am taking any different view as to its importance. But I believe that my noble friend Lord Feversham will agree that the Report recognises that the expanding Mental Health Service constitutes one of the main groups of social work and recommends that every mental welfare officer should take a new general training in social work, in common with other social workers but with an emphasis on mental health. Since these recommendations provide far a comprehensive scheme of training, and are not confined to the training of mental welfare officers, consultation has to take place on the wider front, on training for social workers generally; and it is important that the local authority associations should be fully consulted, since it is the local authorities who are to be the employers of the social workers and will have to provide the practical training in the field which forms a vital element in the training arrangements.

It is also likely that many of the professional organisations concerned with social work, some of which are already training bodies, will have useful comments to make upon the recommendations. I hope, therefore, that your Lordship's will not think it unreasonable for my right honourable friend to say that he cannot act in advance of these consultations, though he can give the assurance that the consultations have already begun and that he will lose no time in completing them and in making the necessary decisions. I feel, therefore, that, as the Younghusband Committee have set the training of mental welfare officers in the context of the training of the health and welfare services, and have not suggested any separate farm of training for mental welfare officers, a new situation has been created since the publication of the Mackintosh Report and one in which my right honourable friend is right to take that line.

THE EARL OF FEVERSHAM

My Lords, I am sorry to intervene at this late hour but it is most encouraging to learn from the noble Viscount that my right honourable friend the Minister of Health has already started negotiations with local authorities. I am most grateful to him for making that announcement at this stage.

THE LORD CHANCELLOR

My Lords, my noble friend Lord Feversham mentioned the same point as was raised by the noble Lord, Lord Silkin, about converting the powers into duties. I have dealt with that question, and I have put a point of view which I should be grateful if noble Lords would consider. The second point I wanted to make clear was that the Ministry of Health circulars have stressed the need for co-operation between local authorities in, among other things, sharing the services of psychiatrists, social workers and mental welfare officers. I need not go into that matter any further but it is something that is in mind.

The noble Lord, Lord Taylor, raised the question of hospital units for psychopaths. I could give him a considerable amount of information on that point. Progress is being made and there is a great deal to be done; but if the noble Lord would like figures I think it would be more convenient if he would care to come and see me rather than that I should give them in detail to the House. I suggest that only if the noble Lord agrees, for I want to answer all the points and I do not want him to think I have forgotten it. The noble Baroness, Lady Wootton of Abinger, raised a most interesting—and, I am sure, to many laymen fascinating—conception of a world from which my profession had been practically eliminated and where the noble Lords, Lord Cohen of Birkenhead and Lord Taylor, ruled supreme. I am glad to think, in the interests of the poor but deserving section of society to which I belong, that the situation is not quite so bad as that.

If one might come to the more serious aspects, I would say, with the greatest diffidence to such an expert on all social problems as the noble Lady, that I feel she did overstate her case in implying that all recidivists would be treated as psychopaths and that psychopaths would be relieved of moral responsibility for their offences and the consequences. I believe the position is that the psychopath can be distinguished from the professional criminal who deliberately chooses crime as a way of making a living by a pattern of behaviour which shows other abnormal features. Psychopaths will not escape trial and conviction. Unless there is a plea of insanity or, in cases of murder, of diminished responsibility, the question of the mental condition of the offender is relevant only to sentence and arises after conviction.

Even where the court has medical evidence that the offender is a psychopath it cannot send him to hospital under Clause 60 unless it is of opinion that that is the most suitable method of dealing with him. The court cannot reach this conclusion until it has considered and rejected ordinary penal methods of disposal; and the fact that the offender is a psychopath does not preclude the court from considering and putting these methods into effect. So that, although I take the noble Lady's warning—and I am glad she delivered it—I do not think the position is quite so near disaster as she suggested.

BARONESS WOOTTON OF ABINGER

My Lords, perhaps the noble and learned Viscount will allow me to point out that I did not say that this was what would happen, but that, taking a long view, this was what could happen; that potentially, as the clause now stands in the Bill, these consequences could follow.

THE LORD CHANCELLOR

My Lords, as I said, I feel that it is a very good thing to look at disastrous possibilities—like the elimination of my profession—but I do not think it has really come within the bounds of possibility. After all, the noble Lady is quite as good a metaphysician as I am and can discuss possibilities with great effect.

Now I come to quite a different point, that raised by my noble friend Lord Grenfell; and I am sure I am speaking for the whole House when I say that we consider it an honour that my noble friend should have taken the House into his confidence in the delightful way that he did. As he has indicated, Clause 12 and the Second Schedule deal with children who are reported unsuitable for education at school on grounds of mental disability. and lay down the statutory procedures. To take it shortly, the procedures are designed to give rights of appeal to parents and therefore include the requirement to serve notice on the parents; and the Second Schedule replaces the comparable procedures under the present Education Act, as my noble friend is aware.

There has been some criticism that these procedures are in practice sometimes made very formal, whereas I entirely agree with my noble friend that it is most important that every effort should be made to explain to the parents why such action is necessary and why it is in the best interests of their child. It is certainly our intention that these procedures, for which there must be a statutory framework, should be administered in as humane and understanding a method as possible; and I am told that, in practice, parents are almost invariably seen by teachers, doctors or other officials dealing with the child before the statutory action is taken. The special visits are not necessarily paid with the notice but almost invariably before it.

I want to give my noble friend this assurance: that when the procedure in the Bill comes into operation advice will be given to local education authorities and local health authorities to the effect that they should give a personal explanation, as well as the necessary statutory notification, whenever possible. There are some difficulties about writing this into the Bill. May I give my noble friend an example? His suggestion to us, which was a very reasonable one, was that the words "health visitor" should be used. But, of course, that is now a term of art to describe visitors with nursing qualifications who visit mothers with very young children, under the maternity and child welfare services; and the sort of person who would visit the children would vary according to the age of child and whether or not it had attended school for a trial period. It might be a teacher or school medical officer, a school nurse, a mental welfare officer or someone of that kind. Therefore, there are difficulties in writing it into the Bill. But I assure my noble friend that local authorities will be warned and instructed to use the method to which I referred.

My noble friend asked me to give him some figures. The number of training or occupation centres for mentally defective children when the National Health Service started in 1948 was 77. By the end of 1958 this had risen to 291 that is to say, 214 had been opened in the ten years. In the first three months of 1959 9 new centres had been opened. Another 39 are included in the local health authorities' programme for 1959–60, although it is not certain how many will be started in the year. The figures are of centres catering for children under 16. They do not include centres for adults only, of which there are a small additional number.

As to the position of making—I was going to say making the local authorities do this, but I do not mean it in any offensive sense; of ensuring that this increase continues, it is at present a statutory duty of local health authorities, under Section 30 of the Mental Deficiency Act, 1913, to provide such centres for children and adults. That duty is preserved by paragraph 1 of the Sixth Schedule to the Bill, subject to any directions which may be issued by the Minister of Health under Section 28 of the National Health Service Act. I have mentioned my right honourable friend's plans for issuing a direction. I hope I have dealt with the points which my noble friend Lord Grenfell wanted.

LORD GRENFELL

My Lords, I should like to thank the noble and learned Viscount most warmly, not only for his great kindness in answering all my questions, and for his very kind reference to myself, but also for the long period he has sat here throughout the whole proceedings. It has been an inspiration to us all.

THE LORD CHANCELLOR

My Lords, I am most grateful to my noble friend. The noble Lord, Lord Winster, sent me his apologies and told me that he had to go. There were one or two of his points to which I should like to give greater consideration. But it seemed to me that the answer to his magisterial difficulty was that in regard to Section 61 (2), none of the other orders that can be made in respect of children beyond control can he made without a parent's consent, and it is clearly right to follow this pattern. But again I should like a chance to read more fully what he said and, if necessary, I can answer him at a later stage.

My noble friend Lord Auckland raised a number of points. With regard to some of them, he was good enough to give me notice, but he added some interesting points to-day. I should like first to deal quite shortly with them, and then perhaps, again, he could come back to me with any additional points he wants to know about. He asked me about the doctor in charge, under Section 59. That will be a senior doctor, normally a consultant or senior hospital medical officer, and not the juniors working under him. The term has a well-recognised meaning in hospitals. He was worried about the compulsory removal of patients to the Irish Republic and also Commonwealth countries. There has never been such a provision in the Acts, but I have had the facts of the matter investigated in order to answer my noble friend, and I am told that no difficulties had been experienced in practice in arranging for the return of patients to their homes, either to the Commonwealth or the Irish Republic. That is our information.

A second problem which has been put by my noble friend, and of which he was good enough to give me notice, concerns emergency action to protect a patient's property—for example, by terminating a tenancy. The suggestion was made that the local authority should act as a tem- porary receiver. We did consider this point very carefully among all the Departments concerned, including my own, when dealing with that Part of the Bill, and we came to the view that it was impracticable; and I am afraid that that is the position. I think the way it could be worked out would he to ensure that the local authorities at their offices, and the Citizens' Advice Bureaux and bodies of that sort, were provided with the information and the forms, so that if anyone is in difficulty he can get the information and the forms locally and get in touch with the office of the Court of Protection in London. I think that would probably deal with most cases. But we dealt with the point carefully and we found that there were difficulties. I am not going to elaborate them to-night, because it was considered over quite a long period between the various Departments. If I have omitted any point I hope that my noble friend will let me know, and I will write to him about it.

LORD AUCKLAND

My Lords, I am very grateful to the noble and learned Viscount the Lord Chancellor for his very elaborate answers to my points, especially as the notice which I gave him was extremely short. I should like to join with my noble friend Lord Grenfell in endorsing what he said about the noble and learned Viscount's most inspiring example to us all to-day.

THE LORD CHANCELLOR

My Lords, that brings me to the speech of the noble Lord, Lord Stonham, who raised a number of points of broader policy. I think that he was the only speaker who really queried both the views of the Royal Commission and their adoption by Her Majesty's Government. I feel that at this stage of the Second Reading they are rather broad points for me to elaborate on, but I hope that he will find the opportunity, if he thinks fit, either to raise them on Amendment or on the Question that the clause stand part, and I shall be happy to develop the reasons which have led us up another road. In regard to the more specific points, for example, on age limits, perhaps again he will put down an Amendment—I think that that will be the most suitable way of dealing with it—or, if he will send me a line, I will deal with it on the Motion that the appropriate clause stand part.

With regard to the Tribunal rules, I of course have considered most carefully what he has said. His points were on the general natural justice point, for which I have the greatest inherent sympathy. But, as I have said, I think one wants to be flexible here. There are many cases where it would be far kinder for the matter to be heard in private, though there are a few cases where it would be essential for it to be heard in public, such as where it contained important points. I think that I ought to consider very carefully the rules in that regard.

LORD STONHAM

My Lords, if the noble and learned Viscount the Lord Chancellor will forgive me, may I say that I was not on the point about a public hearing. I gave the analogy of the hearings of the pensions appeals tribunals, which are by no means public. That kind of set-up, I thought, would ensure justice.

THE LORD CHANCELLOR

I will certainly bear these points in mind. As the noble Lord knows, my office has administered the pensions appeals tribunals since they were instituted in the last war, and naturally we are very familiar with the point he has in mind.

Your Lordships will be greatly relieved to know that I have now come to the last speaker, the noble Lord, Lord Pakenham. I am very conscious that I have not done justice to the speech of my noble friend Lord Cohen of Birkenhead, but I should like to console myself with the thought that I got so much pleasure out of the compliment which, as an old friend, Lord Cohen of Birkenhead has paid me about my own speech, that I hope he will also forgive me for not dealing in detail with the general points on which it is very valuable to have his view.

The noble Lord, Lord Pakenham, raised the points of his own Association, whose work is of immense value, and gave their general approach to the subject. My Lords, I agree, and I think this is Lord Pakenham's view—that that is the most cheerful aspect of the subject that we are discussing. I think we have discovered and taken a small part in creating a new attitude to the illnesses of the human mind. Unfortunately, that happens very rarely in the chequered career of humanity and, when it does, I think we can take a small, modest amount of congratulation to ourselves, on one condition only—that it is not a cushion on which to rest and admire ourselves, but a spur for further action. It is in that way that I ask your Lordships to give a Second Reading to this Bill.

On Question, Bill read 2^a, and committed to a Committee of the Whole House.