HL Deb 05 July 1960 vol 224 cc1011-26

2.50 p.m.

Order of the Day for the Second Reading read.

THE MINISTER OF STATE, SCOTTISH OFFICE (LORD CRAIGTON)

My Lords, the Bill that I have to commend to your Lordships to-day is the first comprehensive revision of Scottish mental health law for over 100 years. The Lunacy (Scotland) Act of 1857 is still a fundamental part of the Acts that we are operating to-day. Amendments and additions have been made to it over the century. It is not surprising that we are now operating under a tangled web of legislation to be found in numerous Acts, not all of them primarily concerned with mental health. What is surprising is that it has worked so well.

To substitute now for this conglomeration a single Act, as simple as the subject would allow, is clearly necessary. The pattern of treatment and care for the mentally disordered has been revolutionised since 1857, and legislation must now take account of this revolution. Indeed, this need for revision has been clear for some time. In 1938 a Committee under the Chairmanship of Lord Russell was set up to look into the matter. At that time psychiatry was about to take a dramatic leap forward. New physical and chemical methods of treatment had been brought into use which had a striking effect on the duration of mental illnesses and the recovery rate of patients. How great was this effect was obscured for a time by the war, when the unfinished work of the Russell Committee had to be set aside. It was only in 1946 that their recommendations for a revision of the law were available. But at Chat time the National Health Service was being prepared and introduced, so it was not until 1955 that the Government issued a White Paper as a basis of discussion embodying their proposals for amending the law. By then—I agree with the policy—it seemed proper to wait a little longer to take advantage of the findings of the Royal Commission set up to look into the English mental health law. The Royal Commission reported in 1957. Then the application of its findings to Scottish conditions was considered and reported upon by a Committee of the Scottish Health Services Council, called, after its Chairman, the Dunlop Committee. So we have this Bill after what can honestly be called more than 20 years of continuous review.

Now for the Bill itself. Part I proceeds to establish an independent central body, to be called the Mental Welfare Commission for Scotland, with the duty of exercising protective functions in respect of mentally disordered persons. This body will replace, so far as these functions are concerned, the General Board of Control for Scotland, which is, consequently, dissolved by Clause 3 of the Bill. It may interest your Lordships to know that the General Board of Control has been in existence under another name since 1857 and under its present name since 1913.

In Clause 4 there are set out in some detail the duties which the Commission are to perform in the exercise of their protective functions. In particular, it is their duty to inquire into any case where there may be ill-treatment or improper detention, or deficiency in the care or treatment of any mentally disordered person, or where his property may, because of his mental disorder, be exposed to loss or damage.

The Commission are among those with the power to discharge a patient subject to compulsion under the Bill. Under Clause 43 the Commission have not only a power, but a duty to discharge whenever they are satisfied that this should be done. Throughout the Bill provision has been made for the Commission to receive all the necessary information and documents to enable them properly to carry out their protective function.

There is one other clause in Part I of the Bill, and that a very short one, to which I should draw your Lordships' attention. Clause 6 defines "mental disorder", for the purpose of the Bill, to mean mental illness or mental deficiency, however caused or manifested. Your Lordships may recall that the Royal Commission concerned with the English law distinguished two categories in addition to the mentally ill—namely, the severely subnormal and the psychopathic. This Scottish Bill, in adopting a definition of mental disorder by reference to mental illness or mental deficiency, follows the advice of the Scottish Health Services Council in rejecting the idea of naming a separate psychopathic group. This matter has been fully discussed with representatives of medical opinion in Scotland, and the approach adopted in the Bill has the full agreement of Scottish psychiatric and other medical opinion, which has also stated a preference for retaining the expression "mental deficiency".

In Part II, the Bill concerns itself with services provided by local authorities. It is in this field of community services that we may expect to see some of the most interesting developments in the future. Scottish local authorities have a fine tradition in the boarding-out of mental patients, and particularly mental defectives, with related or unrelated guardians. We hope to see the supervisory and supporting rôle of the local authorities develop, together with their other services for care and aftercare in the community. This Part of the Bill accordingly has three aims: First, to continue the duty of the local health authority to provide suitable training and occupation for certain mental defectives—that replaces a duty they now have under a part of the National Health Service (Scotland) Act, 1947, which is to be repealed; secondly, to ensure that the local authority is free to use its powers as welfare authority, education authority or children authority, as well as local health authority, so far as possible for the benefit of mentally disordered persons. Thirdly, Clause 7 of the Bill sets out the scope of the arrangements that local health authorities may make for services for the mentally disordered.

Part III of the Bill provides for the registration of private hospitals by the Secretary of State. The words "private hospital" are used in the Bill to mean a place where it is proposed to receive patients subject to detention under the Bill whether as personally paying patients or by arrangement with the National Health Service. There are at present only six such places in Scotland, all provided by the Roman Catholic authorities. In providing for their registration by my right honourable friend the Secretary of State we are continuing the present provision for their central registration. At present this is one of the functions of the General Board of Control. Part III also deals with registration of residential homes for mentally disordered persons, adopting for this the machinery of the National Assistance Act, 1948, the registration authority being the local authority.

In Part IV of the Bill are the procedures for the use of compulsion. Before I refer to these procedures, however, I should like to draw your Lordships' attention to subsection (3) of Clause 23, which makes it clear beyond doubt that nothing in the Bill is to be construed as preventing a patient who requires treatment for mental disorder from getting that treatment without any formality or use of compulsion. This is an extremely important subsection, emphasising as it does our anxiety that compulsion should be kept to a minimum, and used only where it is absolutely essential. I would remind your Lordships that to-day four people out of five going into our mental hospitals do so voluntarily, and we may expect that proportion to increase still further in the future. So compulsion is to be used only in a small minority of cases where the circumstances require it.

The Bill provides for two forms of compulsion—detention in hospital and guardianship. With each, an application for the admission or reception of the patient is necessary. The application must be made by the patient's nearest relative or a mental health officer, who is a local authority official with specific statutory functions under the Bill. Every application is to be accompanied by two medical recommendations, the form of which is to be prescribed. This will secure that compulsion is used only where, in the opinion of the medical practitioners making the recommendations, the health or safety of the patient or the protection of other persons requires it.

Clause 27 (b) requires one of the re-commendations to be made by a doctor approved by the Regional Hospital Board as having special experience in the diagnosis or treatment of mental disorder. If practicable, the other recommendation is to be given by a patient's general medical practitioner or by another doctor with previous acquaintanceship of the patient. Special knowledge of the disorder and special knowledge of the patient are thus assembled together to give the very best chance that the right conclusion will be reached. As an additional safeguard, the documents—that is, the application and medical recommendations—are to be submitted to the sheriff for his approval and become operative only when that approval bas been obtained. Scottish opinion, including psychiatric opinion, is convinced that the sheriff should continue, as at present, to play a part in this way, and in retaining his part in the procedure we are following the recommendation of the Dunlop Committee.

Within twenty-eight days of his being received into hospital or guardianship, a report on the patient must be made by the doctor responsible for him. If the doctor then decides that further detention is necessary, the authority to hold him continues until the end of the year. At the end of the first year the responsible medical officer must seek a second medical opinion on the need for further compulsion. Authority to detain in hospital or keep under guardianship will require to be similarly renewed at the end of the second year, and thereafter at two-yearly intervals.

My Lords, I have spoken of the duration of compulsory powers and of the provisions for their renewal, but there is no question of detaining a patient merely because the current period of these powers has not yet expired. Clause 43 of the Bill empowers a number of persons to discharge a patient at any time. First, there is the doctor authorised by the board of management or by the local authority to act as the responsible medical officer for the patient. We may expect the great majority of discharges to be made by him; and he has a duty, not merely a power, to discharge the patient whenever he is satisfied that he should no longer continue to be subject to compulsion. A similar duty is laid on the Mental Welfare Commission. The board of management, or the local health authority in guardianship cases, as well as the nearest relative of the patient, are also given a power of discharge, which may, however, be barred by the patient's responsible medical officer.

I have mentioned the part that the sheriff is to play in the admission procedure, and here again he comes into the picture. The nearest relative, if his attempt to discharge the patient is barred, may appeal to the sheriff to order the discharge of the patient. Similarly, a patient has the right, at any time when his detention or compulsory guardianship has been renewed, to appeal to the sheriff for his discharge. In these circumstances too, the sheriff has the right to order the patient's discharge. Thus, in addition to a right of access to the Mental Welfare Commission with a request for discharge at any time, the patient and his nearest relative have rights of more formal appeal to the sheriff in the circumstances I have mentioned.

Part V of the Bill deals with those patients who have become involved in criminal proceedings. Let me say at once that the Bill makes no fundamental change in the existing Scottish law which, it is generally agreed, has worked well for so many years. Part VI deals with the transfer of patients between one country and another, particularly between Scotland and other countries in the United Kingdom. The underlying principle is that a patient, on transfer, should move into the appropriate category of patient in the country into which he is received and thereafter be subject to the legislation of that country, so far as it affects that category of patient.

Part VII of the Bill gives the Secretary of State the duty of providing hospitals for persons requiring treatment under conditions of special security on account of their dangerous, violent or criminal propensities. This provision for State hospitals as they are to be called will replace existing provisions for State mental hospitals and State institutions for mental defectives. The present hospital and institution at Carstairs will become State hospitals.

Part VIII of the Bill is concerned with protecting the property of patients. It would not have been appropriate to attempt in the Bill to make any radical alteration even had we wished to do so, to the Scottish law relating to appointment of judicial factors. We have, however, filled in one gap in the present law by laying on the local authority a definite duty to initiate arrangements for appointment of a curator bonis where this is necessary. Part IX contains a number of miscellaneous provisions, the most important of which are concerned with the ill-treatment of patients.

My Lords, this important Bill of 118 clauses and five Schedules, which themselves occupy 25 pages, has been examined most conscientiously in another place—and at no time along Party lines. We are grateful for the care and attention given in nineteen meetings of the Scottish Standing Committee and for the improvements in the Bill that resulted therefrom. For that reason the Government have, for a Bill of this size and complexity, singularly few Amendments still to be considered. I shall listen with great attention to any comments that your Lordships may wish to make, and I will answer them, to the best of my ability, when I come to wind up, in the knowledge that we shall have further opportunities to examine these matters in greater detail. My Lords, I beg to move that this Bill be now read a second time.

Moved, That the Bill be now read 2a.—(Lord Craigton.)

3.7 p.m.

LORD GREENHILL

My Lords, I rise first of all to say that I approve of the Bill that has been presented to your Lordships for Second Reading. If it appears to your Lordships that this is a somewhat belated measure which Members have already considered during the consideration of the English Bill, it should perhaps be regarded as an advantage that that is so, because not only have your Lordships had the advantage of reading the English Royal Commission Report on the Law Relating to Mental Illness and Mental Deficiency, but there has also been the opportunity of considering the English Bill which was based upon the findings of that Report, which passed the scrutiny of another place and of your Lordships' House and which resulted in what is now an Act of Parliament.

To-day, the noble Lord, Lord Craigton, has presented to us in his Second Reading speech the general outline of this Scottish Bill on mental health. Although it deals with the same kind of problem as was dealt with in the English Bill, there are certain differences, both traditional and local, which make it necessary that there should be a separate Scottish Bill. In turn, that separate Scottish Bill has passed close scrutiny in another place; and having, read what has been said there and having re-read the Bill here, I would say only this. The Dunlop Committee not only carefully examined the law as applied to Scotland on mental health generally, but took the trouble to prepare in one of their Reports a close examination of the recommendations of the English Royal Commission on this matter. They gave their criticisms, and, after considering the general recommendations of the Royal Commission, they have come forward with recommendations in certain respects different from the English Bill. This Bill embodies those differences. I am inclined to say that, so far as Scottish conditions are concerned, the Bill reflects more accurately the needs and the wishes of the people of Scotland.

Personally, I am rather sorry about the departure of the General Board of Control. I know personally the man who for many years was Chairman. Everyone who knows him knows what an excellent Chairman he made, and how well he carried out his functions. Nevertheless, I suppose that, with the passing of time and the changes that have taken place, it is necessary now to confine the activities of that Board to protection of patients and to leave the administrative duties which they also carried out to other people more directly under the control of the Secretary of State. I think that that change—although I myself, as I say, regret it on personal grounds—fulfils what are recognised as being the desires of those mainly concerned with the administration of this Mental Health Bill.

I have already referred to the considerations of the Dunlop Committee, who produced two Reports, one of which was based entirely on the findings of the Royal Commission, and I think it only right that those of us who take part in these debates in your Lordships' House should express admiration of the balanced manner in which they have considered the recommendations of the Royal Commission and the careful manner in which they have expressed their differences and put forward their recommendations. There has been nothing of a partisan nature (and by that I do not necessarily mean political partisanship) in their recommendations, and any reasonable-minded man must feel that they have given due consideration to such differences as they have felt themselves compelled to recommend.

I think, too, that in regard to the retention of the sheriff as the man before whom these applications will come, as the man given power to determine whether or not a discharge is proper in certain circumstances, again what is being done here is to place the faith of Scotland where it has always resided—in the hands of the sheriff, whose competence, whose experience, whose knowledge and whose impartiality are unquestionably accepted by all the people. I think, therefore, that in retaining this function of the sheriff in these matters relating to mental health, what is being done is being done in agreement with the wishes of the people of Scotland.

One thing that arouses certain queries in my mind is the position of the local authority in respect of the duties imposed upon it in this Bill. The local authority in Scotland is at one and the same time, as indeed has already been indicated by the noble Lord in his speech, the public health authority, the welfare authority, the children's authority and, where a county council is concerned, the education authority, too. In all these respects they have duties, and in many respects additional duties: for example, the appointment of a mental health officer, the employment of psychiatric social workers, the appointment of domiciliary visitors and so on, all of which will mean not merely an intensification of duties which they are already fulfilling but a considerable addition to the general expense of running these services. One would like to have an assurance that the additional cost to which local authorities will be exposed will be met generously and that local authorities will not be given the feeling that here are more and more duties being imposed upon them without any guarantee that the cost will be met by the State. So the question of finance, however much we may like to ignore it if we can, cannot be avoided and must be referred to and some assurance must be given.

There is also an emphasis in this measure, as there is in the English measure, too, that men and women who have been mentally ill, once they have been treated and are considered well enough to mix in the community at large, must be looked after as a community charge. It does not follow from that that the best place in which to have a returned patient is in the confines of his own home, because we know well enough that patients are inclined to be difficult, even after cure, and that the atmosphere within the home is likely to be considerably disturbed by having to adjust oneself to the peculiar outlook, if you like, of ex-patients. One would like to think that anyone discharged from a mental hospital will be looked after as part of the community care, but not necessarily within the home from which he came. It would be, I suggest, not only to the great advantage of the patient himself, important as that is; it would be of even greater advantage to the family of the patient, to whom the very return of one who has been mentally ill must, in itself, be a disturbing factor. In that sense I hope that when it comes to considering the community care of these people a broad measure of assistance will be taken and not a narrow one, because you are dealing here with a very delicately balanced grouping of people which it is important not to disturb.

In regard to Clause 91, which deals with the local authority's duty to look after the property of a patient, I think it is a great advantage that that duty should be imposed upon the local authority, who, having no axe whatever to grind, can be trusted to give impartial attention to the well-being of the patient in so far as his possession of property is concerned. I mentioned previously a case which was causing a great deal of disturbance by the fact that the law was not sufficiently tight enough to prevent a potential heir from dissipating whatever was coming to him. I am assured that to go to the length that perhaps I indicated would require new legislation which would not be appropriate in a measure of this kind. But short of that, this clause provides protection for these mentally ill people whose property needs some kind of looking after, which hitherto they have not been able to obtain.

Then there is the question of keeping the legislation which we are discussing to-day in pace with the advances in knowledge and the change in outlook which has taken place over many years. My personal reaction to that is that, great as has been the change, great as has been the appreciation that these mental illnesses are exactly similar to physical illnesses and that there should be no suggestion of any kind of difference the fact remains that we are still just groping our way in this field. I think the Scottish Bill is very much better in the sense that it does not draw numerous distinctions between the different kinds of mental illness but just says that there are two kinds which we are dealing with in a more general sense, one mental illness and the other mental deficiency. Nevertheless it does not preclude the consideration of the different branches of mental illness on the one hand and the different kinds of mental deficiency on the other hand. It takes two broad issues in such a way as to deal with any aspect of either of them, without giving them individual detailed descriptions and so confusing the issue rather than clarifying it by trying to make those distinctions in the course of an Act.

There is a further point that I should like to raise, without attaching blame to anyone: that the hospital accommodation—the amenities in hospitals—for mentally ill patients is not what it should be. That is generally admitted. Moreover, the attitude nowadays to what a mental hospital should be is very different from what it was when most of the present mental hospitals were erected. No longer does one see nurses wandering about like warders, with keys hanging from their waists, locking doors when patients come in and out, and so on. There is a much freer and more open kind of treatment in hospitals nowadays, and the patient does not feel that he is incarcerated in some place from which there is no hope of outlet at any time. But in spite of that, I think the time has come when the Government must ask themselves how many more hospitals, and of what kind there should be for patients who are mentally ill.

That it will cost a great deal of money is pretty obvious; that it will mean different kinds of buildings is pretty obvious. But if we are considering, as we are to-day, how to do our best for those people who are temporarily, or for longer periods, mentally ill or mentally defective, I think the time has come when we can no longer ignore the lack of amenities in regard to accommodation for patients. I think that it must have come as a surprise to a great many people to hear how great a proportion of the total number of beds in our hospitals is occupied by patients suffering from mental illness as compared to those suffering from all other conditions. These are unpleasant reminders perhaps, but we cannot ignore there. The fact is that we have a large population who, unfortunately, require accommodation, and I think the time has come when we had better face that issue boldly and bravely.

Finally, I think we are bound to recognise that, while mach has been discovered within the last century (it goes back many more years than a great many people seem to think); while we now use such words as "the unconscious", or "complexes", or several of the other words that have now become almost the currency of ordinary conversation, the fact is that we are merely on the fringe of developments which lie ahead. If noble Lords read their Sunday Times last Sunday they will not have been surprised that a centre-page article was devoted to an examination of Mr. Khrushchev's motives, based possibly upon what nowadays is known as the Pavlovian technique—another illustration of the recognition of the increasing importance and influence which mental warfare, psychological warfare, is having in the affairs of the world to-day. I do not want to expand the examples, although I could give a number of them. But I should like to urge upon noble Lords that when we are considering the future and what might be achieved in the way of understanding mental processes in the human mind, we shall then, I think, have some greater hope that, by that kind of means, we shall be able to achieve a world atmosphere of peace rather than adopt some of the methods that are being adopted to-day. That appears to be a little irrelevant to the issue which is before us, but I thought I would mention it. With those few remarks, my Lords, I beg to express my approval of the Bill that has been put forward, and I hope that it will go through its further stages without diffculty.

3.24 p.m.

LORD SALTOUN

My Lords, I should like from this side of the House to join in the excellent welcome to the Bill given by the noble Lord, Lord Greenhill. I do not want to say much on the subject—in fact, I do not want to say anything, except to refer to what the noble Lord said. I should like to say that I was glad to hear that, in spite of the large number of us in Scotland that the noble Lord found were mad—I trust his great experience—it is consoling to find that, like Hamlet, we are mad "only Nor'-Nor'-West", and that the situation is not so bad as it might otherwise be. I, too, should like to associate myself with what he said about the sheriffs. I have said this before in your Lordships' House. The sheriff is someone with a great social status in Scotland: he is trusted by high and low; everybody in Scotland has complete confidence in the sheriff. I think the position of the sheriff in the Bill is well justified.

3.25 p.m.

LORD CRAIGTON

My Lords, I am grateful to the two noble Lords for giving this Bill such a warm welcome. I agree with everything that the noble Lord, Lord Saltoun, said about the sheriffs. In all the legislation with which I have been connected, if there has been any problem or trouble at all we leave it to the sheriff. We know that a Scotsman will be satisfied with his decision. I am grateful to the noble Lord, Lord Greenhill, for what he said about the Board of Control. It was most difficult for them to wear two hats, the administrative hat and the protective one. I think they will be happier having one hat in the Scottish Office and one in their own office.

The noble Lord asked me about three points, and I should like to reply a little more fully to one, because I think it will be of interest to the local authorities. The noble Lord was worried about the added duties and expenses of the local authorities. What my right honourable friend will do, as soon as the Bill is passed, is to issue a direction to local authorities which will convert into a duty their power to provide services for the prevention of mental disorder and for care and after-care of persons who are, or have been, suffering from mental disorder. This direction by the Secretary of State will be in general terms.

The Secretary of State has also asked the Scottish Health Services Council Standing Advisory Committee on Local Authority Services for their advice on what arrangements the local authorities should include in their proposals. In particular, the Committee have been asked to tell us what services local authorities could put into operation quickly—in other words, we have asked them what aspects of community service for the mentally disordered should be given priority, bearing in mind, of course, the shortage of staff, the shortage of accommodation and the shortage of money. When the advice of this Committee is available, as I hope it will be before the end of the year, local authorities will be called upon to submit their proposals to the Secretary of State.

The sort of thing we think the Committee will suggest is such topics as staffing and other arrangements to secure adequate supervision for persons placed under guardianship, or for mental defectives who do not require guardianship but need the benefit of some form of supervision. They will also make recommendations for setting up residential accommodation for people suffering from mental disorder, and, where it is appropriate, for people leaving hospital, or (this is the noble Lord's point) for mental defectives in the community who need more supervision than they can receive at home. Of course, the proposals would cover the arrangements which local authorities propose to make to carry out Clause 12, to provide suitable training and occupation for adult mental defectives and for those mentally handicapped children whom the education authority cannot help. So, in effect, the local authorities will not be asked to undertake more than they can reasonably be expected to do.

I give the noble Lord an assurance that the increased services will be taken into account in general grant. I can also give him a little more than that. There will, in fact, be a saving of about £300,000—that is about three-quarters of what local authorities spend now on mental health. At present, as the noble Lord will know, the Scottish local authorities have a duty to pay maintenance allowances for boarded-out mental defectives. In the Fifth Schedule to the Bill they are relieved of that responsibility, which will now become the responsibility of the National Assistance Board, so that to start with, they will operate the Bill with £300,000 less cost than they have now.

The noble Lord spoke about medical research and said—and I agree with him—that we are still groping our way in this field. It is common knowledge that there is a need for much more research, and a year ago my right honourable friend asked the Advisory Committee on Medical Research for their advice on this matter. The Committee have now reported, recommending the development of a body of young psychiatrists trained in research method; the encouragement of workers in related scientific departments to take an interest in psychiatric problems; the encouragement of long-term studies of the natural history of particular clinical conditions; and the further development of medical records for purposes of research. These and other recommendations are being most carefully considered by my right honourable friend; and may I say that if there is any good subject worthy of research we can always find the money for it, and there is no reason for it to be held up.

Finally, the noble Lord asked about hospital accommodation. We have a long way to go in the mental health field, and everything is not lovely in the garden; but I can give the noble Lord some reassurance that we are getting on with the work. As he knows, the chief items in our hospital building programme are for mental defectives, not the mentally ill. Schemes are in progress at Ladysbridge, in Banff; at Strathmartine (formerly known as Baldavan), at Dundee; and at the Royal Scottish National Institution at Larbert. Between them they will give us 800 additional mental deficiency beds within the next three years; and I believe the noble Lord will see that 800 in the context of the 5,600 beds we now have. We are also considering, in addition to these schemes, extensive new mental deficiency hospitals in Fife and in the northern region of Inverness. But, of course, we have to watch these proposals with care, for we have to study the impact of local authority developments, such as the provision of residential accommodation, on the need for our providing further institution accommodation.

In the mental hospital field, as distinct from the mental deficiency hospitals, we have not the same pressing need for more beds. What we are concerned about is improving the quality of the accommodation we now have for the mentally ill, and with providing new types of specialised units which developments in psychiatry require. Here again we have to watch developments, because there is a great increase in the number of patients using out-patient facilities, which may make our ideas on beds change considerably over the years. We have two projects which should be mentioned. The first is the provision of 160 new beds at the Royal Edinburgh Mental Hospital. This is a valuable contribution to an important mental teaching hospital—and we need these beds in the teaching hospitals. The second important development is an extension of 226 beds at Bellsdyke Mental Hospital, in Larbert. This is simply getting rid of bad accommodation, using that far therapy or recreational purposes, and putting 226 beds in place of the 226 unsatisfactory ones there now. My Lords, I have no more to say. I trust that I have answered the noble Lord's questions satisfactorily, and I am grateful for your Lordships' reception of this very important Scottish Bill.

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