§ 2.48 p.m.
§ LORD STONHAM rose to draw attention to the problems of the hospital service; and to move for Papers. The noble Lord said: My Lords, I regret that my noble friends Lord Uvedale of North End and Lord Grenfell, who had hoped to speak in this debate, are unable through indisposition to be here, but judging by the list of speakers there are enough to ensure a wide-ranging debate. I think the list also indicates that the subject is considered ripe for discussion.
§ Eighteen months ago the keynote of our debate on the hospital service was dirty hospitals and from it ensued a great and successful effort to achieve physical cleanliness. Unfortunately, less has been done to ensure greater clinical cleanlines, but I hope that to-day we shall give further thought to this vital subject. To-day, the overriding question in the hospital world is how to get full value for the money available. On the one hand, we have the rising demand for medical care, which stems from our success in increasing the expectation of life, and on the other hand, we have the Government's decision to reduce the share of the gross national product, coming from Government funds, made available for the Health Service. So, if we are to maintain, let alone improve, on present standards, every penny must play its full part.
§ The Minister has made a good start by asking for the assistance of the regions in putting on paper a picture of the sort of hospital service which they should expect to have by the middle 'seventies. It really means spending for twenty years ahead, instead of the present five years. It will involve regrouping and amalgamation of hospitals; the enlargement of some and the elimination of others, and the conversion of some general hospitals to serve a more specialised purpose. It will also mean the abandonment of schemes long cherished and highly desirable in the short term which do not fit into the long-term plan of things to Come.
Subject to two vital considerations, it will provide a better service at less cost. Those considerations are, first, that the planning is not forced to fit some preconceived,
tidy, Whitehall paper notion; and secondly, that the Minister realises that it is not the glitter of glass and chromium which makes a good hospital, but the quality of the staff and that he must carry the staff with him in any changes that he intends to make. Unfortunately, Mr. Powell's disastrous speech last month to the National Association of Mental Health ignored both those considerations. He declared that in fifteen years 75,000 (that is half) of our mental hospital beds would not be required; that by far the greater part of our mental hospitals would be eliminated. He said that this 50 per cent. reduction was based on present trends, but he wanted to speed up these trends to pitch the estimate lower still: in his own words
As low as we dare, perhaps lower".
That is dangerous nonsense, because the people with whom, on the flimsiest evidence, the Minister is prepared to take such risks arc the most helpless and defenceless in the whole country.
I speak on this subject with feeling and with a little knowledge. because for four years soon after our hospitals were nationalised I was Chairman of the Mental Health Committee of the six South-Western counties responsible for some 100 hospitals with some 17,000 beds. So I know all about the buildings which Mr. Powell describes as
isolated, majestic, imperious asylums which our forefathers built with such solidity".
Ten years ago I said that some of them should bear the sign outside: "Abandon hope all ye who enter here". But not to-day. Then in the great wards the beds were so close that patients could get out only on one side, and there were two ranks of beds up the middle of the ward. It is on the basis of such overcrowding that the Minister has based his conclusions.
§ Nationally, it is true that the number of mental beds has gone down by 10 per cent., but in no hospital are they yet clown to even the standard level of accommodation. More than 75 per cent. of newly admitted patients go out again within three months, relieved or cured. That is wonderful. But that is only the new admissions. The grim fact is that 75 per cent. of the patients in mental hospitals at any given time are long-stay cases; many of them will never come 853 out, and their numbers will increase with the increasing population, while increasingly longevity will create a need for hospital care in the terminal years and. therefore, a greater need for long-stay beds. Even if, on the wildest assumption, long-stay cases will not need the expert facilities of the psychiatric hospital, they will certainly need beds and nurses. Is there any sound reason for providing new beds in new accommodation and scrapping what we have simply because they are administered within the walls of a mental hospital? Another important fact is that 40 per cent. of those who go home relieved, have to be readmitted to hospital. These facts challenge the validity of the Minister's "statistical projection", let alone his desire to go lower than we dare.
§ Let me quote, as an example, the position of a West Country hospital three miles from a county town which I know very well. It serves a population of 250,000. So, on the Ministry's calculation of 1.7 per thousand, it should have 442 beds. Two years ago it had 1,100; to-day it has 850. By modern standards it should be accommodating fewer than 500. So even if we accept Mr. Powell's 50 per cent. reduction, the hospital will still be full and still be needed. Surely, therefore, we should think not of scrapping, but of using it to provide the best possible treatment at the best possible value for money.
§ The Ministry of Health, quite nautrally, want to achieve spectacular figures by concentrating on the new intake, of whom the great majority will react quickly to modern electrical and drug treatments and can he treated outside the hospital. But treated by whom? The local authorities' psychiatric service does not yet exist; the Minister is only now just talking, in the speech to which I have referred, of calling them together to map the future With the best will in the world. would need years of work and vast expenditure. And we have not yet really started to train the psychiatric social workers or the doctors. There is still no qualifying examination in psychiatry for medical students. We are still pouring forth G.P.s with a wide knowledge of physical illness, but with not even a simple barndoor knowledge of psychiatry. Naturally, it must be our objective to return as many patients to 854 the community as quickly as we can, but only when it is reasonably safe to do so. Many patients find a happier dependence on their 'hospital than in their home, and the capacity of many patients for employment may be out of all proportion to their propensity to disrupt the home, or even the community.
§ If the Minister's hope of abolishing 50 per cent. of our psychiatric beds rests on the simple expedient of "back to the community", it will not only be irresponsibly optimistic, but completely false. There will he a sharp increase in the present 40 per cent. readmissions, and we should have cruelly raised hopes only to create despair. It was because we foresaw this situation that my noble friends and I tried, without success, to get the Regional Hospital Boards written into the Mental Health Act as the main instrument for this work. We had to be satisfied with assurances, which were, of course, honestly given, but which now appear to he of little worth.
§ Just consider how, meanwhile, the hospital to which I have already referred —and it is only one of many—is getting on with the job of improving its service and getting real value for money. It takes particular account of those new entrants who do not respond to the physical treatments; of the 40 per cent. of semi-cures who come back to hospital; and, above all, of the main bulk of patients, the chronic cases, who will be there for a considerable time. With these three groups the physical treatments are less important. Success is being achieved through the basic approach of group therapy, working out patients' problems in small groups, with other patients, the psychiatrist, nurse and social worker all playing a part.
§ The mental hospital has been thrown wide open. It has become the fulcrum of an effort to bring the whole community into the hospital and thus break down all prejudice. It is in beautiful surroundings and still has its own farm. The vegetable gardens have been moved to the back. The entrance is now being informally landscaped. The Assembly Hall has been re-shaped in contemporary style. Large wards are being broken down into smaller units oriented upwards to the sun rather than inwards to the ablution quadrangles. They hold public events, such as a county tennis tournament, which is fixed for Whit 855 Monday. They have a branch of the Women's Institute for patients. There is a thriving social club. Three young artists from London are on the permanent staff and have achieved results beyond expectation. Over 70 patients are finding fulfilment in painting, and in sculpture they have shown a talent that none suspected. The farm is being used as a therapeutic base to return some patients to a simple pastoral pattern of society—not as agricultural labourers under a foreman, but as small holders pursuing simple husbandry such as pig-keeping and calf-rearing. In all, it is a real and successful attempt to relieve or forestall the onset of chronic mental illness.
§ As a means of taking the hospital out to the community, they have started a mental health scheme in the nearest town, and are opening two more in other towns, in order to cover the whole of the catchment area. These centres are partly clinical and partly social, encouraging visitors who seek either information or treatment. The chairman of the centre is a member of the management committee of the hospital. He is assisted by representatives from the county council, a G.P. from the general hospital, the local officers of mental welfare and health, a district nurse and other local people—a first-class joint effort between the mental hospital and the local authority.
§ To me this seems an ideal arrangement, with the hospital taking the initiative and making the fullest use of the knowledge, skill, resources and money that are available now. To destroy it, or even to discourage it, in favour of a local authority set-up which does not exist, and could not exist for many years to come, is both profligate and suicidal. In my view, the Minister and his Department must think again. They must study what is being done in the best psychiatric hospitals, and encourage them to see that, whenever possible, these methods are applied throughout the country. Meanwhile, I fully support the plan to set up psychiatric units in general hospitals. Indeed. I hope within a few months to have one in one of my own acute hospitals. But it needs the most careful planning and preparation if we are to avoid great harm to the existing mental hospitals which to-day are obtaining the Minister's spectacular results.856
§ Apprehension already exists among the medical and nursing staffs. They fear that the older beds will become "dumps" for the discards of the new departments, and that the new hospital units will attract the cream of the medical and nursing professions, leaving only the skimmed milk for the older beds. The effect of this on recruitment for a branch of nursing which has always been the cinderella of the profession needs no imagination—indeed, psychiatric nurses need immediate reassurance about their future. In the past they have been preoccupied about their status; now they are concerned about their security. They should be told, with authority and truth, that the changes will provide increasing opportunities and status, and there must be a scheme for comprehensive training in general and mental nursing.
§ On the administrative side of mental hospitals, they fear that they will get fewer patients with a good prognosis, and that this will inevitably mean deterioration in staffing and general efficiency. This can be avoided only by the closest integration between new and existing psychiatric units. To achieve it we shall need a considerable reorientation of outlook in the staffs of hospitals, and the first step should be to make joint staffing appointments, with consultants from psychiatric hospitals undertaking sessions in general hospitals. We often speak of the need for the orientation of public opinion to new outlooks in the field of mental health; but of even greater importance is the need for this orientation among doctors, nurses, hospital administrators and, I have come to think, the Ministry of Health. I do not doubt the Minister's goodwill, but on the evidence so far I doubt the accuracy of his information and the validity of his conclusions.
My Lords, I should now like to discuss briefly a number of matters concerning general hospitals, which I hope will be dealt with in greater detail by other speakers. Last month an article in The Times, pointing to the increased demand for hospital care, said this:
In a generation, the achievements of medical science have transformed medical care from a necessary evil into something highly to be desired. It is reckoned that, not until 1910, did a patient stand more than a 50–50 chance of benefiting from an encounter with a physician, and even more recently have hospitals ceased to be places where the poor went to die".
In my view, we must now move forward to the position where, except in a few impossible cases, the patient enters an acute hospital in the certainty that he is going to live. This will involve costly improvements, but not necessarily an increase in total cost; because with efficient management a great deal of money can be saved in other directions. We have half a million people on hospital waiting Lists, and many of them have been waiting for more than a year. It might be thought, therefore, that we need more beds and more hospitals. In my view, we do not, except in newly populated areas with no hospital; but we do need to make much greater use of the beds we have.
§ It costs £1,400 or £1,500 a year to maintain one staffed bed in a hospital. Yet most hospitals have empty beds, and in most hospitals all the beds are under-used. If the average duration of stay were cut by one day, we could wipe out the waiting lists. If the turnover interval between patients were cut by one day, it would be the same as providing 15,000 extra beds, which would cost £60 million if we had to house them in new hospitals.
§ If we made these improvements, and others equally easy of accomplishment, at least £80 million of maintenance cost which is at present wasted could be saved each year, and would be available for other hospital purposes. In the same region you will find one hospital with a turnover interval of a single day, and another hospital with a seven-day interval; and the average duration stay in the first is days less than it is in the second hospital. That is because one hospital is under acute pressure of public demand, while the other is not. But it does not mean that the under-used facilities in the second hospital are not badly needed: they are. But they will never be fully used while administrative and nursing staffs suffer financial loss if the number of beds in the hospital falls below a stated minimum. Thus, the number of beds needed is the number available. If you have beds you fill them, even though many of the occupants have no sound clinical reason For being there. After all, the rest can do them no harm, anyway. Then hospitals cling to the children's ward. although, fortunately, it is more than half empty. The T.B. wards cannot be curtailed, though they are rarely, if ever, 858 full. One public-spirited hospital group secretary of my acquaintance recently closed a redundant hospital in the teeth of virulent public outcry. His action, which was 100 per cent. right in the public interest, means that it will be eight years before 'he recovers his loss of salary.
§ The Minister must act in the realisation that, although half our costs are hotel costs, we are running hospitals and not hotels. But so long as the number of beds decides the salaries of our matrons and administrators, we cannot expect them to initiate and carry through the necesary improvements, which would immediately result in a reduction of their status and salaries. A different basis of remuneration, which rewards not complacency but efficiency, would cost a few thousands on the salary bill and save more than that number of millions. Then we should really be getting value for money, because the response to such a lead would be startling. Waiting lists would be greatly reduced; in many hospitals whole wards would be available for other purposes (and in this matter, although I perhaps say it with some regrets, I do know what I am talking about); for example, we could use them as psychiatric units or to help the very great need for additional geriatric units.
§ Mr. Powell is giving very welcome attention to the needs of old people, but I am convinced that the size of the problem is still seriously underestimated. Since I was born—indeed, since most of us were born—the death rate has fallen by 25 per cent., and the expectation of life at birth has increased by 20 years. That means that four years hence the number of men and women in this country of retiring age will be 7¾ million—one in six of the population. The Ministry put the bed requirement at1.2 per 1,000. That may be right as a national average, but it is certainly not enough in large towns, where housing problems make it difficult for old people to be cared for at home. All estimates, all these paper estimates which are trotted out in front of us so glibly, are completely false, and will continue to be completely false unless local authorities can be stimulated into providing' sufficient autumn homes and home care services. It is the bitter experience of all of us who administer geriatric 'hospitals that when we get old 859 people back on their feet we find that we have to keep them expensively in hospital when at less cost they would be very much happier in homes or hostels. It also means, of course, that we cannot take in others who really need hospital care.
We should, I suppose, take heart from the recent joint circular of the Ministries of Housing and Health concerning local services for old people. But The Times, not inaptly, though somewhat acidly, described it as
A succinct summary of the accumulated commonplaces of the past decade",
and asked whether
repetition in this form is likely to make local authorities take them any closer to heart".
When it is realised that not one local authority in six has provided the amount of accommodation regarded as desirable in 1948—and that was a very low standard—one can only regret, with The Times, that it is
precisely in directions ignored by the circular that the Government need to show their hand".
Just to give one example, the debate initiated last week by the noble Baroness, Lady Swanborough, clearly showed that the Government's failure to clarify the powers of local authorities is the chief barrier to the expansion of the "Meals on Wheels" service. That is an important factor in keeping in their own homes lonely old people who might otherwise have to be in hospital. With Ministers of such experience as the present Ministers of Housing and Health, it is impossible to regard that as incompetence. Am I, then, to be uncharitable and think that they are unwilling to provide the little extra money that may be needed? Is it possible that a Chancellor of the Exchequer who, by what he calls an act of social justice, has given £60 million to those of us who pay surtax, would refuse to find £1 million to provide the aged poor with a hot meal once or twice a week? The remark:
How we treat old people is a crucial test of our national qualities",
is as true to-day, as it was when David Lloyd George first said it, and it is high time that the Government and local authorities stopped paying lip service to the needs of old people and started to act.
§ My Lords, I now come, briefly, to the vital question of clinical cleanliness and the alarming increase in staphylococcal infections against which hospitals have to soldier on, with no special financial allocation at all. Since every new hospital is obsolescent before its working days start, it seems reasonable to suggest that available money should be spent first on ending the appalling situation in existing hospitals where the risk of catching a new infection is greater in hospital than at home. Recently the Lancet published an analysis of the records of more than 1,500 infants born in hospital and at home. This showed that the incidence of staphylococcal sepsis among the babies born in hospital was 13.6 per cent., nearly one in seven, and that was three times greater than among those born at home. Small wonder that, statistically, this difference was regarded as "highly significant". Still more alarming was the fact that of the antibiotic-resistant staphylococci 90 per cent. were isolated from children born in hospital. Not surprisingly, the investigators suggested that unless there is any overriding medical reason it is safer for babies to be born at home, and that when confinement in hospital is essential the mother should return home for the lying-in period immediately after the confinement.
§ I am aware that this frightening problem, which of course not only affects babies but affects all of us, is a very difficult one which will take brains, time, money, and above all the will, to solve. But it will surely be intolerable if we do not accord it top priority. So far as I am aware, the Minister has not given hospitals an extra penny with which to fight it.
An example of what we are up against came to me last week in a report I received on the operating theatre in one of my hospitals—incidentally, quite a good one. This is what the report said:
With only one theatre, every type of operation, both clean and septic, has to be performed in the same room. The theatre is not air-conditioned, and the extractor ventilating means that air drawn out is replaced by possibly contaminated air from the wards, passages and lift shafts.
The surgeons' changing room is outside the theatre suite, so that having changed they have to walk past the main staircase, the lift shaft, and near the entrance to two wards.
Incidentally, after the operation is done they have to walk back still wearing their bloodstained clothing.
Nursing staff have to change in a room which also serves as a store, a refreshment room, and sister's office.
After saying that the operative procedures such as the unsafe boiling water sterilising, give cause for concern, the report concludes with these words:
Your visitors consider that in the present unit the minimum requirements for the prevention of sepsis cannot be met, and they strongly urge the building of a new theatre unit as a matter of imperative necessity for the safety of the patients.
§ The Regional Board admit the need, but such is the demand on their resources that a new theatre is not even a first priority in this particular hospital. My estimate is that patients will have to wait and run these risks and dangers for another five years—unless, of course, the Minister decides to make a special allocation of funds for the battle against sepsis. And it is not only with operating theatres that we are concerned. Every hospital, except perhaps those just built, needs a review of its whole practice for the prevention of cross-infection, and then the money to pay for the necessary equipment. I am not, like the Minister, an expert in Greek, but I can say in plain English that if he spends huge sums on glittering new units while denying existing hospitals the money they need to lift the menace of infection and sepsis, then he has got his priorities wrong and his tenses mixed.
§ Finally, my Lords, I want to make yet another appeal on behalf of the people who staff our hospitals. In my experience they are the mast devoted, the most public-spirited and, perhaps for that very reason, the worst paid, relatively, in the whole country. This exploitation of their goodwill is not economy; it is waste. For example, in a memorandum published last month the Royal College of Nursing expressed grave concern at the growing shortage of nurse tutors and pointed to the bad effect that it would have on nursing standards. The fact is that the same salary has to be paid to nurses whether they are good or bad, and it merely adds to costs if we do not ensure that they are properly trained. Obviously, the cheapest way to do that is to pay the key workers, the tutors, well, and I hope that the Government will implement the Royal College's suggestion 862 for new grades, including that of Director of Nursing Education, and for pay scales comparable to those for teachers in establishments for further education. It would seem to me that the case is unanswerable.
§ Then there are the ancillary professions—the pharmacists, the radiographers, the physiotherapists, the almoners and the laboratory technicians. During the holiday season we shall again be paying locum pharmacists eighteen guineas a week, which is far more than we can pay our own pharmacists, and at the same time sending patients from hospital to the chemists to get prescriptions made up. Parsimony of this kind is expensive. Last week I had a letter from a physiotherapist, a man with 25 years' experience. He said that he could not buy a house on mortgage because the building society did not consider that his £12-a-week salary was sufficient guarantee. Yet that man saves the hospital his whole salary every time he gets a patient up two or three days earlier than would otherwise be the case; and he is doing that every day of the week.
§ Then there are the path. lab. technicians. Last month I went to our Group path. lab., who only that day had learned that two of their technicians were leaving. They were young men of 23 who had not passed their intermediate examination. They showed me an advertisement from Glaxo, who were going to pay them £200 a year more, plus a 5 per cent. bonus, and plus all sorts of other inducements. Good luck to them! But the point is that, under the present setup, naturally we cannot get enough trainees to make good this inevitable wastage; and in the ancillary professions we are always understaffed. That does not save money; it wastes it—because patients are in bed longer than they otherwise would be, at £28 a week. That is what I mean by keeping hospitals, not hotels. We cannot run our hospitals properly without these people. Yet by Government decree we are compelled to exploit them in this disgraceful way.
§ It is useless to argue, as it has been argued so often, and as I have no doubt it will be argued again, that their claims are best left to Whitley Council machinery. That machine does not work, because the Government use it not to implement just claims, but to frustrate 863 them. The situation is so bad that on some Councils Regional Board representatives (that is, the administrative side) are making common cause with the staff side. If we are to make any progress, Health Service Whitley Councils must be abolished. Ancillary staffs, having been recognised by Act of Parliament, registered, disciplined and perhaps fined, must be paid salaries in accordance with their status, their skill and their responsibilities. This, in my view, will be best achieved by direct negotiations between the professional bodies, the trade unions and the Ministry. They should be granted what the doctors have achieved —a fair salary first, and proper arrangements for periodic, impartial review afterwards.
§ My Lords, I am conscious that I have not even touched on many important matters, such as the shortage of doctors, casualty departments, the need for more staff training centres and so on. But I know that these and many other questions will be raised by other noble Lords and by my noble friends. But I hope I have made the point that if we upgrade what we have, if we make a sensible use of our resources, spend our money efficiently and wisely, and do not allow ourselves to be continuously tied to things, as we have in the past, simply because we have done them for so long in the Service, we shall get much better value for money and a much better hospital service. If I have, of necessity, concentrated on the deficiencies in the service it is because its virtues are known to, and appreciated by, us all. The men and women in hospitals, devoted and dedicated, have in twelve years achieved a major miracle. We can be proud of them, and proud that so much has been done, though in some ways the tasks ahead are greater still. Nevertheless, if we think and act wisely, honestly and courageously, we shall achieve the goal we all have in our hearts—the finest possible hospital service in the world.
§ My Lords, I beg to move for Papers.
§ 3.27 p.m.
THE EARL OF FEVERSHAM
My Lords, as the noble Lord, Lord Stonham, has said, it was on the occasion of the Annual Conference of the National Association for Mental Health at the beginning of March that my right honourable friend the Minister of Health made his 864 important statement about the future pattern of hospital provision for mental disorder. As Chairman of that Association, I therefore feel, however misguidedly, some responsibility for what was then said: and, thanks to the Motion of the noble Lord—who, as I am sure all your Lordships would agree, has given us a most thoughtful and well-informed speech on the common position of the hospital service—I have the opportunity of declaring in broad principle that my Association supports the blueprint of my right honourable friend. On that occasion Mr. Powell declared that it was his duty, as indeed it was the duty of a National Association for Mental Health, to lean with all their might towards progress. We have learned this afternon from Lord Stonham that he does not think that that speech of my right honourable friend in any way constitutes progress. I hope to show that there is good reason thoroughly to disagree with him on this issue.
We of the National Association for Mental Health are glad to find that the Minister sides with what we regard as enlightened progress. We are glad because we agree most emphatically with the principle he advocates of abolishing the greater part of our old mental institutions; and we agree with integrating psychiatric units in the general hospital service, and with the building up of the local authority provision for community care, on which the noble Lord, Lord Stonham, expressed so many doubts. Like the noble Lord and many others who have worked for a great number of years on mental health and the relief of mental suffering, I have seized the opportunity to get any Member of any Party, and any good Minister, to further that end.
The speech made by the noble Lord, Lord Stonham, contained much important and relevant detail, but it seems to me that he may have been blinded by the details from seeing the big concept. The noble Lord has great knowledge of the administration of his own Regional Hospital Board. I do not for one moment doubt that he has read the circular which was issued by the Ministry of Health after the statement of my right honourable friend at the Conference to which I have referred, that circular being H.M. 165 dated March 28. Although 865 the noble Lord has referred to some real and cogent points that arise as a result of the pronouncement of my right honourable friend—the forecast that within the next fifteen years there will be a fall of 50 per cent. in the total number of mental patients—I cannot but think that there are many, other than the noble Lord, serving on Regional Hospital Boards and management committees who have not had an opportunity of reading these circulars. Only yesterday I discovered from a member of a York Hospital Management Committee, under the Leeds Regional Hospital Board, which is responsible for the North Riding of Yorkshire, that this circular was not issued to members of that committee. When that member of the management committee inquired the reason for that, the answer given was that it was a matter for the officials.
In spite of the noble Lord's comment in another context on the other circular issued jointly by the Minister of Housing and Local Government and the Minister of Health (I refer to Circular 10/61) regarding the services to old people, I feel that very much the same comment applies. Is it the fault of Her Majesty's Government or any individual member of that Government if very good sense is circulated from the centre but is not read by members of committees who form local government? I raise this point more or less in parenthesis, because I believe all of us who have for many years served in local government will realise that there is some defect whereby the ordinary person serving the local interest is prevented from knowing and being well-informed on what is in the mind of, and what is the intention at, the centre. I believe that that applies to administration under any Government.
§ LORD STONHAM
My Lords, if it will help the noble Earl at all, I can assure him that the greatest concern has been expressed by members of his own Association, who had the great advantage of being present at the Conference and hearing the Minister speak.
THE EARL OF FEVERSHAM
My Lords, I am well aware of that fact for I was going to refer to some of the criticisms made by my own Association 866 on the points I am now going to raise; but I am speaking on behalf of my Association when I say that they agree in principle with the big concept as enunciated by my right honourable friend. The noble Lord, Lord Stonham, knows very well, as I know, that for centuries understanding of mental disorder was blighted and retarded by the attitude of segregation which was adopted by the community;, and believe we can all agree that it has been a colossal struggle to break through that conception. At last we are beginning to achieve a new attitude towards mental disorder designed to reduce the incidence and to improve the conditions of all patients.
My right honourable friend has pursued this attitude with great imagination and vigour, but the noble Lord, Lord Stonham, has expressed his apprehension. He has gone so far as to use such formidable phrases as "dangerous speech", "a disastrous speech", and—in respect of the matter to which he referred in quoting the Minister's speech —"dangerous nonsense". Does the noble Lord, Lord Stonham, really mean to say that the Minister is wrong in his contention that it is necessary to knock down old, unsuitable hospitals and replace them with new ones? Is he saying that patients should be kept in hospital when the concept in mental health is that they can live well and happily, to their greater physical and mental wellbeing, in the community? It grieves me that the noble Lord, Lord Stonham, should take this view of the overall policy.
I am sorry that I have to express such emphatic disagreement with the noble Lord because I support so much of what he otherwise has said, and agree with some of the details expressed by him in such very vehement terms: but I believe those problems are capable of solution. Surely they should not be allowed to obscure the broad picture. I suppose it would be true to say that big changes seldom by themselves solve the difficulties that are caused by the details; and these big changes forecast by the Minister, of course, do bristle with difficulties of detail.
May I, for a moment, refer in detail to this question of the main policy which 867 the noble Lord dislikes so much? I believe it is an escapable and laudable fact that the long-stay population of mental hospitals is declining. The statistics of hospital residence which have recently been published in the Lancet by the Principal Medical Officer of the Ministry of Health surely show there is inescapable statistical support for the Minister's view. They show that the long-stay patients whom we have known, as the noble Lord himself said. as a legacy from the old days of the mental hospitals, are not now being replaced. This is at once a challenge for the future and a tremendous tribute to what has been achieved by doctors, staff and medical science.
§ THE EARL OF LONGFORD
My Lords, I do not wish to distract the noble Earl, but am I right in thinking that the right honourable gentleman the Minister excepted the mental deficiency hospitals altogether? I have not been able to obtain the full report of his speech, but I understood that he did so.
§ LORD STONHAM
My Lords, as the noble Earl, Lord Feversham, has been interrupted, may I just make clear, as I believe I did in my speech, that I know it is desirable to return mental patients to the community—wholly desirable, when safe to do so; and that I do not propose the pulling down of very old hospitals but the use, as far as possible, of what we have? That is what I was trying to convey.
THE EARL OF FEVERSHAM
My Lords, I am grateful to the noble Lord for that assurance but I did not clearly understand from his speech what he meant by the word "safe". I did not, any more than my right honourable friend the Minister, refer to the small number of patients there are to-day who, for security reasons, have to be maintained generally on a long-stay basis in what may be regarded as old-fashioned hospitals. I am concerned with the patients who, having received hospital service, can be discharged at the earliest possible date.
The noble Lord, Lord Stonham, did not refer to the article that appeared in the Lancet of April 1. I should like to quote from page 713:Between 1955 and 1959 the long-stay population resident on December 31, 1954, was 868 running down at a rate which, if continued, would eliminate it in about 16 years. At the same time, it is being replaced by a population whose long-stay needs may build up to about 890 beds per million of the population, giving an overall figure of about 1,800 beds per million for all types of mental hospital care.I bring the attention of the noble Earl, Lord Longford, to the fact that it is 1,800 beds per million for all types of mental hospital care.
I will continue to read the quotation:These results have been obtained in spite of the unfavourable conditions imposed by outdated structure and inadequate staffing. It seems unlikely that trends of this magnitude. based on national figures, are no more than temporary phenomena. Though many factors may modify the rate of change, the direction seems to be well established.I do not think that, with the authority of the Registrar General's office, with the survey they made and with the statement that flows from the Chief Medical Officer, it is really just of the noble Lord, Lord Stonham, to say that the Minister is talking dangerous nonsense. Seeing the direction of this trend, I would say that my right honourable friend saw a great opportunity and grasped the nettle. He saw the opportunity of sweeping away altogether the great and forbidding buildings with their corridors like tube tunnels, with wards like barns, crammed with beds, with no room for lockers and no space for personality.
The Regional Hospital Boards, the management committees and the staffs have achieved remarkable results. They have changed the whole atmosphere in mental hospitals; they have changed it from gloom and despondency to hope and progress. Only twenty years ago no one, I think, would have imagined that such changes would be possible. But we must not be dazzled by the improvements; nor, I think, by the comparisons. The needs are greater still. We have learnt to be wary of statistics. We know that human factors often make nonsense of them, and I think it was on that basis that the noble Lord, Lord Stonham, founded his view.
May I refer to two factors which, in my opinion, will affect from opposite directions the role of mental hospitals in the future? All the good intentions and all the carefully thought out plans will, of course, collapse completely if services outside hospitals do not take 869 over those people who do not need hospital treatment. The failure so far of local authorities, to which the noble Lord, Lord Stonham, has referred, to provide for those who are incapable of maintaining themselves is a factor that both he and I have stressed before in your Lordships' House, and it is one to which I want to return in a moment. But the second factor is, of course, the break-through that there may be in the field of research. The Minister based his contention on what I regard as indisputable fact, not conjecture; but the fact also remains that we are only on the frontier of mental health research. There are tremendous discoveries to be made.
My Lords, I speak only as a layman on this subject, but if one is to believe what those who belong to the Mental Health Research Fund and other bodies say, there is very likely to he a breakthrough in the research into schizophrenia in the next ten years. About one person in every 100 born, it is calculated, will suffer from schizophrenia, which is the largest of all the causes of severe mental disablement, and there are nearly 60,000 schizophrenic patients in hospitals in England and Wales now. This is more than double the number being treated for all forms of tuberculosis. A cure for schizophrenia might not be far off. The implications of such a step would, of course, be most dramatic. About one-third of the mental hospital beds could be emptied overnight, and fathers, mothers and children released from this nightmare bondage would be able to be restored to their families. I give that, my Lords, as an example of how the Minister's statement can be affected by research.
May I in that respect refer to the branch of mental medicine that used to be known as mental deficiency and is now known as subnormality? It may well he that there will be a break-through not so far away in that direction. I had the pleasure last summer of opening the international Conference on the Scientific Study of Mental Deficiency, in London, and it was my privilege to hear a number of papers which are shortly to he published. They gave exciting proof that advances on many fronts had been made in this field. I would, therefore, beg the Minister to work for further support and for further success in research when he is looking fifteen years ahead. The Minister 870 failed to take this step into account when he made his statement at the conference to which reference has been made. I do not entirely blame him for having done so, because we all know that there is a great paucity of provision for mental health research. It is not enough that voluntary resources, hospital boards and universities are doing independent research. Mental health research is far from adequate and far too important for the Government not to give all the help within their power.
May I now return for one moment to the community care field? I do not think it is inappropriate for me to draw attention to this subject, as the noble Lord, Lord Stonham, has done, and to refer to a second important statement that was made at the same conference by Professor Titmuss. I will quote from Professor Titmuss's address which was entitled "Community Care—Fact or Fiction". I do not want to weary your Lordships with a recital of what he said. but I would quote this:To scatter the mentally ill in the community before we have made adequate provision for them is not a solution; in the long run not even for Her Majesty's Treasury. Considered only in financial terms, any savings from fewer hospital in-patients might well be off-set several times by more expenditure on the police forces, on prisons, and probation officers; more unemployment benefit masquerading as sickness benefit; more expenditure on drugs; more research to find out why crime is increasing.My Lords, I would entirely agree with the noble Lord, Lord Stonham: there are nowhere near enough trained workers to staff the inadequate services which exist, far from there being enough to establish new and better services. Other noble Lords, I understand, are going to speak to this subject. If the noble Lord and your Lordships' House think that it is quite impossible to get the administration within local authorities to do what is intended under the Mental Health Act, and to do what is intended by the forecast made by the Minister, then I would accept that the noble Lord, Lord 3tonham. is right; but it seems to me to be a policy of pessimism.
I was glad that Lord Stonham referred. among others, to the services of the hospitals, and particularly to that of the psychiatric social workers. This year I have the privilege of being President of that body, and I was glad that Professor Titmuss pointed to the fact that in 1951 there were only 8 psychiatric social 871 workers employed full-time by the 145 local authorities. In 1959 there were 26, which is an increase of 2.25 per year, and Professor Titmuss pointed out that it will take another 53 years, to the year A.D. 2014, before one can say that there is an average of one psychiatric social worker to each local authority. My Lords, why is that? It is because psychiatric social workers themselves prefer to work in hospitals. It is known that they feel that there is less status and prestige in working for a local authority than in working in a wholly medical atmosphere. It is those points that certainly want to be recognised. Therefore, my Lords, may I say that if local authorities are to carry out their responsibility of helping to empty the mental hospitals, then I would agree with the noble Lord that the training, the pay. the status and the conditions of work of social workers in their services must be upgraded.
The noble Lord who is to reply will no doubt say that a start has been made by the implementation of one of the recommendations of the Younghusband Committee Report, by providing a two-year course for mental welfare officers. This week, I met a mental welfare officer of some distinction, who told me that that provision was unlikely to work due to the fact that no local authority, or very few local authorities, would release a mental welfare officer for a period of two years when they could no longer draw upon his services but would still have to pay him for that time. He advocated very strongly that, as an emergency provision, in order to get on with the job now, there should be a twelve-month course established for the present mental welfare officer.
Professor Titmuss has asked for three things, and I must confess that I very much see eye to eye with him. If the community-care services are to advance in the quick and dynamic manner of the hospital service, first, a grant of £10 million to local authorities specially earmarked for community-care services for the mentally ill and subnormal should be provided for 1961–62. Second, Government grants for all social work students and training courses irrespective of speciality should be provided for the universities and technical colleges. Third, there should be a Royal Commission on the recruitment and training of 872 doctors, with special reference to the need for education in social and psychological medicine. I know that the noble Lord, Lord Taylor, has set down a Motion to this effect, and most probably he will speak to it in this debate.
Your Lordships will judge that I have therefore seen fit to support my right honourable friend the Minister of Health, speaking to the National Association of Mental Health, in the broad sense, but we are very alive to many of the details and problems to which the noble Lord, Lord Stonham, has properly drawn your Lordships' attention. Therefore, may I conclude by asking the noble Lord who is going to reply a few questions? First, will the Government pursue the priority of reducing the population of mental hospitals by making a grant to local authorities specially earmarked for community care? Secondly, as I have asked, will the Government give grants for courses for social work students? Thirdly, will an endeavour be made to include education in social and psychological medicine in the training of more doctors?
Fourthly, will the Minister guarantee that the prestige of the long-stay hospital, both for the mentally ill and the mentally subnormal, remains as high or higher than it is to-day? Almost everything that the noble Lord, Lord Stonham, said on that score I support. Fifthly, can the noble Lord who is to reply on behalf of the Government confirm my information that there will be a change in the basis of the payment of administrative and nursing staff, and that no longer will it be determined by the number-of-beds controls which at the moment rule? I know that this matter is being investigated by the Whitley Councils, and I do not join the noble Lord fully in his criticism of the administrative machinery of the Whitley Councils for the National Health Service. Sixthly, will the Minister produce a plan for the integration of medical and nursing staffs of the mentally disordered in the whole of the hospital service?
I conclude by strongly endorsing the words of the noble Lord, Lord Stonham, when he referred to the growing age of our population. Can the House be assured that provisions for the elderly are being given adequate priority by local authorities? I ask that, especially in view 873 of the fact that, at the end of 1958, there were in the population over 5 million people aged 65 and over, of whom nearly 50,000 were in mental hospitals. If you compare this figure with the fact that it is estimated that, in 1974, there will be nearly 8 million aged 65 and over, it will be seen that this matter needs the immediate attention of Her Majesty's Government. Lastly, is the Minister now prepared to make any further provisions for mental health research? My Lords, these are some of the problems of detail which we think are capable of solution and which, in our view, should not be allowed to obscure the great opportunities and the great vistas which are opening up for us, and which were declared by my right honourable friend the Minister of Health.