§ 2.43 p.m.
§ Order of the Day for the House to be put into Committee read.
§ Moved, That the House do now resolve itself into Committee.—(The Lord Chancellor.)
§ On Question, Motion agreed to.
§ House in Committee accordingly.
§ [The LORD MERTHYR in the Chair]
§ Clauses 1 to 3 agreed to.
§ Clause 4:
§ Definition and classification of mental disorder.
§ (4) In this Act "psychopathic disorder" means a persistent 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.
BARONESS WOOTTON OF ABINGER moved to leave out subsection (4) and to insert instead:
(4) In this Act 'psychopathic disorder' means a mental abnormality (whether or not accompanied by subnormality of intelligence) which results in dangerously and persistently aggressive or persistently irresponsible conduct and is susceptible to medical treatment
§ The noble Baroness said: In moving this Amendment, I would like to make it clear that my noble friends and I are well aware that a great deal of thought has been given, both by the Royal Commission and by another place, to the definition of "psychopath" as it now stands in the Bill. At the same time, I would remind your Lordships that this is an important and novel departure in our legislation. The nearest parallel, I think, is the category of moral defective previously statutorily recognised under the mental deficiency legislation. But in the case of the moral defective it was never expressly laid down, and I think that it was never entirely clear, that a quality of intellectual subnormality was not also necessary for certification, and in fact very few persons have been certified as moral defectives under existing legislation.
§ The Amendment which I propose makes one or two apparently small changes in this subsection, and I would say at the outset that their purpose is the same; it is to define a little more precisely, and possibly to circumscribe 92 a little more narrowly, the category of persons who can be dealt with under this new term of "psychopath". The first change that we propose is that where the Bill states that a psychopathic disorder means "persistent disorder of personality" it should say a "mental abnormality". The reason for this proposal is that a disorder of personality is often understood to mean something which manifests itself only in behaviour. In choosing the words "a mental abnormality", we have in mind the language of the Homicide Act, which requires that if diminished responsibility is to be established and the charge of murder therefore reduced to one of manslaughter, it must be shown that this diminished responsibility is due to an abnormality of mind. We are particularly anxious that persons who are going to be labelled as "psychopaths" should manifest some abnormality of mind other than their persistently anti-social behaviour. Your Lordships will see that we have restored the persistence at a later stage in the clause.
§ I would emphasise that the purpose of our proposal is that unless we make it clear that mental abnormality must be established independently of antisocial conduct, the clause lays it wide open for any person within the specified age limits whose conduct is persistently anti-social to be certified as a psychopath. In fact it makes it possible for the great majority of persons within these specified age limits who are at present dealt with through the courts or through the remonstrances of their own family and friends, to be dealt with without judicial procedure as being psychopaths and cases for medical treatment. That is why we attach great importance to some phrase which will make it clear that mental abnormality must be present and manifested by symptoms other than purely anti-social behaviour.
§ Secondly, we propose to substitute the term "dangerously and persistently aggressive or persistently irresponsible conduct" for the present words of the Bill, which do not include the term "dangerously". Your Lordships will see that we have restored the element of persistence there; and I think my noble friend Lord Taylor may have something to say about the significance of the word "dangerously". I will only say at this 93 stage that we want to leave room for abnormally aggressive conduct of which we might approve. We do not want to find the Statute prescribing all occasions of abnormal aggressive conduct as being instances of mental abnormality.
§ Thirdly, your Lordships will see that we have omitted the words "requires or". We have done that because persons of this category are persons who have failed to respond to the ordinary treatment of reward or punishment either in their own homes or, on some occasions, through the courts: they are people for whom all other treatment has proved ineffectual. If we leave in the words "requires or is susceptible to medical treatment" we are allowing any person to be dealt with as a psychopath for whom other treatment has failed, but who apparently requires medical treatment, whether or no medical treatment is likely to be effective. In the Amendment I am now moving we want to confine this category to persons who will really benefit from medical treatment; people who are susceptible to medical treatment and whom the medical profession feel able to help. Otherwise, again we are opening the door to allowing all kinds of anti-social persons, whether or not they have been dealt with through the courts, to be treated as being cases of psychopathic abnormality.
§ Those, I think, are the main points of the Amendment. I should like to say, in conclusion, that I am particularly glad that my noble friend Lord Taylor is associated with me in moving this Amendment. We probably both feel that in the course of time the sphere of medical treatment of anti-social behaviour is likely to expand, and I think we shall both welcome that expansion, but we feel that, so long as the field of medical treatment is restricted by the present imperfect state of medical knowledge, it is undesirable to pretend that we can do more than we can. Therefore we ought to confine medical treatment to cases which are clearly susceptible to improvement under medical guidance. I beg to move.
§ Amendment moved—
§ Page 3, line 6, leave out subsection (4) and insert the said new subsection.—(Baroness Wootton of Abinger.)94
§ LORD TAYLOR
In supporting my noble friend Lady Wootton of Abinger I appreciate the great difficulty which the Government find in attempting to define a psychopath. It is an extremely difficult task and any definition is bound to have certain defects. I wish to address myself primarily to two words in the Amendment. The first is the word "dangerously", which the Amendment substitutes for the word "abnormally" in describing the degree of aggressiveness which a psychopath must show in order to come under the ambit of this definition. I spent some time last week discussing the definition of a psychopath in this Bill with one of our greatest authorities on the matter, who spends his whole life treating them, and I noticed that every time he quoted the definition he spontaneously substituted the word "dangerously" for "abnormally". I think he was right to do that; in my view, it is the correct word to use in this sense. It depends on the meaning which we give to the word "aggressive". Before the war we were brought up in a world where aggression was always regarded as something offensive and objectionable; we associated it with an unprovoked attack. But I think the meaning of the word "aggressive" is changing. When one was in Canada one found it was a routine in selecting anybody for any job to look for "a good, aggressive person". It is, in fact, a most desirable quality in the modern world in which we live, and there should be an enormous number of people full of good aggression. I think the meaning of the word is changing in this country, and if we want to be safe for the future it would be much better to substitute the word "dangerously" aggressive for "abnormally" aggressive.
The second point I wish to direct your Lordships' attention to is the question of medical treatment. Here I do not wish to suggest that there is any important alteration in this Amendment, but one would like to sound a word of warning about the treatment of the young psychopath and how comparatively little medicine can do. At the moment, the treatment of young psychopaths is really a social matter; indeed, the place where they are best treated is Borstal. The other way in which young psychopaths are sometimes dramatically influenced is by religious conversion. When I was 95 thinking about this I could not help remembering some of the remarkable psychopathic conversions which have occurred, where people who have started as psychopaths have had some vivid religious experience and have turned into saints: for example, St. Ignatius de Loyola. That is not a medical process. The amount which the doctor can do for the young psychopath is small. It is a disciplinary process, a training process and an educative process, and I think it would be wrong for medicine to claim what it cannot yet do. We all hope, as my noble friend Lady Wootton of Abinger said, that one day we shall be able to do much more for these unfortunate people; but at present it is matter far more of discipline and training than of pure medicine.
THE EARL OF FEVERSHAM
I should like to address myself to the first part of the Amendment. Your Lordships will see that the Amendment deletes the words "means a persistent disorder of personality" and substitutes "means a mental abnormality". As has already been pointed out, those engaged in this field know the great difficulty of finding a satisfactory definition for psychopaths, but, as I understand it, the words that are in the clause do something that almost any other selection of words fails to do, inasmuch as they are interpretable by both the legal profession and the medical profession. So often one finds that there is a confusion of interpretation by either the lawyers or the doctors. The noble Baroness, Lady Wootton of Abinger, who we all know is a expert sociologist and jurist, may be looking at this Amendment from the point of view of the law. I should like to emphasise that these words are agreed by the great majority of the medical profession.
Perhaps I might be permitted to quote what was said on this subject at the conference of the National Association on Mental Health last year by Dr. Jackson, who was the legal member of the Royal Commission on the Law Relating to Mental Illness and Mental Behaviour. He said this:What the legislation has got to do, I think, is to use language that will enable the doctors to say with reasonably certainty whether they think that a particular person's condition does or does not come within the words that are used.96 He went on:We were right in saying that what matters is whether words are used that doctors will understand so that they can say whether a particular person does go into a particular category or not.I quote one further statement:In the end if there are legal proceedings the decision whether a person comes within a particular term would rest on medical evidence just as it does when the allegation is about tuberculosis or any other illness or injury. …First of all it does put a lot on the doctors—that seems to me inevitable; but if you cannot trust the doctors in that sort of thing I do not believe that any legal safeguards would be worth anything whatever anyway.I think that has a substantial bearing, because it falls from the legal member of the Royal Commission. It is for that reason that I hope your Lordships will resist the noble Lady's Amendment.
§ THE LORD CHANCELLOR
I am grateful to the noble Baroness for the terms in which she moved this Amendment, which certainly appreciate the difficulty of the problem of definition which is in front of us. I am grateful to the noble Lord, Lord Taylor, for throwing what is to me a new light on the life of St. Ignatius, but I appreciate his point. I am also grateful to my noble friend Lord Feversham for his support.
This is a very serious part of the Bill and, of course, the noble Baroness is right in saying that we have had great difficulty and given great thought to finding the definition. I should like your Lordships to consider the arguments on the main changes which this Amendment would make. The first change is that it would transfer the adjective "persistent" from the underlying mental disorder to the aggressive or irresponsible conduct which is the result of the disorder. I do not think that that would be a good change, for these reasons. The word "persistent" is used to ensure that patients are not classified as psychopathic for the purpose of compulsory detention under the Bill until the personality disorder—I repeat, "until the personality disorder"—can be shown to have existed for a considerable period or time. It may be possible to deduce this from symptoms occurring over such a period, but not all these symptoms necessarily amount to abnormally aggressive or seriously irresponsible conduct. That is a point which was 97 made on Second Reading by several noble Lords, including, I think, the noble Lord, Lord Taylor. There may be a pattern of abnormal behaviour culminating in a seriously aggressive act, such as sexual assault. The earlier signs might have been less serious but quite sufficient to show the doctor that the underlying disorder of personality had been there persistently. That should be sufficient to allow the diagnosis to be made without waiting for serious aggression to be repeated several times before the patient can be sent for treatment.
Moreover, although psychopaths are commonly referred to as either aggressive psychopaths or inadequate psychopaths, there is no clear-cut distinction between the two. The pattern of behaviour often combines both inadequate and aggressive characteristics. The wording of the Amendment on this point would apparently require a persistent pattern of aggressive behaviour or, alternatively, a persistent pattern of irresponsible behaviour. According to my information and experience, that is not consistent with the facts about psychopathic patients.
The second point on which we have heard some discussion is that the Amendment substitutes the adverb "dangerously" in place of "abnormally" to qualify the aggressive conduct which may result from the disorder of personality. Despite the most interesting account which the noble Lord, Lord Taylor, gave of his view of the development of the meaning of the word "aggressive", I do not think, with all respect to him, that in this country it has gained great adherence up to now. I should have thought that the adjective "aggressive" is itself implies that the conduct involves some degree of danger, so that idea is already present in the words used in the clause. Frankly, we do not want to take out the word "abnormally", as it emphasises that this is not what one might call ordinary aggression, in the sense which Lord Taylor mentioned in his most interesting speech on Second Reading. There is something peculiar about it: it is a symptom of mental disorder.
The third characteristic of the Amendment is that it deletes the adverb "seriously" which in the clause qualifies the phrase "irresponsible conduct" It 98 replaces this by the word "persistently", with which I have already dealt and given my view. To take out the word "seriously" very much waters down the description of the conduct which must be established before the definition applies. I think everyone would agree that "irresponsible" is a very wide term. "Dangerously irresponsible", which was suggested in another place, is, in my view, too narrow. "Seriously irresponsible" strikes what we consider the right balance
The last line of the definition in the Amendment provides that the disorder must be "susceptible to medical treatment", whereas the definition in the clause says "requires or is susceptible to medical treatment". The Amendment would thus require the doctor in all cases in which a patient is to be dealt with as psychopathic under Parts IV or V of the Bill to say in effect that he expects—I repeat "expects" because I think this is a finely balanced point which is very important—the patient's condition to respond to treatment. If the words "requires or" are there, action can be taken in a case where the doctor hopes that the patient will respond to treatment. On the other hand, we are all hoping that medical treatment will have an improving effect, and that is what we had in mind. I think I did almost a metaphysical analysis of the effect of the alternatives in the absence of one of them. I do not intend to inflict it on your Lordships; but if the noble Baroness is interested I shall be pleased to let her know.
I have tried to keep my answer on broad lines; and for the particular point that has been stated, in the present state of knowledge about psychopathic disorder and methods of treatment, we must provide for cases where improvement is hoped for, as opposed to cases where improvement can be definitely predicated as being expected. I believe that that is right, and that there are few cases in which, as the noble Lord, Lord Taylor, said, it can be predicted with certainty. I think we all agree with that, and that is the reason why, after considerable thought, I prefer the clause in its present form. This is a difficult point. I shall be pleased to consider, in the interval between the stages of the Bill, everything that has been said. I have tried to-day, in view of the weight of 99 the opinions of those who have spoken, to give a considered answer, which I am sure they, in turn, will consider. Therefore, I hope that on this occasion the Amendment will not be pressed.
§ 3.12 p.m.
§ LORD SILKIN
The Committee may remember that in the Second Reading debate, following the noble and learned Viscount, I was critical of the definition in the Bill of "psychopathic disorder." We are, for the first time, taking power to confine this class of person compulsorily, and I think we ought to be extremely careful to make certain not only that our definition is such that nobody who ought to be compulsorily detained can escape but, perhaps even more important, that nobody who ought not to be compulsorily detained may be detained. My criticism of the definition in the Bill was that there were people whom we could all recognise, whom we meet socially or in other ways, who by no stretch of the imagination ought to be compulsorily detained, and yet could be brought within this definition, or by slightly stretching it. I do not think my noble friend Lady Wootton of Abinger would claim infallibility for her definition, but I feel quite certain that the definition in the Bill is not really satisfactory. It may be the best that can be devised at the moment, and I think my noble friends who have spoken gave sufficient reasons for questioning the complete suitability of the existing definition.
For those reasons I would stress the great importance of the Government's giving much further consideration to this definition. I am quite certain that my noble friends would not wish to press the Committee this afternoon to accept the definition they have put forward as an alternative to the Government one, but the Committee will admit that they have rendered a great service in applying their minds to putting forward an alternative. If the noble and learned Viscount will give us an assurance that between now and the next stage this matter will be considered again to make quite certain that, so far as we can foresee, it will not be possible for anybody to be detained compulsorily who ought not to be detained—and we are not dealing merely with eccentric people or people who turn 100 out to be geniuses and may manifest it by being aggressive—then I think we may have served a valuable purpose.
§ THE LORD CHANCELLOR
I will certainly give that undertaking. It is a very important point. I am not sure that the noble Lord, Lord Silkin, would get universal support for his fear of too much action. There is a very strong school of thought which says that one of the dangers is that action will not be taken. It just shows the difference of views on this matter; but, whichever view is right on that, obviously there is great weight in what the noble Lord said.
§ THE LORD CHANCELLOR
That is a point of view which, of course, I shall be very pleased to consider. As I have said, we have given a great deal of thought to it, but it is an important subject and I am perfectly prepared to give it more thought.
§ LORD DOUGLAS OF BARLOCH
May I invite the noble and learned Viscount, when he is giving consideration to this extremely important definition, to consider also this point? He has in his reply to the Amendment stressed the point that we are dealing here with a disorder which requires or is susceptible to medical treatment, and that clearly implies that we are dealing with a mental illness. But in the first subsection of this clause the definition of mental disorder says,mental illness, arrested or incomplete development of mind, psychopathic disorder",and that appears to imply that psychopathic disorder is not mental illness. If it is not mental illness, how does it happen that it becomes susceptible to medical treatment? There seems to be a contradiction in this set of definitions.
I should also like the noble and learned Viscount to consider whether the phrase "disorder of personality" has any definite meaning whatsoever. What is personality? If it means merely mind, this is saying mental disorder, and just that. If that is what it means, why does it not say so? Personality I have always understood to mean the whole of a person's mind and body together. Therefore, 101 there appears to be some degree of ambiguity about it. I know that one noble Lord said that really it does not matter if nobody else understands this definition, and particularly it does not matter whether lawyers understand it or not, so long as doctors do; but the general public are concerned with this and want to be able to understand.
§ BARONESS WOOTTON OF ABINGER
We are extremely grateful to the noble and learned Viscount for the care which he has taken in considering this Amendment, and for his assurance that this definition will not go on the Statute Book until it has been looked at upside down, and round and round, and in every possible light. I would say that we do not attach any great importance to the position of the word "persistently" so long as it is there, and we do not attach importance to omitting the word "seriously" though we felt that the word "dangerously" might be an adequate substitute. We do feel very strongly, I think, that some element of danger to the public perhaps ought to be present before a person is certified as psychopathic.
The two points on which we should like the noble and learned Viscount to have still further meditations are these. First, in the common parlance of the medical world, a person is often diagnosed as a psychopath merely because of his persistently anti-social behaviour; and distinctions are drawn which the layman is not always very well able to follow between a thug and a psychopath, the psychopath being the subject for medical treatment and the thug being the subject for penal treatment. We are very anxious that if persons are to be diagnosed and made liable for compulsory treatment as psychopaths, it should be clear that they have some symptoms other than their persistently anti-social behaviour. That was why we put forward the words "mental abnormality" in place of "persistent disorder of personality". I do not think that the point raised by the noble Earl, Lord Feversham, need concern us here, because the words which we have used are almost exactly those which appear in the Homicide Act, which says "abnormality of mind" and which have to be interpreted both by the law and by the medical profession in that context.
102 The other point is the metaphysical one. The metaphysics on this occasion surely have potentially great practical importance. We are a little disturbed about the prospect that a person may be subjected, on medical certification (if I may use the old word) alone, to indefinite detention in circumstances in which the doctor does not expect that he will benefit from medical treatment.
§ THE LORD CHANCELLOR
May I intervene to say that the noble Baroness has raised a most interesting point. I should like her if she would be so good, to consider it between the two stages. In my analysis I drew a great distinction between benefit and cure. I only want to put that point into her mind. The noble Baroness has probably thought of it already. But I think that in this problem it is something that has to be borne in mind. I am sorry to interrupt her, but I thought the point might interest her.
§ BARONESS WOOTTON OF ABINGER
I am most grateful to the noble and learned Viscount, and I am sure that he will have in mind the necessity that there should be a real prospect of amelioration, if I may put it so, before a person is subjected possibly to prolonged compulsory detention on medical grounds alone. In view of the assurances the noble and learned Viscount has given, and the care with which he has considered the points that we have raised, I beg leave to withdraw the Amendment.
§ Amendment, by leave, withdrawn
§ Clause 4 agreed to.
§ Clause 5 agreed to.
§ Clause 6:
§ Functions of local health authorities
§ 6.—(1) In relation to persons who are or have been suffering from mental disorder, section twenty-eight of the National Health Service Act, 1946 (which relates to functions of local health authorities with respect to the prevention of illness and the care and aftercare of patients) shall have effect subject to the following provisions of this section.
§ (2) The purposes for which arrangements are authorised or may be required to be made by a local health authority under subsection (1) of the said section twenty-eight for the care or after-care of such persons as aforesaid shall include the following, that is to say:—
- (a) the provision, equipment and maintenance of residential accommodation, and the care of persons for the time being resident in accommodation so provided;
- (b) the provision of centres or other facilities for training or occupation, and the equipment and maintenance of such centres;
- (c) the appointment of officers to act as mental welfare officers under the following provisions of this Act;
§ 3.26 p.m.
§ LORD PAKENHAM moved in subsection (2) to leave out "or may" and insert "and shall" [be required to be made]. The noble Lord said: I hope that the Committee will allow me to dwell on this Amendment for a few moments, on the strict understanding that my later interventions will be carefully rationed. In the view of most of us it is vital that this Amendment should be inserted if the excellent intentions of Clause 6 are to be realised. As the Committee are aware, Clause 6 is quite fundamental to the Bill and seeks to give effect to one of the two main purposes of the Bill—namely, to lay emphasis on community care. Your Lordships will see that Clause 6 is concerned with the provision, equipment and maintenance of residential accommodation, the provision of centres for training or occupation, the appointment of officers to act as welfare officers, and other related purposes. If Clause 6 fails, surely it is obvious that the whole Bill will fail. We who support this Amendment fear that without some Amendment on these lines Clause 6 is quite likely to fail. There is quite likely, not to-day or to-morrow but in the years ahead, to be a tragedy of disappointment, and people will say that the whole Bill, in those respects at least, was just a matter of "eyewash".
§ The Committee will recall that when the Bill was first published the one big criticism, amidst a great deal of sincere praise, was that the powers under this clause were only permissive and were not to be mandatory. In view of the directives—on the whole, they seem to be very sensible directives—that the Minister is issuing, it can be argued, and I dare say will be argued by the noble and learned Viscount the Lord Chancellor, that the powers conferred on local authorities by Clause 6 will in fact be mandatory even though the clause is permissive n form. Neither I nor any of us who support this Amendment wish to haggle over words, and I will say, 104 therefore, that our object in putting forward this Amendment is to see that the powers conferred on local authorities under this clause will be effectively binding on them and in practice will be fully used by them. We believe that this will be achieved under our Amendment. But without it we consider that no Minister in the world in this Year of Grace, 1959, however sound or unsound his Party politics may be, and quite irrespective of Party politics, and however greatly we respect such a Minister, can possibly say what will happen in the distant future. In that way no Minister can remove our great anxieties.
§ Clause 6 (2), as the Minister said last week, is primarily an expansion and amplification of Section 28 of the National Health Service Act, 1946. The powers to which it refers, and which I am talking about, already exist there to a large extent in a permissive form; and in one case, at least, they exist in a mandatory form. But whether these powers we are now conferring on local authorities have been hitherto mandatory or permissive, or non-existent, or whether it is not quite clear what their status was, they have up till now been used on a scale which in no way matches up to what we all insist on in future as a necessity. We are, in fact, calling on local authorities to expand their services to a degree which virtually constitutes a new service.
§ According to the Minister, the total expenditure by local authorities for this purpose in 1958–59 was £4,100,000. When we remember that one child in every 100 is mentally handicapped, and that one in every 20 of us, I believe (this does not apply to Members of your Lordships' House because it is not a representative sample of the population) spend some time in a mental hospital; when we reflect that half, or nearly half—about 40 per cent.—of the patients in hospital are in mental hospitals; and when we remember (I am not complaining that the figure is too big) that the total cost of the National Health Service is close on £500 million a year, this figure of £4 million for community care hitherto spent by local authorities, can be described only as "chicken-feed".
§ Some Members of the House may not be aware of the great disparities between the quantity and quality of the services 105 rendered by the different authorities. That was a point made by various speakers on Second Reading. I am glad to think that the noble Lord, Lord Grenfell, is supporting this Amendment: he made such a remarkable speech on that occasion. But as was pointed out in another place, in regard to the services which are responsible for over 90 per cent. of the expenditure, Cambridgeshire, which is top of the list, pays 2s. 4d. per head of the population towards this work, while Rutland pays 3d. We have a graduation all the way between 2s. 4d. per head and 3d. per head which goes towards this work. Among the county boroughs, Oldham pays 4s. 5d. per head, which is three times the national average; and we go all the way down to Barrow-in-Furness with 8d. One finds these tremendous variations between towns and areas, as the noble Earl, Lord Feversham, is so well aware.
§ Perhaps I could put these calculations into more concrete form. If your Lordships would look at the figures of the number of places in occupation centres for subnormal children per 100,000 of the population you will see that London, Middlesex (referred to last time by the noble Lord, Lord Grenfell) and Northampton provided 30 to 39 places per 100,000. Bedfordshire, Berkshire and Durham provided only 10 to 19 per 100,000. So there are these colossal, staggering discrepancies. In view of their very mixed and chequered record in the past, there seems no reason to assume that local authorities as a whole—apart altogether from some very good ones—will do what is necessary in future unless three requirements are satisfied by Her Majesty's Government. First, there must be an inspiring lead—and here let me pay tribute to the personal intentions of the right honourable gentleman the Minister, which I believe have won the appreciation of all concerned with this work. Secondly, very stern pressure is required from the centre on the weak and the slack; and thirdly, an adequate supply of money.
§ In our proposed Amendment we make these powers statutory. We put them in the Bill. It will be said, as it was said on Second Reading, and no doubt will be said again, that the Minister intends to achieve the same results by means of various directives. It is perhaps just 106 worth asking—though I do not want to dwell on this aspect, as others may raise it—why, if the duty is to be mandatory, that should not be made clear beyond all doubt. Perhaps the noble and learned Viscount the Lord Chancellor will supply the answer to that question. I am bound to say that it does not seem to me to be by any means the most important of all the points involved. I can think of an argument why he would prefer to do it in that way—the argument of flexibility. That, too, arose on Second Reading.
§ If one looks further there is the fundamental financial aspect. Whatever may be the theory of it, we are all aware that local authorities will never, in practice, provide these much-desired services unless adequate resources are set aside by the central Government to assist them. The right honourable gentleman the Minister has said that his grant to local authorities is to be increased in 1959–60 by nearly £1 million, to about £6 million a year. I believe those figures are about right. I am afraid that, in view of the magnitude of the problem and the fact that the Minister's total budget for his Ministry is about £1,200 million a year, including, of course, housing and other items, I must regard this £6 million a year for this wonderful new service to which we are all looking as still belonging to the "chicken-feed" variety.
§ The noble and learned Viscount the Lord Chancellor may point out that until local schemes are ready, and staff are available and ready, adequate expenditure cannot be embarked upon. I do not want to set that aside as an unimportant point, for I accept that there is a great deal in it; but up to the moment there is no visible sign that the necessary resources are ever going to be set aside for adequate development work. In other words, surely what will really matter will be the scale of assistance provided, not just to-day or to-morrow but a little later; and so far we have bean given nothing which will give us a real clue. There is no kind of guarantee.
§ I must emphasise the obvious point that the directive, even a directive by an excellent Minister, can be modified under conditions of financial stringency. We have seen that often enough. We saw what happened to the Youth Service, and we have seen economy campaigns under various Governments in 107 past years. But a statutory duty will remain, come fair weather come foul, and in the long run, therefore, that is the only way of achieving continued progress until the goal is reached. Putting it in another way, I would say that a statutory duty would seem to make it a moral obligation on the part of the Minister and the Government of the day, whatever their complexion, to provide the necessary funds. It would certainly make it far more inescapable than an order which the Government of the day were free to vary as they thought necessary according to the economic climate. For all these reasons we are certain that we shall never see adequate provision, whatever we may hope now, unless it is clear for the world to see, from the beginning, that it is and will remain the duty of the Minister and local authorities to combine in providing them as rapidly as possible, and that whoever fails to play his part in that operation will be certainly frustrating the whole intention of Parliament and, in the case of a local authority, will be actually breaking the law of the land. I beg to move.
Page 3, line 41, leave out ("or may") and insert ("and shall").—(Lord Pakenham.)
Since I put my name to this Amendment I have found myself in rather a quandary about it. I want that word "shall" very badly, because I realise fully that something must be done, and that while some councils are doing a great deal others are doing very little. But I see in this Bill a completely new vista in the treatment of mental health, and I have been veering about in my mind as to whether it would not be better to see how the Minister is going to bring about his regulations and whether we should tie down some of the smaller councils to-day in enforcing the requirement with that forceful word "shall". Although I should particularly like to see that word in, I have in the back of my mind a feeling that we might be moving a little too fast. This may sound rather cowardly in a way, but personally, after very careful thought, I rather veer towards the view that we should wait to see what these regulations are going to produce. For that reason—and I can assure the noble Lord, Lord Pakenham, that I have thought this over 108 very carefully—I must tell him that, should he take the Amendment to a Division, I should find myself forced to abstain, because although I should like this provision I have some slight doubts as to what would be the effect.
§ 3.37 p.m.
THE EARL OF FEVERSHAM
I should like to congratulate the noble Lord, Lord Pakenham, who moved this Amendment, on the extraordinarily valuable facts he has brought to his support of the argument on the "Cinderella" treatment of this service in our National Health Service in this country. On the Second Reading of this Bill I said that I should like to see a statutory provision made and imposed on local authorities, and the noble Lord, Lord Pakenham, has elaborated some of the arguments that I then brought to bear on the great necessity of getting local authorities—and particularly those more backward and recalcitrant authorities—into operation at the earliest possible date.
Since the Second Reading of this Bill I have had an opportunity of closely analysing both the circulars sent by my right honourable friend the Minister to the Regional Hospital Boards and to local authorities; and I have also seen and followed the statement he made about direction as an alternative to imposing a statutory obligation on local authorities. As I understand it, the Minister said that as soon as this Bill is passed he will issue a formal direction, under Section 28 of the National Health Service Act, making it the duty of local authorities to provide mental health services. As I interpret it. Section 28 is a permissive section; and, incidentally, I do not quite see how the noble Lord's Amendment imposing a duty upon local authorities can apply to the governing section of another Act which is permissive. But I will leave that aspect to my noble and learned friend the Lord Chancellor, because I feel that he will understand that legal question much better than I do. But then what does the Minister do? He will make it a duty, under Section 20 of the National Health Service Act, in the light of the former section, Section 28, for local authorities to submit schemes saying how they propose to carry out these duties. So far, so good, in that we may expect to have from all local 109 authorities a fully-planned scheme submitted to the Ministry of Health showing what is planned under the broad heading of community services.
In those cases where the local authority fail to carry out the duty of providing the service, this Bill, by Clause 141, together with Section 57 of the National Health Service Act, empowers the Minister to declare the authority in default. These default powers would permit the Minister, after the appropriate and necessary inquiries, to take over the Mental Health Service from the authority. This default power is, of course, very stringent, and I should like to ask my noble and learned friend the Lord Chancellor whether these powers under Section 57 have ever been used in the case of local authorities' failure to make provision for any specific physical illness. So far as I am aware, the default power of the National Health Service Act, 1946, except possibly in one case, has not been brought to bear by the Minister on a local authority, due to the fact that by its very nature it is stringent and is the sort of thing we object to in this country.
The noble Lord, Lord Pakenham, referred to the money spent on mental health by local authorities. Six and a half per cent. of the total, which the noble Lord quoted, is spent on preventive and after-care services and 93½ per cent. on the services laid down by previous Statutes, namely, the Mental Deficiency Act, the National Assistance Act, and the National Health Service Act. As the noble Lord pointed out, we are anxious not only that there should be greater provision by the local authority for the staffing and provision of centres to house mental defectives who require training which they are not at the moment receiving, but that the officers of the local authority should be concerned with preventive and aftercare treatment of those patients who have been discharged from hospital but need care in their own homes.
So far as I can see, it is going to be a very long time until there is sufficient personnel trained and acquired by the local authorities, even on the assumption that local authorities will provide £900,000 in increased allocations next year and £1¾ million the following year to this subject, because I think the devotion of their allocations will largely go 110 to existing services. Therefore there is great content in the Amendment moved by the noble Lord, Lord Pakenham; indeed it is a most serious consideration. But I should like to know from the noble and learned Viscount the Lord Chancellor whether the same eventuality will succeed under the plan devised by Her Majesty's Government and the undertaking of my right honourable friend the Minister as under that of the noble Lord. Lord Pakenham.
§ 3.45 p.m.
§ THE LORD CHANCELLOR
May I at once deal with the legal aspect that my noble friend Lord Feversham has raised? I think he has made an important point. I hope that the noble Lord, Lord Pakenham, will not for a moment think I have not got his wider points in mind, but I believe it will be convenient to show that difficulty first, because I consider that my noble friend is right in his doubts. The intention of the Amendment, as the noble Lord, Lord Pakenham, said, is to ensure that the services listed in paragraphs (a) to (e) of Clause 6 (2) are provided by local health authorities as a duty. It does not, in my view, succeed in this purpose for the reasons that my noble friend Lord Feversham foreshadowed. The arrangements for services to which the duty would apply are arrangements made under Section 28 of the National Health Service Act, and the clause as proposed to be amended would presuppose that there is an existing duty to make arrangements under that section. In fact, as my noble friend Lord Feversham pointed out, the arrangements under that section are permissive unless they are converted into a duty by ministerial direction. I think that that was the difficulty my noble friend saw; and that is a difficulty that exists.
There is another point on the drafting of the Amendment. I do not think that it is really necessary, because my right honourable friend has undertaken to issue a direction shortly after the Bill becomes law to convent these permissive functions under Section 28 of the National Health Service Act into a duty in respect of the mentally disordered, That course has this advantage: that when the duty becomes operative in accordance with revised proposals to be made by local health authorities under Section 20 of 111 the Act, to which, again, my noble friend referred, the arrangement will include the services listed in Clause 6 (2) paragraphs (a) to (e) as well as other necessary services, and the Minister's directions will therefore have the effect of going beyond the intentions of the Amendment by embracing all necessary services.
May I come—I think this is the most convenient order—to the point that (if I may put it this way) was crystallised by my noble friend Lord Feversham as to the effect of Clause 141 of the Bill, which empowers the Minister to declare a local health authority to be in default for failing to carry out functions under the Bill. As we heard, similar powers exist under Section 57 of the National Health Service Act in relation to functions under that Act. Therefore it is absolutely correct that in the last resort the Minister may secure the provision of services by transferring them to himself and recovering the cost from the authority concerned. But that is not the method by which my right honourable friend intends to secure that authorities carry out effectively the duties which will be imposed on them by his direction. These duties will be carried out in accordance with proposals which authorities will be required to make to the Minister under Section 20 of the Act. The proposals in turn will be based on advice previously issued by the Minister and may be approved or amended by him: and he can also direct at any later time that the proposals be amended or, in default of this, himself make proposals which then become operative. In this way the arrangements which an individual local health authority will be required to make will be spelt out in some detail, while at the same time leaving ample scope for local development and local initiative. These statutory provisions will no doubt be supplemented by advice from the Minister, such as that contained in his recent circular to local health authorities about development of their services, and by visits by his officers to the authorities. I think that that is a better method than using default powers to meet the second point of the noble Lord, Lord Pakenham, which was that there should be continual pressure. I am sure the noble Lord did not mean, by "pressure" simply prodding. What he wanted was drive, coupled with constructive help in 112 the work, and that is the mainspring of the system which I have described.
Now, in fairness to the authorities, having taken up and proceeding from Lord Pakenham's point, I want to say that we have no reason to suppose that authorities, generally or individually, will wish to shirk their responsibilities or will be found wanting in the fulfilment of their duties, so long as it is accepted that the development of their services will naturally be spread over a period of time and will depend on the availability of physical resources and of staff, which we are going to discuss in a short time. I am afraid I have wearied your Lordships in many contexts with my theory and belief that, between the central Government and local government, there must be, if the work is going to be well and healthily done, a real partnership; and it is with that in mind that my right honourable friend would prefer to take the course which I have mentioned.
My noble friend Lord Feversham was doubtful, and wanted to know, whether the Minister's default powers had ever in fact been used. In the eleven years during which the National Health Service has been operating—that is, under both the Administration of the noble Lords opposite and our own—this has not been found necessary; but the Minister has used (and I think this is important and is what is really in the minds of both Lord Pakenham and Lord Feversham) the method already described of the approval of schemes under Section 20 of the 1946 Act. It is that method on which he will mainly rely in future, with the application of the methods and encouragements which I have mentioned, in guiding the development of the community mental health services.
Now I come to the question of finance. My noble friend Lord Feversham, going on from what was said by the noble Lord, Lord Pakenham, asked about the division at present as to 6½ per cent. for prevention and after-care and 93½ per cent. for the services which are a statutory duty—such as occupation centres and the mental deficiency supervision service. There is one point—I was not quite sure if my noble friend Lord Feversham had it in mind, and I ought to explain it—namely, that the services which local authorities provide as a duty and which account, as I have said, for something like 93 per 113 cent. of their mental health expenditure, are not confined to services for mental defectives. This expenditure also includes the salaries of duly authorised officers performing their duties under the Lunacy Acts for the admission of mentally ill patients to hospital. The same officers undertake a substantial proportion of the work of home visiting which local authorities at present do for mentally ill patients living at home, and that is included in the 93 per cent.
The 6½ per cent. includes various smaller items, such as the running of social clubs, the provision of milk for children, training centres, and the salaries of staff undertaking home visits who are not also performing statutory functions for mentally ill and defective patients. Having said that, I want to make it clear that we do not dispute that the local authorities' community services for mental defectives are at present more extensive than services for the mentally ill. This is, in one way, only to be expected, because the mental deficiency services have always included a great deal of work for defectives living at home; but until comparatively recently services for the mentally ill were provided almost entirely in and from the hospitals. Home visiting and other social work for mentally ill patients living at home, including after-care for those discharged from hospital, is a comparatively recent development.
When my right honourable friend has issued his promised direction under Section 28 of the National Health Service Act, services for all types of mental patients will be a duty, and we naturally expect that those parts of the services which are at present least developed will, in the course of time, expand to account for a greater proportion of the expenditure. I think that: that was one point that Lord Pakenharn had in mind—namely, that we should see not to the end of the present tunnel but an expanding course of action down the vista of the future. In the circular which my right honourable friend sent to local health authorities last month, he reviewed the scope of the services which would be needed and the developments expected. He indicated that he did not wish to lay down any precise order of priority in which the various needs were to be met but that he thought it right to seek to meet, at an early stage, the 114 needs of the children by providing training for all who are suitable; and expenditure on this part of the service is therefore bound to continue at a substantial level.
We have no reason to think that the authorities will unfairly or improperly favour one part of their mental health services. In the field of prevention, however, I think everyone who has studied the problem would agree that there is, unfortunately, no easy course to be adopted, and the preventive services, measured in terms of expenditure, may well continue to be less than the services for training and occupation centres and residential homes, all of which require expensive buildings and staff. But I should like to assure your Lordships that they are very much in our mind, and that the effort will be continued along that path.
I fully understand the desire of the noble Lord, Lord Pakenham—which, indeed, I think is the desire of all of us—that we should produce not merely a lengthy piece of legislation but something which has an active effect in the country. I believe that, apart from the technical difficulties that I have mentioned, the method which my right honourable friend wishes to adopt is the better method. On the general point, I suggest—I am not dictating to your Lordships; it would be no use if I did, and I hope that your Lordships will not take it amiss—that there are so many important points that noble Lords may like to consider again the facts that I have put; and if you feel, after consideration, that they are inadequate, you will have your remedy on Report stage. But I do not press that at all. It is often necessary in politics, for very good reasons, to make a gesture, and if noble Lords feel that they must make a gesture I should be the last to be affronted by it. I put forward this suggestion only because the problems on this Bill are difficult and I should be glad to consider again what has been said on important points on every one of these Amendments.
None of us on this side, and I am sure it is true elsewhere, will ever take anything amiss which comes from the noble and learned Viscount; he is far too highly esteemed. If ever I came near to taking anything amiss, it would be the suggestion, even 115 if meant in a jocular sense, that any Amendment moved from this side must be only a gesture.
§ THE LORD CHANCELLOR
I am sorry. What I meant to say (I was wrapping up my words in the usual way) was that if the noble Lord felt that he ought to make a gesture on this subject and push the matter to a Division, I should not take it amiss. I did not mean the Amendment—far from thinking that the Amendment is a gesture, I think that it is a most interesting contribution to the subject.
I am obliged to the noble and learned Viscount for his courtesy. The noble and learned Viscount informed us—and I take it from him as a statement before which I must bow—that legally this Amendment was not quite correct. But the noble and learned Viscount is so fair and such a good lawyer that I can afford not to lay too much stress on that legal point, because I am sure that if this Amendment were carried, it would be perfectly possible to put it in a form which would pass the scrutiny of the noble and learned
§ Viscount. Our intention is perfectly plain, and as I opened at some length I hope that the noble and learned Viscount and the noble Lords, Lord Feversham and Lord Grenfell, will not think me discourteous if I do not seek in any sense to reply to their points. I have set up my side and the other side has now been set up. We consider that unless there is very strong pressure on local authorities—I realise that any Minister must express high hopes about the intentions of local authorities, but I am afraid that the record is there—they simply will not do their duty. I feel sure, for the reasons I have pointed out, that the only effective form of pressure is the kind indicated in this Amendment. Therefore, I know that the noble and learned Viscount will not take it amiss, and will not even take it as a gesture in a light-minded sense, if I say that we believe that we must push this matter to a Division.
§ 4.4 p.m.
§ On Question, Whether the said Amendment shall be agreed to?
§ Their Lordships divided: Contents, 32; Not-Contents, 56.115
|Addison, V.||Hall, V.||Pethick-Lawrence, L.|
|Alexander of Hillsborough, V.||Henderson, L.||Shackleton, L.|
|Amwell, L.||Kershaw, L.||Shepherd, L. [Teller.]|
|Archibald, L.||Latham, L.||Silkin, L.|
|Chorley, L.||Lawson, L.||Stansgate, V.|
|Crook, L.||Lucan, E. [Teller.]||Stonham, L.|
|Darwen, L.||Macpherson of Drumochter, L.||Taylor, L.|
|Douglas of Barloch, L.||Mathers, L.||Williams, L.|
|Faringdon, L.||Milner of Leeds, L.||Wise, L.|
|Geddes of Epsom, L.||Ogmore, L.||Wootton of Abinger, Baroness|
|Granville-West, L.||Pakenham, L.|
|Ailsa, M.||Gosford, E.||Polwarth, L.|
|Albemarle, E.||Hampton, L.||Raglan, L.|
|Baden-Powell, L.||Hawke, L.||Rank, L.|
|Balfour of Inchrye, L.||Hereford, V.||Rathcavan, L.|
|Bathurst, E.||Home, E.||Robins, L.|
|Buckinghamshire, E.||Howard of Glossop, L.||St. Aldwyn, E. [Teller.]|
|Chesham, L.||Iddesleigh, E.||St. Oswald, L.|
|Conesford, L.||JesseL, L.||Salisbury, M.|
|Cottesloe, L.||Killearn, L.||Saltoun, L.|
|Craigmyle, L.||Kilmuir, V. (L. Chancellor.)||Simonds, V.|
|Denham, L.||Lansdowne, M.||Sinha, L.|
|Dovercourt, L.||Margesson, V.||Soulbury, V.|
|Ebbisham, L.||Merrivale, L.||Stair, E.|
|Fortescue, E.||Meston, L.||Strathclyde, L.|
|Fraser of North Cape, L.||Milverton, L.||Swinton, E.|
|Freyberg, L.||Monckton of Brenchley, V.||Twining, L.|
|Furness, V.||Morley, E.||Waldegrave, E.|
|Glyn, L.||Newall, L.||Waleran, L.|
|Goschen, V.||Onslow, E. [Teller.]|
Resolved in the negative, and Amendment disagreed to accordingly.
§ 4.13 p.m.
LORD PAKENHAM moved, in subsection (2) (b), after "centres" to insert:
and the provision of adequate numbers of suitably trained and remunerated staff".
The noble Lord said: I do not want to detain the Committee so long this time, not because this is not an important question, but because the noble Lord, Lord Grenfell, will speak about this matter a good deal better than I can. We are all concerned in this Amendment with the strengthening of Clause 6 (2) (b), which refers to
the provision of centres or other facilities for training or occupation, and the equipment and maintenance of such centres".
Here we are concerned with the provision of adequately remunerated staff in sufficient numbers. I am sure we all agree that we shall not get anywhere under this clause without sufficient, adequately paid and adequately trained staff. There is general agreement among the medical and psychological experts who work in this field that much more can be done to develop the subnormal child within the limits of his capacity than has been done hitherto, and that this type of work requires a similar kind of training to that given to nursery school and primary school teachers. At the present time we find an extraordinary disparity between the remuneration received by a teacher who chooses to operate in an occupation centre and that of a similar kind of teacher who operates in an educationally subnormal school.
§ To take one obvious comparison, the occupation centre teacher's maximum expectation under the Whitley scale is £535 a year, while the E.S.N. teacher's maximum expectation under the Burnham scale is £796 a year. I feel that there is obviously something wrong there, and the result is what one might expect: that it is difficult at present to recruit into occupation centre work people with the educational qualifications required, which in this case we regard as every bit as essential as those required for the nursery school teacher in an ordinary school. I beg to move this Amendment, and I know that those with greater first-hand experience—though I have recently come into this field rather intensely—wish to support it.118
Page 4, line 9, after ("centres") insert the said words.—(Lord Pakenham.)
Whilst I had some doubts about the last Amendment, I have no doubt whatever about this one. I think it is an important Amendment, and I hope that the Government will feel able to accept it. Again I speak rather from the point of view of the children, because that is what I know most about. The training in these centres is very exacting and specialised. There are all sorts of ways of moving those small minds so that they work in one direction and get an advance. At the moment, some of the councils set up their own training courses and, of course, provide trainees for training in the centres. I know that my noble friend Lord Feversham will be speaking about the part that his society takes in this matter. I am certain that those who volunteer for this work are longing to learn, but it is obvious that at the moment the facilities for training are insufficient. I have talked to a number of these trainees, and they all agreed that they would not ask for more remuneration until they felt they were qualified to a certain standard to teach these children. But then they feel that the remuneration paid to them is not conducive to encouraging a great many people to take up this invaluable work. We must remember, as I said on Second Reading that, owing to medical science, many more of these children will be growing up into adults than was the case before. Hence we shall need new teachers who, with the greater responsibilities, will need more specialised training. I think the words "adequate numbers of suitably trained and remunerated staff" are the right ones, and I support the noble Lord, Lord Pakenham, in this Amendment.
§ LORD STONHAM
I, too, strongly support this Amendment. The noble Lord, Lord Grenfell, who I am glad to hear also supports the Amendment, has said that facilities for training the kind of staff we need in these training establishments for backward children is inadequate; but in my view they do not exist at all. We are not talking here about psychiatric social workers but about people who, to my mind, really must be born to the job. Last 119 Friday I officially opened the first purpose-built centre in the County of Devon for mentally handicapped children. It is the first of its kind in the county, and I think there are only six such centres in the whole of the country. This centre accommodates some thirty children. I learned there how it started. It started because some years before the war a schoolteacher found that young children were coming to her school during lunch periods and intervals, and they proved always to be backward children. The headmistress did not understand the reason, and spoke to the teacher about this, and asked why it was.
The reason was that that particular teacher understood the children; and the children, with what little understanding they had, knew that they could obtain from her understanding, sympathy and teaching. So, as a voluntary effort, assisted by charitably minded people, a small house was taken and a school was set up. It was out of that school that this centre, now officially opened by the Devon County Council, grew.
There are no training facilities for people of that kind anywhere in the country. The only way they can be trained is by being put in contact with people such as the teacher I have described, who has not merely an aptitude but the charactistics, heart, knowledge and monumental patience which this particularly rewarding kind of work requires. We want men and women who combine craft and teaching qualifications with that particular kind of patience which is necessary for dealing with the mentally retarded. It is no good talking about large-scale training schemes of the kind of which we think for ordinary educative purposes. A totally different kind of teaching is required, and there are no training courses of that kind presently available. I hope that in considering this Amendment the noble and learned Viscount will realise that fact.
We hope that, instead of these children going into mental deficiency hospitals, they will live at home and go to centres of this kind for their education and training. That is the ideal embodied in this Bill. But for the moment there are literally no centres; and secondly there are not the teachers to man them. The 120 National Society for the Mentally Handicapped has just started a scheme at Slough, estimated to cost £50,000, for fifty children. There are 500,000 men-mentally handicapped children in this country—five times as many as the blind. That is a five-to-one ratio, and it gives some idea of the size of this particular task.
The Amendment moved by my noble friend Lord Pakenham mentions adequate pay for the people who do this work. Let me say at once that these people are not in this work for the pay they receive. But it is not right that we should continue to impose upon these people and pay them less, in many cases considerably less, than we pay to factory workers. Therefore, it is necessary, first of all, for the Government to decide upon appropriate salary scales, and then to set the machinery of training in motion. I suggest that we must begin to recruit from male and female nurses in mental deficiency hospitals; and we must seek advice on training, and on the syllabus, from the Guild of Teachers of Backward Children who have been making tremendous progress in recent years, and whose advice in this respect will be invaluable. I believe that it is only in that way that we shall get the nucleus of people we need at the beginning to train others—the people who are born for the job. In the beginning, it is not necessary for them to have advanced academic qualifications.
I remember, a few years ago, going into one of the mental deficiency hospitals for which I was responsible, and there were in the room 30 to 40 young men from the age of 18 to 25. Not one of them could speak because their mental age was too low. They were in the charge of a male nurse who was one of those inspired people, and he has actually taught those very young children (if I may use that expression) behaviour, handicrafts and to understand each other, and has shown them how to be happier—a truly marvellous work which could not be learnt from books, but which, somehow, such a man could impart to others. Those are the people we must seek out to take charge of these centres, when we have them, to train the necessary staffs and then build up a syllabus to encourage others. Unless the Government take the lead with the local authorities in requiring the inclusion of such plans in the centres 121 which they will eventually have to submit, and unless they take the necessary steps to ensure that there will be adequate rewards, then this section of the Act will remain a dead letter; it will be no more than the ink and paper upon which it is printed. I hope, therefore, that this Amendment will be taken very seriously, because it is an extremely important matter and will go a long way towards solving one of the great remaining social problems of our time.
§ 4.27 p.m.
THE EARL OF FEVERSHAM
The noble Lord, Lord Stonham, has said that there are no training facilities for supervisors and teachers of the mentally handicapped. I should like to assure the noble Lord that in this respect he is entirely wrong. The Association of which I am Chairman, the National Association for Mental Health, is the training body at present recognised by the Ministry of Health for the training of staffs. And I may say that this organisation is the only recognised organisation which provides training with a diploma attached. There may be other training facilities undertaken by local authorities, but there is no diploma attached.
I should like to detain the Committee for a few moments, in supporting this Amendment, to speak of the more important aspects of it. We started training in 1945 with 17 students. In 1956, we had 108 students, and so far we have trained over 600. That 600 does not take into account certificates awarded to experienced students who come for refresher courses. In 1948, there were 77 occupational centres; today there are 293. My noble and learned friend the Lord Chancellor, in the debate on the Second Reading of this Bill, said that there were 16,500 patients in centres, but we know that there are another 8,500 who still need training, and that three-quarters of them are persons over 16 years of age. The emphasis up to date has, I think, properly been given to the training of the young and those under 16 years of age; but now the vital requirement, after meeting the demand for all those under 16, is to meet the demand for adults.
We are at present discussing with the Ministry of Health a revised form of training for supervisors working in these centres. My Association is also closely 122 concerned with the Association of Teachers of the Mentally Handicapped, a body which lays down the conditions of service for these staffs. We have done our best to see that their status and remuneration is improved, but, as the noble Lord, Lord Pakenham, has instanced to your Lordships, our endeavours have not been as successful as we should have hoped. In these training schemes not all local authorities pay the full fees for students to receive our course. I do not fully know the reasons, the variety of reasons, why local authorities will not pay the full fee for the course, but we endeavour to make up whatever grant is made by that particular local authority, out of the block grant that we receive as a voluntary association from the Ministry of Health.
It may well be that the intent of this Amendment is already covered by the power that the Minister has, but I should like an assurance from my noble and learned friend the Lord Chancellor that it is agreed by the Ministry that this training is of vital interest and vital moment for the mentally handicapped, and I would support the Amendment because undoubtedly it underlines a need which deserves to be recognised by all local authorities and others.
THE EARL OF ONSLOW
First of all may I say on behalf of Her Majesty's Government that we are in full sympathy with the intention of this Amendment and fully recognise the last remarks of the noble Earl, Lord Feversham. Adequate staff will be necessary for the proper functioning of all the local authority mental health services; that is, for example, the residential accommodation specified in Clause 6 (2) (a), and for the after-care services for mentally disordered persons at home which are not specifically mentioned in Clause 6 at all. The provision of a service implies, of course, the employment of a sufficient staff, and therefore it is thought not necessary to single out a particular branch of the service and say that it shall be adequately staffed. It is true that in Clause 6 (2) (c) the appointment of mental welfare officers is mentioned, but this is to bring into Clause 6, and thus into Section 28 of the National Health Service Act, 1946, the appointment of mental welfare officers to perform the numerous functions which are specified in later parts of the Bill.
123 We agree that staff at training centres certainly need to be skilled at their job, whether employed at a centre which trains children or whether employed at one which trains adults. The National Association for Mental Health, of which the noble Earl is Chairman, at present provides two courses of three terms in London and Manchester for supervisors in training centres, and these lead, as the noble Lord said, to a diploma which is accepted as a suitable qualification by local authorities and by the Ministry. The Association, I understand, also runs from time to time in various centres a longer in-service training course. It also provides an annual residential refresher course. The Association, I also understand, is currently considering whether to provide a course specifically for supervisors in adult centres and is in touch with local authorities on this proposal. The Ministry of Health encourages this training by including in its annual grant to the Association an amount for bursaries to be awarded to students at the Association's courses. So far as the Ministry knows, there is no shortage of staff for training centres, but it may well be that as standards of training rise and the number of centres continues to expand a shortage of suitably trained staff will develop and the training arrangements will need to be expanded, as the noble Lord who moved the Amendment suggested.
It would not be helpful to provide in the Bill that staff should be suitably trained since this would require some definition and interpretation. At present a requirement that the qualification should be the possession of the diploma of the National Association for Mental Health would be unduly restrictive. The Minister can, however, at any time make regulations under Section 66 of the National Health Service Act, 1946, to prescribe qualifications of officers employed by a local health authority, and this could include staff at training centres. The Minister will certainly bear in mind whether at some future date the making of regulations would be helpful.
THE EARL OF FEVERSHAM
Before the noble Lord leaves that point, I would ask him how he substantiates the statement that it would be unduly restrictive to require students to receive the diploma. It seems to me that it would be necessary 124 to make all those entering centres as supervisors or teachers able to receive the diploma, and that would enable the local authority to go to the right source of training facilities in order to obtain that diploma. As it is, untrained personnel can be employed by the local authority, and that is the thing that the movers of this Amendment deplore.
THE EARL OF ONSLOW
Perhaps the noble Earl misunderstood. I think the Minister has in mind to wait a little while to see whether there are other sources which would also have some form of diploma, rather than to tie it down as the noble Earl suggested.
THE EARL OF FEVERSHAM
I am grateful to the noble Earl for that explanation, but I hope his right honourable friend the Minister will not wait too long.
THE EARL OF ONSLOW
I think I can assure the noble Earl that my right honourable friend has it very much in mind.
On the question of remuneration, it is really unnecessary to provide in the Bill that a particular group of officers should be suitably remunerated. The remuneration of staff at training centres is a matter for negotiation by the recognised machinery for the settlement of salaries and conditions of service of local authority staff.
THE EARL OF FEVERSHAM
I am sorry to interrupt the noble Earl again. I would point out that the revision of salaries and the training and appointment of local authority social workers has now been exhaustively reviewed by the Younghusband Committee, whose Report was recently published, and this category of teachers in centres for the mentally handicapped is excluded from the terms of reference of the Young-husband Committee. Therefore I think it needs special, particular and specific consideration by the Minister.
THE EARL OF ONSLOW
Yes, I quite agree with the noble Earl; but it would still have to go through the recognised machinery. I would end my reply to this Amendment by saying that the Government wholly sympathise with the intentions behind the Amendment, but, for the various reasons I have given, I hope the noble Lord will not press it.
I know the noble Earl will not think me discourteous if I say I am disappointed with his answer. It was kind of him to refer to our intentions and I appreciate his courtesy. I know that those who have been working in this field for many years (I have recently joined in), some of whom have spoken to-day, will be as disappointed as, and perhaps more disappointed than, I am. I find it difficult to know what is the appropriate Parliamentary practice. It would be impossible to express oneself satisfied, to lie down under this answer. Equally, it seems to me it would be unwise this afternoon to flare up and demand a verdict, "Yes" or "No". I think the wisest thing—particularly in view of something very pertinent which the noble Lord said about the fact that other categories ought to be mentioned—would be to withdraw this Amendment now and reserve the right to return to it, as I expect we shall do, at a later stage.
§ Amendment, by leave, withdrawn.
§ 4.40 p.m.
§ THE EARL OF FEVERSHAM moved, in subsection (2) (c), after the first "of" to insert "qualified".
§ The noble Earl said: I can assure your Lordships that on the ensuing clauses of this Bill I do not intend to speak at the length that I have already done. I have put down this Amendment because I consider it to be a most important and far-reaching one. Training for mental welfare officers has been asked for ever since the Report of the Mackintosh Committee was published in 1951. Their training has been put off time and again.
§ The matter was considered by Lord Percy's Royal Commission on Health Visitors and subsequently by the Young-husband Committee, and the reason always given has been that because the Reports of those bodies were in preparation no long-term action could be taken. We now have a recommendation from the Younghusband Committee that mental welfare workers should be trained for two years, along with certain other social workers in the local authority service. Of course this proposal requires consultations, and I hope that at a subsequent date your Lordships may have an opportunity of debating the far-reaching recommendations of the Younghusband Committee. But I would 126 point out that this service has suffered for nearly ten years through having no training for new entrants. The duties and powers which this Bill places upon mental welfare officers require them to have qualifications and experience in mental health work. As the Committee will know, there is at present no recognised qualification for welfare officers. Since 1948, appointments have generally been made in the light of the individual's knowledge and experience, especially as a relieving officer; and appointments have been made in the knowledge of his general aptitude for the work. In addition to administrative work, about 97 per cent. of mental welfare officers have visiting duties, and they are mainly concerned with the responsibilities under the Mental Deficiency Acts.
§ Your Lordships may be interested to know that the designation "mental welfare officer" throughout the country differs greatly. In the Younghusband Report various grades of local authority officers carry out this work to which I have referred. It is a most confusing subject. I do not want to go into it at any length, but it is interesting to see from that Report that 349 welfare officers do not act as mental welfare officers but 428 welfare officers do act also as mental welfare officers, while 625 mental welfare officers do not act as welfare officers. Therefore it will be seen that there is great variation of appointment in this sphere. I should like to refer your Lordships to tables in the Younghusband Report, at pages 85 and 86, showing the numbers in local authorities who act as mental welfare officers and those who do not. Even more significant in this Report is the table which gives the ages of mental welfare officers; it shows that nearly half the men, and over one-third of the women, are due to retire within 15 years. That is a most significant and important aspect if the whole principle of the Bill, the development of community service, is to fall upon one of the key workers, the mental welfare officer. Because of a lack of status of social workers in the eyes of local authorities, because there is no training, and because there is no qualification, there are very few new entrants.
§ Mental welfare officers themselves have sought for a long time to have a recognised course of training and to be 127 able to receive a recognised qualification. I submit that a sufficient number of the right people will never be collected in sufficient numbers to do this kind of work unless there is this qualification status. The reorientation of mental health work means that we have to get away from the extraordinary fascination of buildings and concentrate on services. I have for many years been a member of a local authority, and I think those of your Lordships who have served in that capacity will share with me the sense of great accomplishment felt when one sees an institution or bricks and mortar going up; whereas the assessment of what is done by community service is very much more difficult to arrive at. I would say that if the consequences of this Bill are to be sensible we must get away from the domination of buildings, and must provide services for patients in the community.
§ What is the good of providing excellent treatment within our hospitals, and in out-patients' departments, if there is no form of after-care or community care when the patient is discharged? I cannot emphasise too strongly that, if this Bill is to be translated into effective action, it needs the combined skills of administrative and clinical departments of the medical officers of health and of the specialist psychiatric service. I think this is the whole crux of the problem underlying this Bill. We have to bring together the respective technical skills of the psychiatric and public health specialist. The mental welfare officer is, in fact, the key worker in this team. Why? Because he has four duties to fulfil. First, he has the duty of visiting patients in their homes, and he will be one of the main participants in preventive work. Secondly, he is the officer responsible for obeying the regulations for the compulsory admission of patients. Thirdly, he will be responsible for maintaining contact between the patients in hospital and their families or employers. Fourthly, he will have work to do on behalf of patients outside the hospital in after care in the community.
§ I would say, in underlining the necessity to get this service properly established at the earliest possible date, that the purpose of the Bill is not based upon the claims of individual authorities, but upon the need to provide clinical con- 128 tinuity in the treatment of individual patients; and the mental welfare officer obviously has a very big claim to make for adequate training if he is to fulfil, and if he is expected to fulfil, his part in this comprehensive service. I have already referred, and reference has been made on a previous Amendment, to the large amount of money available under the existing service. My noble and learned friend the Lord Chancellor was good enough to give me a full reply in respect of those services which are not in existence at the moment. This is one of the services which, in many respects, virtually is not in existence at the moment, and which will require a far greater figure than the £900,000 increase, making a total of £4 million, and, the year after, a total of £6 million, which the noble Lord, Lord Pakenham, mentioned, if we are to be effective in this treatment.
I have raised this point and spoken at some length on it, because my right honourable friend the Minister said, in another place, in respect of this subject, that
We shall be able, by the time this Bill goes to another place, to see whether we can proceed more appropriately and quickly by regulation or by introducing something in another place.
As my right honourable friend made this observation in commenting upon the need for appointing qualified mental welfare officers, it seems quite reasonable to ask the noble and learned Viscount whether any action has been decided upon by Her Majesty's Government on the steps they propose to take. I would also ask the noble and learned Viscount whether he would give me an assurance that emergency training will be provided for selected officers and that some emergency arrangements will be made for new entrants. Such an important interim provision seems very necessary in order to fill the gap until the Report of the Young-husband Committee is considered and possibly implemented. As I said in commencing my remarks on this Amendment, the gap is already too wide and ought to be closed at the earliest possible date. I beg to move.
Page 4, line 10, after ("of") insert ("qualified").—(The Earl of Feversham.)
THE EARL OF ONSLOW
Clause 6 (2) (c) of this Bill makes it clear that under 129 Section 28 of the National Health Service Act, local authorities' functions include the appointment of officers to act as mental welfare officers under the Bill. The Amendment would provide for appointment of "qualified" officers. It is doubtful whether the insertion of "qualified" at this point of the Bill would achieve anything without further amendment to indicate what "qualified" actually meant. The object, however, is clearly similar to that discussed at both Committee and Report stage in another place [Commons Committee E, cols. 125–135, and OFFICIAL REPORT, Commons, Vol. 605 (No. 107), cols. 247–257) when stress was laid on the importance of ensuring that mental welfare officers have training and qualifications appropriate to their important duties under the Bill.
The objections to the Amendment are, first, that in so far as it achieves anything at: all, it would differentiate between mental welfare officers with functions under the Bill and those doing general home visiting and welfare work for mentally disordered people under Section 28 of the National Health Service Act. The second objection is that it is unnecessary to make special provision in the Bill because the Minister already has power under Section 66 of the National Health Service Act to make regulations with respect to the qualifications of any officer appointed by local health authorities if it seems necessary to do so. The general policy of the Minister is to relax Government controls over local authorities and we should not make such regulations without full justification.
Thirdly, as the noble Earl, Lord Feversham, has said, Her Majesty's Government must have regard to the recent recommendations of the Younghusband Working Party which was set up by the Minister and Secretary of State for Scotland to inquire into the proper field of work and the recruitment and training of social workers at all levels in the local authorities' health and welfare services. The Report is a very long document which will require careful study. No comments can yet be made on the recommendations, but the Minister has already sought the views of the local authority associations and I am glad to be able to tell your Lordships, on his behalf, that he will be happy to have any comments from the many inter- 130 ested professional or other organisations concerned. He will lose no time in considering what action is called for, but clearly cannot reach any decisions until all the necessary consultations have taken place. These are now in progress but naturally must take some time.
The noble Earl, Lord Feversham quoted the statement by the right honourable gentleman, the Minister, on the Report stage of this Bill in another place, and I can tell him that the consultations with local authorities are now in progress, and that it is clear that the most appropriate course is to rely on the Minister's power to make recommendations under Section 66 of the National Health Service Act, for use if necessary, I hope, therefore, that the noble Earl will not press his Amendment
THE EARL OF FEVERSHAM
I thank the noble Earl, Lord Onslow, for the reply he has given, although I cannot pretend that I am in the least satisfied with it. It seems a particularly unresponsive and ungenerous reply to have received, in view of the fact that this matter has been well ventilated by all those interested in the status and welfare of mental welfare officers for a great number of years. I had hoped that I should receive from the representative of Her Majesty's Government at this stage in the progress of the Bill a statement to the effect that some provisional interim training would be allowed for mental welfare workers.
I am not satisfied with the statement made by the noble Earl telling me that the Minister is in consultation with local authorities where necessary. Nor am I at all satisfied with the answer given by the noble Earl that it is impossible to establish specific and well-defined qualifications for mental welfare workers because they would be in a separate designation from other welfare workers employed by the same local authority. If that is the only answer we can receive, it seems that there ought to be an inquiry to look further into the recommendations already made on this subject by the Younghusband Committee.
If I may be permitted to say so, it seems that possibly through the exigencies of this Bill those who have advised my noble friend, Lord Onslow, have not had time to appreciate the full implications of the recommendations contained in the 131 Report of the Younghusband Committee, because it is there clearly stated that one of the duties of qualified trained social workers employed by the local authority, and one of the most important aspects of their social work, is the underlying permissive powers contained in this Mental Health Bill. Therefore, while I do not mean to press this matter to a Division, I hope that at a subsequent stage of the Bill the noble and learned Viscount will be able to give a little more satisfaction in regard to this matter.
§ THE LORD CHANCELLOR
I am sorry that my noble friend has been dissatisfied, because there are really three points which I hoped we should have as common ground. I do not think he appreciates that the difficulty felt by my noble friend, Lord Onslow, was that the Amendment would differentiate between mental welfare officers with functions under the Bill and mental welfare officers who are doing general home visiting and welfare work for mentally disordered people under Section 28 of the National Health Service Act. I believe that there is the difference on that point. If we are going to differentiate between two sections of mental welfare officers, it seems to me that we are running into difficulties. That was what my noble friend Lord Onslow and I felt.
THE EARL OF FEVERSHAM
May I intervene to say that surely in the Amendment which we have already discussed we have had the assurance of my right honourable friend the Minister that Section 28, which gives permissive duties to local authorities, is now to be made mandatory by his direction on those local authorities, and therefore the mental welfare officers will not have, as hitherto, specific duties under previous Acts and permissive duties which were never applied. When this Bill is passed, the mental welfare officer will be on the same ground, whatever his duties may be.
§ THE LORD CHANCELLOR
I take the noble Earl's point that he thinks that the effect of the Bill, applied to Section 28, would be to remove the differentiation between these categories. I must say, to be quite frank, that it had not occurred to me in that way. I thought that there was the difficulty that the noble Earl's Amendment would mean 132 a special position attaching to welfare officers who did work which was specifically mentioned in the Bill. That is certainly what my noble friend Lord Onslow and I thought was the effect of the Amendment, but may I have another look at that, in case there has been a misunderstanding?
On the second point, I want to make clear, with regard to the Younghusband Report, that my noble friend Lord Onslow and I had in mind the recommendation of the Younghusband Report for the provision of emergency one-year courses for a strictly limited period to give suitable training to officers such as mental welfare officers, which is what I think my noble friend had in mind. That is one of the matters that my right honourable friend the Minister is discussing with the local authorities at the moment. With respect to my noble friend Lord Feversham, I think he will appreciate that it is a long and important Report and that one must therefore allow a certain time for discussion. That does not mean that we do not consider the matter important. My right honourable friend in fact had in mind in the passage which my noble friend Lord Feversham quoted, that there were two possible courses: to deal with it in the Bill, or alternatively, to deal with it by regulation. The position is that the discussions are still going on and he will deal with it if necessary by regulation.
I should like to repeat what my noble friend Lord Onslow began by saying: that the Government do not for one moment dissent from the need that mental welfare officers should be appropriately trained for their vital work in the local authority mental health service. We realise that the main task will fall on them in providing care and after-care services in the homes, as my noble friend Lord Feversham pointed out, as well as the more formal functions laid down by the Bill. We appreciate—my noble friend will remember I stressed this point in the debate he initiated some eighteen months ago—that most of the present staff have, from long experience, achieved great skill at their work. They all bring to their work, as I said before and I am very glad to say again, the sympathy and understanding which is so necessary, and they accept that further improvement would come from training; and it is certainly the Government's wish that this 133 should be provided as soon as possible. I hope that my noble friend Lord Feversham will not himself think, or that any of those whom in a broad sense he represents will not think, that my right honourable friend is treating the Younghusband Report as an escape. He is not. The discussion of that Report is the method by which we hope to get the best results.
THE EARL OF FEVERSHAM
I am deeply indebted to my noble and learned friend the Lord Chancellor for having amplified the earlier reply and for having gone so fully into the question. I think the noble and learned Viscount will appreciate that my concern was that, as the recommendations of the Younghusband Committee's Report were so far reaching and in many ways radical, it would perhaps be possible, rather than waiting a further period—the period of waiting has already been ten years—for my right honourable friend the Minister to allow the appropriate body, whether it is my Association or another, to have an interim scheme whereby new entrants can be attracted to the service and the existing members of that service can have some opportunity of higher qualification. But I am greatly indebted to the noble and learned Viscount the Lord Chancellor for the full answer he has given and I beg leave to withdraw the Amendment.
§ Amendment, by leave, withdrawn.
§ Clause 6 agreed to.
§ Clause 7 [Conduct of premises of local health authorites]:
§ On Question, Whether Clause 7 shall stand part of the Bill?
§ 5.6 p.m.
§ LORD CRAIGMYLE
Clause 7 is called "Conduct of premises of local health authorities", and here we come up against a question which has arisen in another context already this afternoon: the question of permissive or mandatory power. It is obviously impossible to put down in detail in mandatory form how these premises should be conducted, but I raised on Second Reading one particular aspect of hospital management and that is the chaplaincy services to be provided. I pointed out that the very old Acts are being repealed, and that parts of them have already been 134 repealed (including a part I quoted, although I did not realise it at the time), and that all the specific detailed provisions contained in them are being done away with. I feel now, not that we need to put into this Bill specific provisions on these matters but that we need to have an assurance that the chaplaincy services will be as adequate in the future as they have been in the past. I understand that the appointment of officers for mental hospitals, as well as in all types of hospitals, has for many years now been at the discretion of hospital boards and committees. There is, of course, nothing at all wrong with that principle and I have no doubt that the system works perfectly adequately. But what is essential is that mental patients, and, indeed, all other patients, should be guaranteed the right of access of their chaplains.
The matter is largely dealt with by circular, and I understand that a circular on the subject ensures that the parish priest or minister of each patient shall have the right to visit him. I am not certain what is the statutory status of these circulars. I take it that if the Minister makes a regulation under a Bill of this nature, that regulation has statutory force. Presumably a circular does not have such force, but no doubt if the Minister found, on any important point, that a circular was not being complied with he could give it statutory force by regulation. Perhaps the noble and learned Viscount can clear my mind on that point. The sum total of the matter of this question is whether the Minister, in making regulations for the conduct of these hospitals, will make some regulations that will guarantee to every patient the right of access of a minister of religion of his own particular denomination. Perhaps the noble and learned Viscount, if he is able to answer that point, will confirm also that it will apply, as it surely ought to apply, equally, if not a fortiori, to special hospitals referred to in Part VII of the Bill.
§ THE LORD CHANCELLOR
I have an apology to make to my noble friend Lord Craigmyle. He raised this point on Second Reading and owing to some failure of my conjuring capacities with the various papers I had to deal with in making a reply to many speeches, I lost the note containing his point. I hope that he will not be angry with me for that human failure. No responsible person 135 could dissent from what my noble friend said about the importance of ensuring that every patient in hospital should have the services of a minister of religion of his own persuasion. To put the matter at its lowest, the visits of a chaplain are clearly an indispensable part of the cure of many patients. Indeed, the noble Lord, Lord Taylor, rather foreshadowed that in what he said on the first Amendment. The only question with which I think I need deal to-day is the method by which the provision of these services should be ensured.
It is generally thought inappropriate in modern Bills to make elaborate provision for such matters as the appointment of officers of a hospital, if they can be dealt with satisfactorily by administrative arrangements and where the rigidity of a statutory provision is out of place: but I do want to assure my noble friend that this does not mean that the matter in question is considered to be unimportant. My noble friend had in mind that the Lunacy Act, 1890, after the fashion of its time, dealt expressly with officers of asylums; but, as he mentioned in his speech to-day, Section 276 of that Act was repealed by the National Health Service Act, and since 1948 the appointment of officers for mental hospitals, as well as for all types of hospitals, has been at the discretion of the hospital boards and committees set up under the Act.
The current practice is that chaplains of any of the denominations concerned are appointed, full-time or part-time, according to the needs of the patients in the hospital. Again, as my noble friend had in mind, circulars issued by the Ministry of Health also require that any patient shall have the right to be visited by his own parish priest or minister, if he so wishes. I do not think that my noble friend would particularly want that the only special provision remaining of the 1890 Act—namely, Section 277—should be re-enacted in its present form, because I think it would be repugnant to modern ideas to re-enact a provision that discriminates in favour of the Established Church at the expense of the others in so far as the medical superintendent now has statutory power to regulate the conditions under which ministers of any other persuasion may visit patients. We feel that this is a matter which can be 136 dealt with administratively, and that by that means we can deal with the situation as it exists, or as it may change.
I feel that this is a matter in which the general public control of administration is so tender and responsible and strong that it is something which can safely be left to flexible administrative procedures. I want to assure the noble Lord, Lord Craigmyle, that we do not underestimate the importance of his point; and I shall, of course, convey to my right honourable friend what he has said to-day. But, so far as I have examined the matter since his Second Reading speech, I am satisfied that he need not worry about anyone being deprived of the great benefits which religion may give.
§ Clause 7 agreed to.
§ Clauses 8 to 13 agreed to.
§ 5.15 p.m.
§ LORD TAYLOR moved, after Clause 13 to insert the following new clause:
§ Regional Hospital Boards
§ ".—(1)Nothing in Part II of this Act shall be construed as removing from regional hospital boards or hospital management committees any of the functions exercised by them under the National Health Service Act, 1943 in respect of the treatment of patients outside hospital.
§ (2)Local health authorities shall consult with regional hospital boards and hospital management committees in making arrangements for the care and after-care of patients suffering from mental disorder.
§ (3)Joint schemes between local health authorities and regional hospital boards and hospital management committees for the care and after-care of patients suffering from mental disorder may be made, and the cost of such joint schemes may be divided between the authorities in any manner agreed between them, subject to the approval of the Minister.
§ (4)Local health authorities may secure provision for the care and after-care of patients suffering from mental disorder by means of agency arrangements with regional hospital boards and hospital management committees.
§ (5)If the service for the care and aftercare of patients suffering from mental disorder provided by any local health authority is, in the opinion of the Minister, inadequate to meet the needs of the patients in the area, the regional hospital boards and hospital management committees may make such provision as they deem to be necessary."137
§ The noble Lord said: I beg to move the insertion of the new clause standing in my name and that of my noble friends. May I say that I was thinking of the noble and learned Viscount the Lord Chancellor when he spoke of his conjuring capacity. So far, he has made four Amendments disappear up his sleeve. I hope he will not make all of this Amendment also disappear in his capacious and very skilled manner. My noble friend Lord Stonham and I have both keen chairmen of mental health committees of Regional Hospital Boards, and my noble friend Lord Lucan is himself a member of a hospital management committee. I think we all feel that the substance of this Amendment will, in fact, have to operate whether or not the Amendment is written into the law. Section 28 of the National Health Service Act, to which a reference has already been made, has given local authorities power to take care of persons suffering from illness or mental defectiveness, and to provide the after-care of such persons, without making it mandatory; and under that section a great deal has been done for mental defectives—not so much as we want to be done for the mentally subnormal, but a substantial amount.
§ On the other hand, I think everybody agrees that in the case of mental illness very little has so far been done by the local health authorities. In every case where there has been developed a good service for the after-care of the mentally ill, it has been a joint effort between the local health authority and a hospital management committee. Strangely enough, I think that in every case except one it has been a county borough. I suspect that the reason for this is that in a county borough the medical officer of health is usually in close personal contact with the medical superintendent of the local mental hospital, and they have been able to work together. In the case of a county, there may be four or five medical superintendents concerned, often with overlapping catchment areas, and similar difficulties; so that very little has developed, and what has been done has sprung from the Regional Hospital Boards.
§ Our concern is to make sure that the Regional Hospital Boards are not inhibited in the good work they are already doing. Take, for example, the home-visiting of discharged patients. 138 This is normally done by psychiatric social workers, or social workers from the hospital working under the psychiatrist who has looked after the patient in a hospital—and this is really essential, There must be a continuity between hospital care and home care; and the danger of this present Bill arises at the point where the Regional Board service meets the local health authority.
One of the best of these local health authority services is in the City of York, and in 1953 the Medical Officer of Health for York and the Superintendent of the York Mental Hospitals prepared a memorandum showing how such a joint scheme could be worked out. These words are so striking that I propose, if your Lordships will forgive me, to quote them. This is what the memorandum said:
Unless steps are taken to overcome the administrative fissure between the responsibilities of the hospital authorities on the one hand and the local authority on the other, it is not possible for either of them effectively to discharge their duties to the public as far as psychiatric help is concerned.
Moreover, unless there is close clinical and administrative liaison between the two authorities, not only is the mental health of the public not effectively treated, but there is also a waste of public money. Thus, if a family has one member a defective, another a maladjusted child, and a third a patient in Naburn or Bootham Park Hospital, then no fewer than three social workers of one sort or another may visit the house for mental welfare purposes.
It is essential to create a comprehensive mental health service, and this entails combining the specialist services of the hospital with the local authority service, under a joint user arrangement
The Report goes on—
This idea is one which has been most effectively put into practice elsewhere and earlier. Portsmouth in this country evolved such a practice in about 1926, under Dr. Thomas Beaton
§ In York, where they have established an organisation on these lines, a joint committee of the hospital management committee and the York City Council has been set up, and this joint committee has been responsible for running the mental health after-care service. This joint committee includes three representatives of the City Council and three of the hospital management committee, together with the officers of both—that is to say, the medical superintendent and the medical officer of health. They have found 139 in practice, as inevitably would occur, that they have had to work out ways of splitting the cash costs. The hospital management committee bear 25 per cent., of clerical staff salaries, and the corporation pay the remainder. Five per cent. of the cost of the mental welfare officer is paid by the hospital management committee, and they split the rent of the joint premises used and the salary of an assistant psychiatrist, of which six-elevenths is paid by the management committee and five-elevenths by the local authority. I feel that that is inevitably what happens where such a scheme is set up. It is the only way to work it.
§ I am hoping that the Government will say that this is the way matters will be worked under the Bill. If they say that, of course, there is no need whatever for us to insist on this clause. The phrasing of the clause is in no sense sacrosanct. We are amateur draftsmen, and doubtless we have made errors in our clause. If, for example, the noble and learned Viscount were to throw out subsections (4) and (5), saying they are absolute nonsense—in fact, they are attempts to make sure that the local authority do their job—there would be no ill-feeling. We should still feel that we had achieved the essential thing—which is, that this service, to provide a continuum for the mentally ill patient, shall be provided by the hospital management committee and the local health authority. Unless that is done the idea will not work. That is all there is to it.
§ I hope that the Government will be able to say that this is how they intend it to work, that the hospital management committees and local authorities will consult together and that, as inevitably will be necessary, there will be a sharing of officers. For example, with the great shortage of psychiatrists, it will be essential to use the hospital board's psychiatric staff, and to split costs. That seems to us the only practical working basis on which they can be used. I beg to move.
After Clause 13, insert the said new clause.—(Lord Taylor.)
§ 5.25 p.m.
§ LORD STONHAM
I beg to support the Amendment moved by my noble friend Lord Taylor. The noble and 140 learned Viscount will probably recall that it embodies suggestions I made on Second Reading, particularly about the need for joint schemes between local authorities and hospital boards. Before I proceed with my brief remarks, I hope that I shall be allowed to apologise to the noble Earl, Lord Feversham, and to the National Association for the Mentally Handicapped, for my remarks on a previous Amendment, and for not merely underestimating but totally ignoring the considerable work that the Association does in teaching, and training teachers of, the mentally handicapped. I sincerely hope that any misunderstanding I may have created will not hurt anybody's feelings and will do no harm.
In support of what my noble friend said, may I put to the noble and learned Viscount the position of one hospital group, one of many for which I was formally responsible in the South West? I will not mention the group, but it was in South Somerset, and was responsible for a population of some 260,000 in South Somerset and North Devon. It consisted of a central mental hospital with some 950 patients and about 150 other patients in long-stay annexes—something like 1,100 all told. In January of this year—six months ahead of this Bill—the management committee sat down and considered what their responsibilities would be under this Bill and how they should meet them. The first thing they decided to do was to get in touch with the local authority. So long ago as January, the management committee of that hospital laid down:Our responsibility is primarily to fit patients for living responsibly in the community; secondarily, to bring maximum fulfilment to those unfortunate patients who are unable to live in the community by their own effortsIn order to devote themselves to that primary object, they must link up with the local authority. They reviewed their staff, which consists of nine psychiatrists, four of whom are junior hospital medical officers and three of whom are consultants. Of the 950 patients in the main hospital only 561 receive active treatment at least once a week and the other 419 do not. In other words, sixty-two patients per doctor receive one or more active treatments per week. The three consultants run four out-patient clinics in general hospitals with a total of 150 patients, and see every patient 141 on an average four times a week, in the general hospitals thirty or forty miles away, as they serve a wide area. This means that they keep those 150 patients from coming into the mental hospital in nearly every case. If we do not continue this service, the mental hospital is likely to be swamped.
I make this point to underline what my noble friend says in his Amendment about the need for the continuation of the services exercised by the hospital management committees under the Health Service Act in respect of the treatment of patients outside hospital. It is essential to continue those services to avoid a complete breakdown. I do not want to condemn or appear to over-criticise the local authorities, but I would quote this comment of the hospital management committee to which I have referred.Whilst the management committee feel that there should be greater liaison with the local authority, until the county council are able to give a positive reply to the management committee's letter inviting them to discuss this proposal it would be apparent that some patients will be kept in hospital needlessly; and the committee would like to arrange for more suitable care to be provided immediately.That is one of the major difficulties in this matter. We are going to place heavy additional responsibilities on the local authorities for which they have not yet immediate access to trained staff. Therefore it is most essential that everything possible should be done to ensure that these services continue, and that the mental hospitals and regional hospital boards are in no way discouraged, because in the beginning, as I see it, the initiative for co-operation must come from them. In my view, it is only in the mental hospitals and mental deficiency hospitals that we have the necessary reservoir of trained psychiatrists and staffs who are going to assist in this co-operative effort that is so badly needed. I feel that the objectives that we have in mind cannot be realised without full co-operation between the local authorities and the hospitals. The special efforts which have to be made to keep potential hospital patients at home will not be successful unless the hospitals are allowed to play a full part as equal partners. It must not be a case of schemes being imposed on 142 them; they must be encouraged to use their initiative, to play a full part and to be partners with the local authorities.
My noble friend said a few moments ago that we want to put in the Bill what is actually happening or what is going to happen. How right he is! Only last week I had the same kind of discussion with a county medical officer of health and psychiatrist. They are already starting. But there is every reason for putting these provisions, or something like them, in the Bill, so that we can ensure that there is uniformity and that not only the good ones but those not quite so good also will do it. Therefore there is need for the last subsection in the Amendment; that is to say, if the local authorities do not get on with it, then the Regional Hospital Boards should have power remaining unto them to carry on with the services and to do what is necessary. I hope, therefore, that the noble and learned Viscount the Lord Chancellor will give careful consideration to this particular proposal. If he cannot accept it in its present form, perhaps he will give an assurance that he will think about it between now and the Report stage, when something of a comparable nature can be brought forward.
§ 5.33 p.m.
§ THE LORD CHANCELLOR
I should like to make a suggestion to the two noble Lords which would, I think, leave the position entirely unprejudiced. The Government are entirely in favour of co-operation between the hospital boards and the local authorities. The noble Lords will remember from their study of this matter that the Royal Commission, in recommending a general shift in emphasis from hospital care to community care, went on to declare against too rigid a classification of functions; and they realised that the movement would have to be gradual in many areas. Therefore we have felt that this was not a matter for inclusion in the Bill, but rather for administrative encouragement. But I should like to read carefully and to consider with my advisers from the Ministry what both noble Lords have said. I hope they will not misunderstand me. My noble friend and I are fully prepared to deploy the arguments at any time, but as both noble Lords have made considered speeches in the matter, I should still want to hold myself free to 143 give full consideration to those speeches. So, while I cannot make any promise in the matter, I should like to consider those speeches. It might therefore be convenient for the Amendment now to be withdrawn and I will consider it. If we find that we cannot do anything about it, I will let noble Lords know, so that they can, if they wish, put it down again on Report.
§ LORD TAYLOR
I thank the noble and learned Viscount for that helpful suggestion; it is indeed what we should like the Government to do. We are only desirous that this thing should work, and we feel sure it is essential, if it is to work, that these provisions should be made. Whether it is done through the Act or administratively is of secondary importance. We hope it will be in the Bill so that there may be no inhibitions on the part of the Regional Boards in doing their duty. We willingly accede to the Lord Chancellor's suggestion, and I beg leave to withdraw the Amendment.
§ Amendment, by leave, withdrawn.
§ Clause 14 agreed to.
§ Clause 15 [Special provisions as to registration of nursing homes]:
§ Amendment moved—
§ Page 9, line 40, after ("home") insert ("(excluding persons carrying on or employed in the home and their families)").—(The Earl of Onslow.)
§ On Question, Amendment agreed to.
§ Clause 15, as amended, agreed to.
§ Clauses 16 to 19 agreed to.
§ Clause 20 [Special provisions as to registration of residential homes]:
Page 13, line 4, after ("home") insert ("(excluding persons carrying on or employed in the home and their families)").—(The Earl of Onslow.)
§ On Question, Amendment agreed to.
§ Clause 20, as amended, agreed to.
§ Clause 21 agreed to.
§ Clause 22 [Powers of entry and inspection of other premises]:144
THE EARL OF ONSLOW
This is little more than a drafting Amendment. This clause gives a mental welfare officer (as defined in Clause 146) power to enter and inspect premises (other than hospitals) in which he has reason to believe a mentally disordered person is not under proper care. Subsection (2) excludes mental nursing homes and residential homes and was inserted to avoid duplication with the powers of inspection in, respectively, Clause 17 of the Bill and Section 40 of the National Assistance Act. The following Amendment proposes to delete subsection (2) because (a) there is not likely to be any clash in practice between the powers given in this clause to mental welfare officers and the powers given in the other provisions mentioned to other persons, all of whom act on behalf of the same local authorities; and (b) the subsection as it stands might have had the effect of excluding any power of entry and inspection under the clause in cases where, for example, there was reason to believe that a member of the staff of such a home who was mentally subnormal was not being properly treated. I beg to move.
§ Amendment moved—
§ Page 13, line 39, leave out from beginning to ("a").—(The Earl of Onslow.)
§ On Question, Amendment agreed to.
Page 14, line 1, leave out subsection (2).—(The Earl of Onslow.)
§ On Question, Amendment agreed to.
§ Clause 22, as amended, agreed to.
§ Clauses 23 and 24 agreed to.
§ Clause 25:
§ Admission for observation
§ .—(1) A patient may be admitted to a hospital, and there detained for the period allowed by this section, in pursuance of an application (in this Act referred to as an application for admission for observation) made in accordance with the following provisions of this section.
§ 5.40 p.m.
§ LORD DOUGLAS OF BARLOCH moved, in subsection (1) to leave out "admission" and insert "detention". The noble Lord said: In moving this 145 Amendment I will, if I may have your Lordships' permission, deal also with the subsequent Amendment in my name which is directed to precisely the same point. If these Amendments should be carried they will, of course, entail a large number of consequential verbal Amendments. I had, indeed, originally placed them upon the Order Paper, but I was advised that for the sake of simplicity it would be better to put down only these two.
§ We are dealing in this Part of the Bill with the compulsory detention of mental patients in hospitals, and there is laid clown a procedure by which people may be so detained. They can be detained for either of two purposes—either under Clause 25, for observation, or under Clause 26, for treatment. The procedure in either case is that a document called an application should be completed which is founded on the written recommendation of two medical practitioners. This is referred to under the provision in brackets in subsection (1) of Clause 25, and similarly in subsection (1) of Clause 26 as "an application for admission." This language is distinctly misleading. In fact, the patient may be already in hospital, and the essence of this procedure is the compulsory detention and not the admission to hospital, because patients can be admitted as voluntary patients without being compulsorily detained.
§ If noble Lords will look at Clause 31 they will see that the application for admission has the consequence of enabling the managers of a hospital not only to admit the patient, if he is not already there, but to detain him; or, under subsection (2) of Clause 31, if he is already in the hospital to detain him there. This is a serious step to be taken. We are dealing here with the taking away of the liberty of the subject and keeping him compulsorily in hospital, and I think it is very wrong that this should be described in words which are misleading.
§ I do not know the details of what is going to happen, but I presume that there will be prepared—and there are possibly already in draft—a series of official forms to be used under Clauses 25 or 26, and that they will be headed, in accordance with his wording, as "an application for admission for observation" or as "an application for admission for treatment." 146 That will probably be in large letters across the top of the form, and the relative of the patient who has to be a party to this application—unless the patient is under the guardianship of somebody else—has to sign this application. I do not know why it has been chosen to describe this in such misleading terms, when in fact the really important operative part of this is the compulsory detention. It may be that it is under the theory that it will hurt the feelings of the patient. But the patient ought to know what is happening to him, if he is capable of understanding it at all, especially as he is given in this Part of the Bill the opportunity of applying to a tribunal for a review of this so-called application which is, in effect, an order for his detention. His relatives, also, ought to be perfectly clear what is happening. They should not be presented with forms which are liable in any way to mislead them. I think that as the Bill stands it is quite misleading.
§ Of course I acquit the noble and learned Viscount who is in charge of this Bill of any intention to mislead anybody, because I know, and everybody who knows him will agree, that that is the last thing that would ever enter his mind. But it is nevertheless a somewhat deceptive description; and I submit, in all seriousness and sincerity, that it ought to be described in words which make it quite clear what is being done. I beg to move.
§ Amendment moved—
§ Page 15, line 7, leave out ("admission") and insert ("detention").—(Lord Douglas of Barloch.)
§ THE LORD CHANCELLOR
I hope that the noble Lord, Lord Douglas of Barloch, will not press this Amendment. I sympathise with the general approach to life that it is in most cases better to call a spade a spade than "an adjectival agricultural implement". But I think we have to consider this matter a little more deeply than on that general principle. First of all, it will be observed, as the noble Lord pointed out, that this substitution is to apply whether for observation under Clause 25 or treatment under Clause 26. The application is, in fact, both for admission and detention. I should have thought that either term could be used, and that in the circumstances, "application for admission" is preferable.
147 One of the main objects of the Bill, as every speaker pointed out in the Second Reading debate, is to treat compulsory patients, so far as possible, in the same way as informal patients and to discourage the attitude which regards them as quite different from other patients. We hope that increasingly an initial period of compulsory treatment will be followed by another period of informal treatment. The term "application for admission" is commonly used in relation to patients other than mental patients, and it places the emphasis where it should be, on admission for treatment or observation, rather than on the fact of detention. One cannot ignore the fact of detention, but I cannot see why it is necessary to force it on the attention of patients, their relatives or the general public.
If there were any question of deception or confusion that would be another matter, but the Bill makes it quite clear that the application for admission provides authority for detention; that is quite clear in Clause 31. And it makes special provision for the patient who is already in hospital when the application is made; that is under Clause 30. I point out to the noble Lord, Lord Douglas of Barloch, that there is a parallel in the words "reception order" in the present Lunacy Act, which provides authority for reception and detention and does not lead to confusion. In those circumstances, I see no reason for not using the term which is, I think, more consistent with our general approach, so long as there is not confusion. For that reason, I ask the noble Lord not to press this Amendment.
§ LORD DOUGLAS OF BARLOCH
I confess that I am a little disappointed with the reply which the noble and learned Viscount has made. I do not attach very much importance to the point so far as Clause 25 is concerned, because observation under the provisions of the Bill is of itself necessarily of a temporary character. But admission for treatment under Clause 26 is of a different nature; it may continue for a long time. It is true that it requires renewal from time to time, but it may nevertheless continue for a very long period of time.
148 I am fully aware of, and very sympathetic to, the view that, so far as circumstances permit, there should be no differentiation between patients who suffer from mental illness and those who suffer from other illnesses; but this is arguing, I should have thought, a long past battle. The time has surely gone by when mental illness carried with it some special stigma, as happened years ago, and was regarded as something of an extremely disgraceful character. I am sure that it would not make the slightest difference to the way in which mental patients are regarded if this Amendment were to be carried, and I reject completely that part of the noble and learned Viscount's argument. I do not believe that it is true that calling a spade a spade is going to interfere with the treatment of the patient, or with his happiness or the happiness of his friends and relations. But I do think it most important that they should be made clearly to understand what is happening, and that this very serious step should not be glossed over. However, I am not going to press the matter, at this moment, at any rate, and I shall therefore ask your Lordships' permission to withdraw the Amendment. Before I do so, I want to correct one point that the noble and learned Viscount made. With all respect, admission is not the important thing in this series of clauses. Indeed, I should think that in the majority of cases which will be dealt with the patient will have already been admitted to hospital before this step is taken which enables him to be detained. That, in my experience, is the position, and I should think it will still continue to be so in the future.
§ Amendment, by leave, withdrawn.
§ Clause 25 agreed to.
§ THE LORD CHANCELLOR
If your Lordships would allow me to intervene, may I say that we said that we would adjourn the Committee stage at some time between half-past five and six o'clock, and it is now nearing the second of those times. Perhaps, if noble Lords find it convenient, this would be a convenient moment for the adjournment. I beg to move that the House do now resume.
§ Moved, That the House do now resume.—(The Lord Chancellor.)
§ On Question, Motion agreed to and House resumed accordingly.