§ 2.48 p.m.
§ THE EARL OF FEVERSHAM rose to call the attention of Her Majesty's Government to the working of the Mental Health Act, 1959; and to move for Papers. The noble Earl said: My Lords, I beg to move the Motion standing in my name on the Order Paper. The Mental Health Act, 1959, came into force in November, 1960. I felt Chat the time was ripe for some consideration in your Lordships' House of how that Act, of which we all had such high hopes, is working. I, and those on whose behalf I speak, were greatly encouraged that my judgment was so well endorsed by the fact that a number of your Lord-ships who are so eminently qualified to do so have intimated your intention to participate in this debate.
§ I have been very much helped in the remarks Which I want to make by letters and memoranda submitted to me by a large number of individuals and 1236 organisations. I am particularly grateful for the help of the Royal Medico-Psychological Association and the Association of Psychiatric Social Workers, who at my request conducted a nation-wide survey among their members in hospitals and local authorities. The Citizens' Advice Bureaux and the National Association of Chief Male Nurses have sent me memoranda, and I am also greatly indebted for the valuable material that I received at the hands of the National Association for Mental Health. I want to say at the outset that all these bodies are unanimous in welcoming the Act and, indeed, in saying that it is a good Act. Some of the points that these bodies have raised in detail I shall pass on to my right honourable friend the Minister of Health, as I do not think it appropriate that I should trouble your Lordships with them.
§ It is opportune now to consider the working of the Mental Health Act, because my right honourable friend the Minister has recently laid before us his Hospital Plan. A Bill dealing with social work training is at present before your Lordships' House and, as many of your Lordships will recall, it was debated in Committee last week. It is, of course, no good having a first-class Act unless we have first-class hospitals in which the Act can be put into effect; unless we have a first-class community service to support the hospitals; and unless we have first-class and contented staff to man both. In some senses the Mental Health Act contained very little that was new. It confirmed the theory and practice which was already in force in the best areas. It followed the Royal Commission's Report, which was concerned primarily with methods of entry and discharge for patients in mental hospitals, not with their treatment, and was thus limited in scope. It was an Act to deal with mental ill-health; despite its name, it was not a Mental Health Act at all. At the same time I think we all recognised, as it went through this House, that the Act provided a framework of treatment, both in and out of hospital, which offered the best chance that we could then devise for the doctors to exercise their skills and for patients to secure early and adequate treatment for acute illnesses in circumstances which would lessen the 1237 stigma attached to mental illness and its treatment.
§ Certain things in the Act were new. We created a single code for all mental disorders. We made it possible far mental patients to be treated in general hospitals. We made it as easy to enter a mental hospital as it is to enter a general hospital, no matter what the nature of the mental disorder. We made it possible for mental hospitals, like general hospitals, to refuse to accept patients. For those cases where some compulsion was necessary for the protection either of the patient or of the public we said that two doctors were to sign a recommending certificate, of whom one should be an expert in psychological medicine. We thus eliminated the magistracy from the compulsory procedure. For cases where there were certain doubts we instituted Mental Health Review Tribunals, and in this way the civil check which had been represented before certification by the magistrates was now replaced by safeguards at a later stage. With some hesitation on both sides of your Lordships' House, we introduced the category of psychopath, and we made it possible to detain psychopaths up to the age of 25. Contrary to the advice of the Royal Commission, we introduced the category of sub-normal as well as the category of very subnormal. We also made care and after-care of patients in the community the duty of the local authority.
§ In considering how that Mental Health Act is working, it seems to me that these provisions that I have mentioned are the ones that will no doubt engage the attention of your Lordships. Some of them, I know, are to be raised by other noble Lords taking part in this debate. One very important effect of the Act, and one to which I hope that the noble Lord who represents the Ministry of Health, Lord Newton, will refer, concerns the number of discharges and admissions to hospital. My information is that, contrary to the widely expressed fear, there has been no wholesale discharge of patients into the community. I am informed, however, that there has been some increase in some areas in the discharge rate for chronic patients who seem to move more often between the hospital and the community. The general admission rate is rising, and there are 1238 indications that the number of compulsory admissions is also on the increase. In one Midland area I am told that admissions rose from 629 in 1959 to 811 in 1961. Of these, informal admissions rose from 427 in 1959 to 569 in 1961; and compulsory admissions in this Midland area rose from 202 to 242. It is disappointing, to say the least, if compulsory procedures are being used more widely, even though, as has been suggested to me, this is sometimes a way of persuading a patient to accept informal status after 28 days.
§ The second cause for alarm is the remarkable increase in the number of people who are discharged from hospital and then have to go back again. If we look at the rate of discharge from hospital alone, it looks very fine to see large numbers being discharged every year. If we look at the average length of stay of patients, that also looks very fine. But, my Lords, we are being deluded if we do not see the complete picture. If we do not see how many of the patients discharged have to go back again, and if we do not appreciate that the average length of stay in hospital is for the one session only and that patients, therefore, may have an average stay one year and another average stay the following year.
§ Figures published by the Registrar-General show that readmissions had risen from 40 per cent. in 1954 to 48 per cent. in 1959. The Ministry of Health have kindly provided me with comparative figures for the years 1959 and 1960. These show that in 1959, of the total of 105,742 admitted into mental hospitals, 50,695, or nearly half, were patients who had been in hospital before. Figures for 1960 show that, of 114,552 admissions, 55,991 were readmissions; so that for 1960 readmissions were running at the rate of 49 per cent. No figures are yet available for 1961, but, so far as I can understand, there is no evidence that there is any decrease in this high rate. In fact, opinion is to the contrary.
This trend appears to be due to a number of factors, one of which is the result of modern ideas of treatment. I feel that your Lordships will agree with me that it is doubtful whether the present state of our knowledge would enable us to devise better legislative measures.
One doctor, however, has put it to me like this—and I quote:
Readmission may simply mean a recurrence of an illness whose nature it is to recur, or it may follow deliberate and intelligent decision to let an uncured patient spend most of his time outside hospital returning from time to time as circumstances demand. Of course, it can mean that there has been hasty and superficial treatment and insufficient assessment of the patient's stability, as well as inadequate effort towards a patient's reintegration into community life.
This observation was made to me, in confidence, by a most eminent authority, and I feel much as he did, that it is the latter part of that observation that must necessarily concern us: has there been hasty and superficial treatment and insufficient assessment of the patient's stability in considering his discharge from hospital?
§ The noble Lord, Lord Newton, to whom I have given prior warning of this observation, as well as the purport of my general remarks, will perhaps be able to tell your Lordships the Ministry's view as to whether there is a deliberate intention to let uncured patients spend part of their time in the community, whether there is any evidence of insufficient assessment of a patient's ability to return to the community, or whether there is inadequate community care. The noble Lord might also consider whether doctors are reluctant to use the powers under Section 30 of the Act to detain in hospital those acute patients who may be free to leave. Certainly, if the community is being asked to accept partly cured patients, much effort ought to go into helping families to understand what it is they are asked to face. I submit that too little is being done to meet this challenge.
§ There are two points in admission procedure which I find disturbing. All my informants are unanimous that Section 29 of the Act is being misused. This is the section which provides for emergency entry in compulsory cases with the certificate of only one doctor. Our intention when the Act was before us was that in the case of compulsory admissions the two-doctor procedure contained in Sections 25 and 26 of the Act should be used. It is, of course, much easier to get the signature of only 1240 one doctor, and that a general practitioner. But even though this is an advance on the old Act, where an emergency admission could be secured without the signature of any doctor, this was not our intention. We are, after all, dealing with compulsory admissions and with the unfortunate stigma which such admissions will imply, and we are anxious that the emergency procedure should be used as little as possible. So I think we ought to correct this trend which tends to repeat the practice under the emergency procedure in the old Acts.
§ I understand from the Ministry of Health that no figures are yet available to show how many patients were admitted compulsorily under Section 29, compared with the admissions under Sections 25 and 26. However, I am very glad to hear that figures are now being collated for 1961 and that an analysis will be made. I think it is most important that we should have those figures.
§ The second point which I find disturbing is the situation of the over-65 age group in mental hospitals. Now that doctors there can refuse patients, I am told that there are areas where the local mental hospital refuse automatically all patients over 60 years of age. The grounds of these refusals are, I presume, that no treatment is possible for these old people and the emphasis in the Mental Health Act is that unless treatment is advisable cases should not be admitted to hospital. So I am not saying that the mental hospitals are necessarily wrong in their refusals, but I am saying that hospitals and the local authority services must somehow provide appropriately for these old people. The strain that they represent to an ordinary family if some service does not stop in to help seems to me out of all proportion.
§ Here are the details of two typical cases, sent to me by the Association of Psychiatric Social Workers, which I think the House may find illustrative of the point I am now making. The first concerns a woman of 78 years, grossly demented; she lives alone with her husband, who is in fairly good health but recently had a major operation. Her daughter-in-law lives down the road with her children of school age. The daughter-in-law has been receiving an 1241 average of 20 telephone calls a day from the patient's husband asking her to come at once to deal with a crisis. She has not had an undisturbed night for months, and the patient was taken into hospital for four weeks, and four weeks only, to enable the daughter-in-law to have her first holiday in ten years. The patient, this old woman of 78, will have to go back home to the same conditions.
§ The second case, which concerns a mentally disordered woman, is slowly deteriorating. Her husband has to work and support the home, and he is assisted by a "home help" and by visitors from a mental health department. But this woman needs full-time care. She is not a fair burden for an ordinary "home help". Before the coming into force of the Mental Health Act hospitals would have been obliged to accept such a case under certification. Now their care seems to have become more difficult. I think that the Government should look more closely into the question of the care of elderly disordered patients and should put a firm responsibility on Regional Hospital Boards and local authorities. There is an obligation under Section 26 of the Mental Health Act to care for patients of any age, both in the interests of their own health and safety and for the protection of other people. I would suggest that the Government should not allow this obligation to be circumvented. I say this with some force, for the urgency of the situation grows every day. In 1960 people over 65 formed 11.6 per cent. of the total population. It is estimated that by 1975 this number will have increased by a further 1½ million; and it is a reasonable forecast to assume that a high proportion of this number will require some form of care.
§ No one has reported to me any criticism of the disappearance of the magistrate from the compulsory entry procedure. It seems to me that the provisions of the Act have done much to dispose of the criticisms, which the Royal Commission were at pains to examine, that cases were being held in hospital which should not be there and were being certified improperly. Indeed, a criticism that has come to me is one showing the difficulty of getting into the mental deficiency hospital certain subnormal patients who might well benefit from training there.1242
§ I feel bound to call attention to this criticism, though I personally feel that it is one of the prices that we have to pay for ensuring that no patient is detained improperly. It concerns subnormal patients over 21 years of age. Such cases can be admitted to hospital for the first time compulsorily only by order of the court. In effect, no such patient can be admitted to hospital unless some trouble arises which causes him to be brought before the court. So here is the reverse side of the coin. We used to be concerned that such patients were detained in hospital when they were perfectly capable of being abroad in the community; now some concern is being expressed that such patients cannot get into hospital. We have to decide which of these two situations is the worse; and I feel sure that the noble Lords, Lord Stonham and Lord Grenfell, and the noble Earl, Lord Longford, will wish to speak further on this aspect of the Act.
§ My information is that the mental health review tribunals are allaying such public fears as there were about wrongful detention. Some doctors complain to me that it is a large hammer to crack a small nut when the majesty of the mental health review tribunals comes to consider the case of some simple-minded subnormal patient. But I thank we have to pay this price for justice being seen to be done. I find the review tribunal figures illuminating and, on the whole, reassuring. Up till last December 741 applications were heard, 624 were refused,20 were adjourned, 11 withdrawn and 86 discharged. Some may say that 86 ostensibly improper detentions were bad enough. I think we have to remember that discharge in some of these cases has been a matter of risk which a tribunal now shares.
§ I have had had some correspondence with my right honourable friend the Minister of Health about the follow-up of these cases. It seems to me essential that these patients should be kept in con-tacit, and giving the maximum support that the community can give them outside hospital, both for their own sake and for that of the community, is of great importance. I hope that the Government will tell me that some follow-up is to be undertaken. Follow-up is necessary both for research and for the welfare of these patients.1243
§ Your Lordships will not be surprised that this brings me to consider once more the need for community care services without which the hospital service cannot operate and whose absence puts the Act in jeopardy. I am very glad indeed to know that my right honourable friend the Minister of Health has not only asked all the local authorities in the country to submit their community mental health services to him, but has now asked for a 10-year development plan from them, as he has from the Regional Hospital Boards. When these are available, no doubt he will issue guidance to the local authorities; and I hope he will emphasise that good social work and well trained staffs must be given high priority by local authorities.
§ When we talk about development plans in any context, so often we envisage the need for development in bricks and mortar and buildings. In this context, I emphasise that the provision of trained personnel is a priority needing consideration. My informants say emphatically that more people could be discharged, and certainly fewer could be admitted and re-admitted to hospital if adequate community care were available, if there were places in hostels, if there were enough places in training centres, if there were sufficient skilled social worker support which could he given to families. Hostels cannot be run without staff; training centres cannot be developed without teachers—and when are we going to have the Report of the Scott Committee?—and families cannot be supported without first-class social workers. At present we have little of these.
§ My recent information was that there are four hostels so fax—which were included in the Hospital Plan—although 150 have appeared in projected plans. There are not enough adult training centres, though the Press release that has only just fallen into my hands, one issued by the Department that the noble Lord, Lord Newton, represents, says that there are now more training centres—I think it mentioned 56, but 300 are planned. Vacancies for social workers and for psychiatric social workers, particularly month of the London area, are advertised almost daily in our newspapers, which indicates that there is a severe shortage—I estimate that at least 1244 two-thirds of the local authorities have no psychiatric social workers on their staff—whilst the gallant mental welfare officers, who have carried this burden for so long, are only just beginning to reap the benefits of organised training, fourteen years after the passing of the National Health Service Act.
§ Quite clearly, all this calls for money, and a lot of it. The recommendation of the Royal Commission, as your Lordships will remember, was that central Government grants should be made available for all these purposes. Equally, your Lordships know that the Government refused this, and we are having to bear the higher cost of taking people back into hospital. We all, or almost all, advocate community services, but we are not willing to pay for them. So far as I know, no Government research has been put into the value of this preventive work. Moreover, so far as I know, no assessment has been made of a saving that could be made out of the enormous total of, to-day, £809 million which the National Health Service cost last year. Yet surely this is the most fruitful field for research. Let us hope that the research at present being undertaken by Political and Economic Planning into inter-community care with a grant from the Nuffield Foundation, will yield important results. Here I must say that not only is my right honourable friend the Minister of Health most interested in the terms of reference of the P.E.P. undertaking, but he has given his active and personal support towards implementing and assisting any findings that it may reach.
§ I have already delayed your Lordships long enough, but my survey would be more than incomplete if I did not say, shortly, that we urgently need hospital units for adolescents and children; we need diagnostic units for the subnormal, and counselling services for their parents; we need special units for psychopaths and alcoholics. I am very glad to see that on Saturday last my right honourable friend the Minister issued a circular on the treatment of alcoholics. I find this circular extremely interesting, although I have only just received it. I notice that Whereas there were 775 people suffering from alcoholism in 1953, the number rose to 1245 2,044 in 1959. That simple figure indicates that this is a very important aspect that needs prompt attention, and I would say that the provision of special units both for alcoholics and for psychopaths still remains urgent. Without such units the ordinary wards of the psychiatric and mental hospitals are disrupted from their normal course by these and other patients. I hope other noble Lords will deal further with this point.
Finally, I would suggest the time is ripe for an inquiry into the staffing and running of our mental health services. These subjects were excluded from the terms of reference of the Royal Commission, and the anxieties which are so widely expressed to-day about the shortage of psychiatrists in our hospitals and about the future of the mental nursing profession might be laid to rest by a Royal Commission or Departmental committee of inquiry. In the last resort it is the people who man our mental health services who make or mar the implementation of the Mental Health Act. I should like to pay my tribute to the fine work which they are doing, and to give a quotation from the Royal Medico-Psychological Association, who say:
With all its faults the Mental Health Act has created a new atmosphere within our hospitals, and a vast improvement in the outside community care of the mentally disordered. Having experienced its benefits, none of us would wish to revert to the former procedures.
I hope, my Lords, that one of the results of this debate will be to endorse the more satisfactory side of the working of the Act, and to bring even more emphatically to the attention of the hospitals and local authorities those gaps which have to be filled if the intentions of the Act are to be achieved.
§ 3.23 p.m.
§ LORD NEWTON
My Lords, both in your Lordships' House and in the country at large my noble friend Lord Feversham's deep interest in mental health and his untiring efforts to promote it are deservedly well known and appreciated. It is most appropriate, therefore, that it should be he who is giving us the opportunity of this debate, and I should like to thank him for moving his Motion and for setting the tone he has set.
1246 It must have been apparent to your Lordships, as it was to me, that my noble friend regards the Mental Health Act as a good Act and one of major importance. My Lords, I am sure it is. Yet its provisions are concerned almost entirely with powers of compulsory detention and admission—and compulsion, though an important matter, is being used to a decreasing extent, and now affects only a small proportion of admissions to hospital. The Act makes very little mention of services, the reason being that the basis is provided by the National Health Service Act, 1946. What the Act does is to clarify, and slightly to extend, the powers of local authorities. I should like to try to put the matter briefly in its historical setting. Until quite recently the care of the mentally disordered was only marginally a medical matter. Asylums were properly so called, being places of refuge with an almost entirely custodial function, though often a kindly one. Little treatment was given, because there was none to give. The general public looked on mental disorder with fear, and were only too glad that those afflicted by it should be shut up, out of sight.
Mental health legislation began in the first half of the eighteenth century. For the next 200 years its main objects were, first to protect the public without infringing improperly the liberty of the individual; secondly to provide a refuge for those who could be shown to need it—that is to say, a service was being provided, and entitlement to benefit from it had to be established. It followed naturally from these general objectives that patients could not be admitted without certification (which was a proof that care was needed), and that the procedure was judicial rather than medical.
In the later nineteenth century the public attitude was particularly unenlightened, and mental hospitals therefore became particularly restrictive. In the twentieth century therapeutic advances began to be made, and psychiatry started to have some influence on medicine in general—in particular, understanding of the interaction of mind and body began to develop. This led to a Change in the public attitude towards mental disorder and also to a change in the general nature and objectives of mental hospitals. In 1930 these 1247 developments were reflected in the Mental Treatment Act which for the first time made it possible for people to be treated voluntarily in mental hospitals. The 1940s saw the development of the "open door" principle, a growling appreciation of the therapeutic value of occupation, and the beginning of physical methods of treatment.
A major change occurred in 1948, when the National Health Service Act came into effect. This ended finally the old isolation of the mental health services which had formerly been administered by the Board of Control. They now came under the care of the Ministry of Health and became an integral part of the National Health Service, being at all levels under the same management as the rest of the Health Service. Largely as a result of these major administrative changes, a great deal of money was put into the upgrading of psychiatric hospitals. There was at the same time a development of services for outpatients and day patients, and psychiatry began to appear in general hospitals. Meanwhile, the public attitude continued to improve; this meant, in particular, that voluntary admissions increased, that patients were willing to seek early treatment (with consequently better chances of recovery), and that the community became more willing to tolerate the early discharge of psychiatric patients.
Then in the 1950s came the appointment, and later the Report, of the Royal Commission. This Report reflected and endorsed the current view that community mental health services had a major part to play and that separation from the community, which is liable to be caused by admission to hospital, should, where possible, be avoided or at any rate be kept to a minimum. From this Report stem the major developments in the community mental health services which are now taking place. The Royal Commission also proposed a complete recasting of the legal code for compulsory admission and detention, in order to bring it into line with modern practice and attitudes. This the Act did by making informal admission the normal procedure and by completely reshaping and simplifying the procedures used in the minority of cases where compulsion is needed. The most important feature of the new code is that compul- 1248 sion is now a medical, not a judicial, matter. In the 1950's, too, appeared the new tranquillising and anti-depressant drugs, which have had so deep an effect on psychiatry and on the prospects of psychiatric patients.
I think it can be seen, therefore, that as a leading article in the British Medical Journal pointed out in 1960, the Mental Health Act is important:first and foremost because it gives unequivocal recognition to the new position of psychiatry. It assumes as its starting point that psychiatry is like any other part of medicine and that mental health services are an integral part of the health services generally; that the object of psychiatric care is the treatment of the patient; that treatment for mental disorder ought to be available in the same way as treatment for any other illness, without formality; and that the psychiatric services are as well able to keep their house in order as any other part of the health services.The article also said:The Act also does away with the previous arrangements under which a number of functions were reserved to the Board of Control as the central authority. Many of those functions are now transferred to individual doctors, hospital authorities and local authorities. Special arrangements for central inspection are brought to an end, and the mental health services come on to the same footing as other parts of the National Health Service. The Act thus gives the clearest possible recognition to the fact that the psychiatric services have come of age.That, my Lords, was the view of the British Medical Journal, in 1960. Finally, by abolishing designation, the Act made it possible for detained patients to be treated in any hospital, which meant that there was no longer any statutory reason for regarding the mental health services as a separate entity.
My Lords, if one looks at the matter in this very broad way, the Act, and the general attitudes upon which it was based do seem to have justified themselves. This can be illustrated, first, by a consideration of the operation of the main provisions of the Act itself, and, secondly, by examining some of the developments which are taking place in the mental health services. First, I should like to say something on the operation of the Act.
In all mental health legislation it is necessary to try to strike a proper balance between, on the one hand, preserving the liberty of the individual, and on the other hand, ensuring that in proper cases people who need treatment, but 1249 cannot appreciate their need because of the nature of their illness, do in fact receive it; and ensuring, also, that where necessary the public is protected from people who are liable to commit antisocial actions as a result of mental disorder. Where this balance should be struck varies according to medical knowledge and the state of public opinion. But it is always difficult to achieve, particularly since the public attitude towards the detention of the mentally disordered is often highly ambivalent. The Mental Health Act strikes a new balance and, as I have said, the use of compulsory powers has greatly diminished. This is a most desirable change, and sò is the adoption of the "open door" principle by psychiatric hospitals. But it must not be overlooked that the mental health services still have a clear duty to the public as well as to the individual patient. It is for this reason that the Act confers such substantial powers on the courts and on the Home Secretary under Part V, and, in particular, provides for the imposition of restrictions on discharge. It is for the same reason that hospitals are being asked to provide security for those patients who need it, and that the Special Hospitals—Broadmoor, Ramp-ton and Moss Side—are provided for patients who need treatment under conditions of special security.
Detailed statistical information about the working of the Act is at present available, as my noble friend said, only for the first six months of its operation. This was the initial period provided for in the Act, when hospitals had to review the position of all existing patients in accordance with the new code. Although the period is too short for more than tentative conclusions, there are encouraging signs that the main expectations of the Act are being fulfilled. On April 30, 1961, over 90 per cent. of the patients occupying psychiatric beds for any form of mental disorder were receiving treatment informally; that is to say, they were not subject to any of the Act's provisions. Until 1958 virtually all mental defectives (who would now be classified as suffering from severe subnormality or, in a few cases, psychopathic disorder) were subject to detention under the Mental Deficiency Acts. By April 30, 1961, only just over 10 per cent. of these patients were subject to 1250 detention. In the case of patients suffering from mental illness, voluntary treatment had been available since 1930, but even so the removal of certain legal restrictions which affected voluntary admission, and the review of patients carried out under the Act, have resulted in a considerable decline in the proportion of detained patients, from well over 30 per cent. at the end of 1959 to only 6.5 per cent. in April, 1961; plus another 1 per cent. who were in hospital under Sections 25 and 29 for a short period of observation.
To turn now to admissions, the figures for the first six months of the Act show that most patients—19 per cent.—were admitted informally, and that, where compulsory powers were needed, it was the procedures for compulsory admission for a short period of observation (under Sections 25 and 29) that were mainly used. These procedures accounted for nearly 18 per cent. of all admissions, and only 3 per cent. of admissions were under other, long-term, compulsory provisions. The contrast with earlier years is greatest as regards the subnormal and severely subnormal, virtually all of whom would until 1958 have been admitted under compulsory powers. But in the case of the mentally ill, too, it is clear that, despite the existence of voluntary treatment before the Mental Health Act came into effect, fewer patients are now being admitted compulsorily. In 1958 some 30 per cent. of admissions were under short-term compulsory powers, and 8 per cent. were under longer-term powers. During the first six months of the operation of the new Act, the comparable figures were only 18.5 per cent. and 2.5 per cent. Compulsory admissions have also been reduced in terms of absolute numbers. In 1958 there were nearly 31,000 admissions under short-term compulsory powers, and nearly 8,000 under long-term powers. The comparable figures for the first six months of the Act are 12,800 and 1,750.
My Lords, it was expected that many of the patients admitted under the short-term observation procedures of Sections 25 and 29 would be able to receive the treatment they needed within the 28 days' period, and that most of those who needed a longer-term period of treatment would be prepared to receive it informally. The figures available tend 1251 to confirm this. Of the 13,000 patients admitted in the first six months under Sections 25 and 29, only 4,500 remained in the same hospital on April 30, 1961. Nearly a third of these had been admitted only recently and were still subject to short-term compulsory powers. Most of the remainder had become informal patients, and only 421 had had to be detained under longer-term compulsory powers—mainly under Section 26. It also seems that, once a patient has been admitted informally, compulsory powers do not often have to be used later. Of the 17,000 patients compulsorily detained at April 30, 1961, fewer than 200 had either been informal patients on November 1, 1960, or been admitted informally after that date. Thus, while there is not yet sufficient information to enable conclusions to be drawn with certainty, the indications are that the hopes that under the Mental Health Act compulsion would be used only where really necessary in the interests of the patients or of the community, are in general being fulfilled.
I turn now to the mental health services, beginning with the hospitals. As I said earlier, there has been an immense change in the nature and function of mental hospitals. They have ceased to be custodial and have become therapeutic. The need for continuous periods of in-patient treatment has greatly diminished. Earlier discharge and reliance on the community mental health services are now thought to be desirable in the patients' own interests. But these trends, of course, derive from changes in the practice of psychiatry and not from administrative policy or from the Mental Health Act. All this has had a profound effect on plans for the future of the hospital psychiatric services.
In the Command Paper, A Hospital Plan for England and Wales, it was forecast that by about 1975 the bed needs for the mentally ill will be met by only 1.8 beds per 1,000 population, compared with the present figure of 3.3. This is a very large reduction. This conclusion derives from a survey by the General Register Office of the histories of all patients admitted to mental hospitals in 1954 and 1956. This showed that the needs of patients who were discharged from hospital within two years were at 1252 that time in fact being met by 0.9 beds per 1,000 population. It is estimated that the needs of longer-stay patients would, over a period of fifteen years, build up to about the same total. It is estimated also that, after a period between sixteen and twenty-five years, none of the long-stay patients who were in hospital at the time of the survey would remain; and that at that point, therefore, the total beds needed would be 1.8 per 1,000 population.
My Lords, my noble friend Lord Feversham pointed out that admissions and readmissions of mentally ill patients have been increasing. However, there is no reason to think that this is connected to any significant extent with the legal changes made by the Mental Health Act. The increased readmissions are to a large extent the result of new methods of medical treatment, as he himself suggested, which mean that it is possible to avoid the need for a patient to stay in hospital for long periods with consequent risk that he will relapse into a chronic condition. Instead, a common pattern is for a patient to be discharged after a relatively short period of treatment and to return if necessary for a subsequent period or periods of treatment, again often short. In the meantime, he can live in the community and is often able to live a normal or near-normal life. The trend for admissions and readmissions to increase was well-established at the time of the survey by the General Register Office, and there is no reason to think that it invalidates the conclusions reached. The most recently available information suggests that the decline in bed needs which began just under ten years ago is progressing in broadly the way that might be expected.
While results are not yet available from the studies which are continuing by the General Register Office similar to those on which the original estimates were based, there is no indication from the overall totals of patients in mental hospital beds that the decline in numbers has levelled off since 1954 to 1958, the years covered by the original survey. At the end of 1954 there were 148,080 patients in mental hospital beds—a ratio of 334.5 per million population. Over the next four years the total declined by just over 5,000, whereas over the following two years provisional figures show a decline of over 6,000 to 136,162: 1253 a ratio of 297.6 per million population. There was thus an increase in the rate of run-down in the two years following the period covered by the General Register Office survey. These figures have been adjusted to allow for changes in the designation of beds in mental hospitals; that is to say, the decrease is a real one. Therefore, there is likely to be a substantial and progressive decline in the number of hospital beds required, and good reason to hope that a ratio of 1.8 beds per thousand population will in the long term be adequate, and perhaps more than adequate, to meet the needs.
My noble friend discussed provision for the old. It has for some time been the practice for mental hospitals to admit old people with mental symptoms who could more properly be cared for in other types of accommodation but who have had to go into a mental hospital because no other type of care was available. In our planning for the future we are trying to correct this by ensuring that other more suitable types of accommodation or care are available in sufficient quantities, so that mental hospitals will have to admit only those patients who really need to be there. But we should expect mental hospitals to continue the past practice so long as it is necessary, and we are aware of no general evidence that they are not doing so.
§ LORD TAYLOR
My Lands, would the noble Lord allow me to interrupt Mm for one moment? He said that 1.8 beds par 1,000 was the target for the mental hospitals. Does that include the Daises of which he is now speaking, or does it exclude them? In other words, will there have to be a build-up of psychogeriatric beds in general hospitals to make good the decline in psychiatric beds?
§ LORD NEWTON
I should rather like to consider that before giving the noble Lord a definite answer. Otherwise, I might mislead him. There is no doubt that all who are concerned with these matters do appreciate the size and seriousness of the general problem of caring for the elderly, but it is undoubtedly true that medical opinion generally is against old people living permanently in hospital unless this is the only solution.
1254 I come now to community care generally. My noble friend Lord Feversham referred to deficiencies in the services provided by local health authorities and to shortages of staff. We must not lose sight of the fact that a comparatively short time has passed since the relevant section of the Act came into force. Many authorities, at the instigation of the Ministry of Health, had begun their planning, and in some cases had begun building, as much as a year before the Act became effective. Authorities are well aware of the kind of services which are comprised in the term "community care". They know, for instance, of the need for expansion of training centres, hostels and social clubs, and for the recruitment of suitable staff to provide skilled and sympathetic supervision and guidance for the patient and his family.
Considerable progress has already been made, but there is room for a good deal more; and, in view of the amount of capital investment involved and the need to recruit staff, it will have to be spread over some years. But this is a matter to which I know local authorities are giving considerable attention in drafting the ten-year plans for their health and welfare services which my right honourable friend has invited them to prepare. The pattern of services which is at present emerging is not necessarily final. There is scope for variation between authority and authority. Each part of the community service may vary in scope and importance with developments in medical knowledge and methods of treatment, in the pattern of the hospital service and the needs of the patient in the community. These changing trends will be reflected in the annual unfolding and revision of authorities' ten-year plans.
My noble friend mentioned in particular the need for places in training centres and hostels. In their capital building programmes local health authorities have tended to concentrate on the provision of training centres for the mentally subnormal. Over 50 centres, many of them replacing smaller centres in unsatisfactory premises, were opened in 1961, and plans for a further 50 centres, at an estimated cost of about £2£ million, were agreed. A number of authorities are widening the range of 1255 their services by introducing facilities for the more severely subnormal, usually in the form of special units in junior training centres where day-care is provided. At the same time, many authorities are taking the opportunity, as part of the expansion, to develop centres for adults separately from those for children. It is estimated that 86 per cent. of the mentally subnormal children in the community and 72 per cent. of the adults considered to be suitable for training were receiving it at the end of 1961.
As to hostels, I must explain that the number of places available at any given time is not a true index of the extent to which authorities are coping with the problem of accommodation for the mentally disordered. Accommodation can be provided, and in many cases is already being provided, in ordinary lodgings or in homes or hostels run by voluntary organisations, apart from direct provision by the authorities themselves. The up-to-date figures for local health authority hostels show that 15 were opened during 1961, and that plans for 20 more, at an estimated cost of £520,000, were agreed. At the end of 1961 there were about 460 places available. A further 175 are likely to have become available since then, and another 800 should be provided in the next twelve months or so.
§ THE EARL OF LONGFORD
My Lords, if I may be forgiven for interrupting the noble Lord, I am sure he gave us the correct figure, but 460 places is .an astonishingly small number. I should have thought that he would hardly dare mention that figure.
§ LORD NEWTON
My Lords, it seemed to me a good thing to give your Lordships such figures as ware available to me, and I did so.
From the debates we have had recently in this House, your Lordships will be aware of the Government's plan for setting up a Council for Training in Social Work, which will be likely to give early consideration to the training of mental welfare officers. But some training is already proceeding in the pioneer courses of general training and social work, attended mainly by officers in the local authority health and welfare ser- 1256 vices, at a number of centres. Moreover, a new full-time course for one year for specially selected local authority officers starts in September under the aegis of the National Institute for Social Work Training. My noble friend asked when we shall see the Scott Report, which is the Report of the Sub-Committee of the Minister of Health's Standing Mental Health Advisory Committee, appointed under the chairmanship of Dr. J. A. Scott to advise on the training and the number of staff required at training centres. The Report will be published on the 13th of this month.
My Lords, my noble and learned friend on the Woolsack will be replying to the debate. Meanwhile, I hope that the introductory review and report which I have given will be of some help to the House and to your Lordships. I would add only that I find all matters relating to mental health of absorbing interest, and I shall look forward to hearing the observations of your Lordships.
§ 3.53 p.m.
§ LORD TAYLOR
My Lords, I remember when I read the terms of reference of the Royal Commission on Mental Health thinking to myself: "They have set up the wrong Royal Commission", and I was absolutely delighted to hear the noble Earl, Lord Feversham, say that there ought to be an inquiry into the staffing and the running of mental health services. Of course, that is what it ought to have been when the original Royal Commission was set up. But there was a reason why. If you set up a Royal Commission to investigate and alter the law, it does not cost any money at all, or very little money; but if a Royal Commission were to investigate the state of our mental hospitals and community mental health services, they would indeed reveal a cause for an enormous expenditure of public money, which ought to be spent in the interests of patients. Therefore there has not been the inquiry that there should have been, and I have no doubt that the Government will resist such an inquiry to-day. I hope that they will not, and it will be splendid indeed if they were to have such an inquiry.
I am very glad that the noble Earl should have suggested it in his closing 1257 remarks, and if he had said nothing else it would have been a very worthwhile thing to have said. Butt he said a great dead else. He has introduced a most important and valuable Motion, and I think he is showing a way for Parliament to work most usefully: that is, by looking at our own work and seeing how our work is working. Some people might say that one and a half years is not a very long time before you have a look at your work and see how it is working. I think the noble Earl was right to do that now. It is much better to look now and see what lessons we can learn; to see where we can congratulate ourselves, and where we went wrong, because now is the time to put it right.
The noble Earl has sought advice from many very sensible and worthy people with immense experience, and I have taken the precaution of doing exactly the same thing, but I have seen the position through the eyes of a different class of person. I wrote to twelve of my friends who were senior psychiatrists in mental hospitals and asked their opinions on how the Act was working, and about where things were going right and where they were going wrong. These people were scattered all over the country. They were people of great eminence, and they had one thing in common, and that may make my remarks differ a little from those of the noble Earl. I knew that they were all in first-class mental hospitals. Now, that may mean that I will give your Lordships a little better picture, in some ways, than he did, simply for that reason: because he was taking the totality, whereas I am taking a pick.
I am not going to say anything about mental defectives, or very little about them. I am going to say very little about rehabilitation, and very little about the detailed working of the Act in relation to the courts, because my noble friends Lord Longford, Lord Stonham and Lady Wootton of Abinger will be dealing with just those things. We felt that we should try to give your Lordships an overall consensus from this side of the House, so that we can get as good and as healthy a picture as possible.
First of all, there is general agreement that the purely legal provisions of the 1258 Act are working well, and I think my informants agree with the informants of the noble Earl. They are working well from the point of view of the patients, of their relatives, and of the hospital medical staffs. Admission is smooth and easy, especially for what one of my colleagues describes as the not unwilling brand of elderly patient, by which he means the old person who really has not got the capacity to express a view either way—and those old people used to be quite a problem. Another of my informants says:The majority of admissions are now informal, but about one in five"—and that is about the same figure which the noble Lord, Lord Newton, gave—have to be brought to hosiptal under compulsion".And this is in a large county country area.We find the procedure much easier and less traumatic"—that is, damaging—for the patients now that the magistrate is no longer involved.The picture which presents itself in a mental hospital now is this, and I will quote a typical, big mental hospital. The situation in this hospital last week was that admitted under Section 29—that is, the emergency admission for up to three days—there was one patient. Under Section 25—that is, compulsory observation for 28 days—there were nine patients. Under Section 26—that is, long-term compulsory detention for treatment—there were 50 patients. Under Sections 60 and 72—that is, the prisons and the court admissions—there were 13 patients. All the rest were informal admissions, numbering 1,852, as opposed to those small groups. In that hospital 3.7 per cent. were compulsorily detained last week.
In that same hospital last year, over the whole of the year, there were 1,730 admissions, of which 91.7 per cent were informal. That is a good figure, and yet, interestingly enough, it is a lower figure than the hospital had before the Act, when they were admitting 95 per cent. without certificate. The reason for this change—and this shows how statistics can mislead you—is very simple. They used to take a lot of the acute cases from observation wards to which they had been compulsorily 1259 admitted; but after they had been through the observation wards they were no longer a compulsory admission. Now they are coming straight to this hospital, and, as my medical friend says, it is to the great benefit of patients, doctors and nursing staff that they should come straight in, and not go to the observation wards. But it shows that we have to treat these figures with a little care.
The noble Earl said that the machinery for compulsory admission under Section 29, which needs one doctor only, is misused. I must say that this has not been my finding as a result of my inquiries. This is how I have summarised my findings. In a number of areas, this has been used as a routine method of compulsory admission, sometimes justifiably—for example, in remote country areas where long journeys are needed to see every patient and a second opinion, after the general practitioner has seen a patient, may be impracticable and may delay admission for a number of hours. Here is a quotation from a hospital in such an area:When there is time to spare, we use Section 25 but when, as is often the case, there is a degree of urgency, we use Section 29. It is our rule that this must be discussed between the general practitioner who has seen the case and the hospital's responsible medical officer before compulsion is applied, but we do feel that it is not right to keep patients waiting in their homes for some hours until the consultant psychiatrist can come out and see them.So there is another side to this picture. It is not just something that may be going wrong one way. However, it is true that Section 29 can be abused and I have found one example, at least, of how it was done.Too many cases have become 'urgent necessities'. … For example, I admitted a young girl from outside our catchment area under Section 29; it turned out the father had applied to the general practitioner because the girl had a bad temper"—I know it is difficult sometimes to distinguish between loss of temper and madness—Ira furore brevis est—and the father turned to the general practitioner for help. He, finding the girl sullen, approached the mental welfare officer, who assured me admission was necessary. Two or three days later the father removed the girl from hospital, stating that if she were any more trouble he could always use the threat of hospital to keep her in order.1260 It is the case here that the section was grossly abused, but it is the only case that I have had drawn to my attention, so I do not know that it is very common. But it is certainly something on which we have to keep an eye. Some mental welfare officers are finding it more convenient to use this section, it is also said, but again I should not like to say how extensive this is.
However, there are a number of real difficulties over emergency admissions, especially of old people at week-ends. I quote:Facilities for the emergency treatment of old people are lacking, particularly at weekends. Too often such patients with delirium (commonly secondary to a chest or other congestion.) have to be admitted to a psychiatric hospital, which may be remote from their home. This is particularly undesirable as they often have lucid intervals and are disturbed by the presence of demented patients, which is usually unavoidable in an over-crowded psychiatric hospital. It should be stressed that, at any rate in this area, hospitals are still overcrowded and experience great pressure on their beds.When these old people recover in a few weeks, there is little suitable local authority accommodation for them. They are usually mildly confused and unable to live alone. On the other hand, they need only minimal supervision, and are not truly a hospital responsibility.To turn to Sections 25 and 26, dealing with longer-stay compulsory detention, which requires two doctors, there has been some difficulty of a kind that the noble Earl did not mention. Of these two doctors, one has to be designated by the local authority as having special experience of the diagnosis and treatment of mental disorder. This is done by a panel set up by the local authority. In some areas these panels have worked satisfactorily and they have designated all the doctors that need to be designated, but in other areas they have unaccountably omitted some doctors and included others. For example, a number of senior consultants have not been approved for the purpose of making recommendations for compulsory detention.
If a person is fit to be a senior consultant of the National Health Service and to have the care of such patients in hospital and order their detention in hospital if they require to be detained when informal patients, surely he is equally suitable—and indeed in most areas is recognised automatically to be 1261 suitable—for this compulsory detention work. If such a doctor is called out for consultation with a general practitioner and finds the patient in need of compulsory admission for treatment, he cannot do it. This also arises if a patient is under treatment from a consultant and appears before a court. The court may ask whether he is an approved doctor for the compulsory detention of this patient and when the doctor has to say that he is not, the court may then refuse to take his evidence and demand another consulting psychiatrist. That is very unsatisfactory.
On the other side, there is the inclusion in the list of doctors who are not especially experienced in the diagnosis and treatment of mental disorder. They are included because it is necessary to have a general practitioner in a certain area for certain kinds of work, or because they are medical officers of health who are doing "subnormal" work, or because they are making recommendations for probation orders and have to be included under the Seventh Schedule to the Act, which automatically makes them approved for other purposes besides making probation orders. We should like the Government to have a look at the detailed working of this to make sure that the practice in the best areas is applied in all areas. I do not think that more than that is required, because there is no complaint from the good areas. Incidentally, the forms which are used under Sections 25, 26 and 29 do not give the patient's age, I am told, and it would be a great convenience if they did, particularly as the age is sometimes involved, as in the case of subnormal people and psychopaths.
I now come to admissions from prisons and courts, under Sections 60, 62 and 72 and under Section 65, which controls the restriction of discharge. As the noble Lord, Lord Newton, said, over the past ten or fifteen years our mental hospitals have absolutely changed. The doors have been unlocked throughout. One thing that the Act has done has been to give a stimulus to the open door policy throughout the mental hospital. In such a hospital, it is no longer possible to have custodial security; in fact, it is contrary to the way of treating patients. You cannot get them better 1262 if you have custodial security. I remember after the war being shown by Dr. Rees his wonderful hospital at Walling-ham Park. He said to me, "We haven't had a door locked for ages here. If you were locked in a room like this, wouldn't you try to tear the walls to bits after a while?"
The answer was, of course, that anybody, or almost anybody, would. So in the modern mental hospital all doors have been unlocked and the effect of this is that it is impossible to guarantee that people will not walk out. Everything depends on extremely good nursing staff, plenty of it, and endless attention to detail. Supposing there is trouble with one patient, you need to have eyes in the back of your head and all around. It is inevitable that some people should sometimes walk out if we do it in this way.
At first there was some tendency for the prisons to try to off-load their cases on to the mental hospitals. But now that sort of thing is straightened out, and generally the relationship between the prisons and the hospitals is good. But courts do not always realise this lack of security when they are making orders; and indeed, not only courts, as the following story shows.Last autumn",says a colleague,we took from Broadmoor a woman who had been sent there in 1945 after committing a murder in our local city. After spending the winter quite peaceably and, we thought, happily with us, she slipped off one day and presented herself back at Broadmoor asking to be re-admitted, because she said life was so dull in our hospital.This, I think, has two little lessons: first, it shows that you cannot get security of the kind that is in Broadmoor; and secondly, if I may say so, it shows that Broadmoor is not too bad. If the courts judge that a person needs custodial care, that person must be in a special hospital or a prison hospital: and I think it is essential—it is not always done, although it is now done increasingly—that evidence should be before the court of the conditions at the receiving hospital, if they are to make a wise decision.
Then there is admission by the police under Section 316, after three days. A person who is found wandering in a state of disordered mind can be 1263 admitted by the police to a place of safety, one place of safety being the police station. Occasionally the police try to get rid of their drunks from the police station to the local mental hospital. This is done only occasionally; but it is done sometimes, and it is rather naughty. They occasionally dump people in casualty departments after they have been using the police station as a place of safety. They say: "This place of safety has lasted long enough, and we will transfer them to another place of safety", which is the general hospital; and this is sometimes a little embarrassing. But there is little use of this section.
There is the power of the hospital to refuse admission, to which the noble Earl, Lord Feversham, referred. Here my experience is a little different from his. I think it is partly because I have been looking at the best mental hospitals and getting opinions and information from them, whereas he has been getting his from the generality. In the hospitals to which I refer there has been very little trouble, and few of them have been refusing anybody. The great problem is the old people who are senile or semi-senile and are becoming disordered or demented. This is, in my view, easily the biggest single problem facing the mental health services at the present time. Physical illness in old people often leads to mental upsets as well. In such people it is quite transitory, and they can recover from it quickly if they are properly nursed and cared for and their physical illness is properly nursed and cared for. They need treatment in special geriatric accommodation in general hospitals. Yet how much of this is there? We had a debate about this subject, and we know of the awful situation, the "bunging up" of the geriatric units, to which the noble Lord, Lord Amulree, so vividly introduced us, because there is nowhere for them to send cases which need only care. So these psychiatric geriatric cases, which should really be looked after by general physicians, with psychiatrists helping if need be, get pushed into mental hospitals. There are some old people who become psychiatrically ill with acute confusion states or depressions. They are proper admissions to mental hospitals straight away.
1264 Again, as the noble Earl, Lord Feversham, mentioned, the effect on these people if they are not dealt with as family is awful; and the effect if they are in isolation on their own is also awful. Some doctors I know, and some hospitals, have tried to keep them out, and they are within the law; legally and administratively they are right in keeping them out, but morally they are quite wrong. There is nowhere else for these people to go, so they ought to be taken in. And the hospitals to which I am referring are taking them in. But the result is that they are filling up their acute beds with these chronic cases; instead of being able to deal with the acute cases, they are full up with what are really chronic psychiatric sick. There is a double failure here: first, the failure of the hospital service to provide the necessary geriatric beds; and secondly, the failure of the local authority to provide hostel or care-and-attention beds for these old folk. The brave words of the Minister of Health about reducing mental hospitals to zero will not mean very much until we have provided alternative accommodation for these people. Therein lies the rub.
The second group is again those to whom the noble Earl, Lord Feversham drew attention. They are very small in number, but their effects on the hospital are out of all proportion to their numbers. These are the psychopaths. Here a colleague says:We do try not to re-admit the occasional disruptive psychopath.This is a case where the hospitals are trying to keep them out deliberately. Another colleague says:There are four serious disadvantages which result from their admission to a psychiatric hospital. They cause an enormous amount of distress to other patients who are already in a troubled state of mind. Their behaviour demands most of the available doctor—nurse time on their ward. Although usually less than one per cent. of the hospital population, their bad behaviour, smashing windows in the hospital, breaking up local pubs and causing trouble in the community around the hospital, has a very serious effect on the community's attitude towards the other 99 per cent. of patients in hospital. This stigma, in turn, sometimes deters patients with mental disorders from agreeing to come into hospital for treatment. The presence of such potentially aggressive, destructive patients leads to overcautious methods of nursing and treatment, which in turn produces such dreadful effects on patients as institutional neurosis.1265 That is the case against the psychopath in the general hospital; and I am sure it is absolutely right.
Your Lordships may wonder what a psychopath is. Psychopaths are far easier to describe than to define, but if I may spend a minute to describe a typical story, you will see what a problem they are in the mental hospital.This patient had been in hospital on several occasions; she had attempted suicide sixteen or seventeen times; she had threatened the night nurses that unless they gave her sodium amytol she would smash a window, and had attempted to persuade another patient to strangle her. On two or three occasions a great deal of social work had been done to get her employment. The patient had been found a job at a local general hospital, and that same night smashed a window at the hospital, stole some barbiturate tablets and attempted suicide. Because we are short of trained nurses, because she so successfully blackmailed them to obtain drugs and because she consistently upset other patients and deprived them of nurses' time and attention, one of the senior psychiatrists here refused to admit the patient to hospital for examination. The local magistrates, through their chairman, deplored the lack of co-operation on our part, and, of course, it made local news headlines. The patient was remanded at … Prison on a charge of attempting to commit suicide by taking poisonous substance, to which she pleaded guilty. She reappeared before the local magistrates with a medical report signed by the prison doctor and a general practitioner recognised under Section 28 of the Mental Health Act, 1959. In coming to their conclusions, these doctors stated the patient was schizophrenic, because she said she had 'seen a face'. The doctors did not approach our hospital for the patient's previous notes, and the doctor who signed the second part of the order did not make arrangements for the patient to enter our hospital.Accordingly, in the interests of the majority of patients here … I appeared in court, remarked that although the last thing we would wish is that a patient should become a missile in an administrative battle, I was not prepared to authorise her admission under Section 60. However, I said we would accept her on an informal basis for the time being, but I was not prepared to compulsorily detain her. The magistrate expressed his obligation, but did not accept my offer. The patient returned to prison, representation was made to the Regional Board, the senior administrative medical officer rang me up asking for advice and the only thing I could advise him to do was to overrule me on this occasion. The patient was admitted and behaved very well thereafter, to our constant embarrassment. After she left hospital she wrote complaining of her lack of treatment and asking why she had not been found a job locally.That is the psychopath, and that is the problem. They are impossible people. If we arc to do any good for them they must be compulsorily detained on order 1266 from the courts in full security institutions, special institutions. Our fear; about doctors having to make order; without lay assistance, which we ex pressed when the Bill was going through the House, have just not been realised because they are almost all dealt with by court proceedings by lay people which is the right and only way to deal with psychopaths; so in that respect I think the Act has worked far better than we anticipated.
The third group—again a small group to which the noble Earl, Lord Feversham, referred'—are the adolescent psychotics, the young people who go mad, and the grossly maladjusted young people for whom there are almost no beds. These people just cannot be nursed in an adult ward. It is perfectly dreadful to have to send young people to a ward with a lot of old and middle-aged people who are mentally ill. It is bad for all, and something must be done pretty quickly.
Now with regard to alcoholics and the drug addicts: here I am quite sure that the World Health Organisation has grossly over-estimated the number of alcoholics in this country. These enormous figures for alcoholics may occur after we get into the Common Market, but I do not think there is any evidence that we have vast numbers of undetected alcoholics. But we have no special units for the few that we have.
The final group are the coloured immigrants. A doctor writes:Not surprisingly, immigrants are liable to mental illness. It is often desirable in the interests of their health that they should be cared for in the cultural surroundings with which they are familiar. This gives them the best prospect of early recovery. My colleagues and I are distressed by the time taken, and difficulty experienced, in having such patients repatriated.Now tribunals. Here I must say that I entirely agree with what the noble Earl said. In the mental hospitals with which I have been in touch there have been no problems at all, and, indeed, most have had no cases referred. Cases arise mostly out of mentally subnormals, and the thing seems to be working perfectly all right, though it is a big hammer to crack a very small nut.
On the hospital side may I make one last point, and that is with regard to psychiatry in teaching hospitals. Here, 1267 one of my informants says something which I think is very important. At the moment, psychiatry in teaching hospitals is in a much less satisfactory state than the psychiatry in the best mental hospitals, because these teaching hospitals have no catchment area which they have to look after and Where they can build up community services. They have no ancillary services—occupational therapy, social therapy and the rest—which makes up a good psychiatric unit. He says:Things are developing well in the newer regional hospitals. They have their large 150-bed short and medium stay units, complete with day units, out-patient departments, child psychiatry units and provision for social and industrial therapies. By comparison the teaching Departments are in danger of becoming the newer psychiatric slums.I think it is time the teaching hospitals pulled up their socks about this matter; and, indeed, they can do it, because, owing to the isolation of the boards of governors, the burden has been put on them. Regional Boards cannot influence them, the Minister cannot influence them a great deal, and even the University Grants Committee cannot do a great deal because it has not very much money with which to do it.
Now I turn to the services outside hospitals, with which I am sure most of my colleagues will be dealing later. Here the picture is very unsatisfactory, and it is a question as to whose fault it is and what we ought to do. The local authorities have concentrated their efforts—and I think they have been right to do so—on the subnormal side of ascertainment, on providing child guidance clinics, training centres, sheltered workshops, and so on. On the adult side they have done much less. The arrangements for admission are not too bad, though the mental welfare officers are still of varying quality. It would greatly help if local authorities, when making appointments of mental welfare officers, could have a consultant psychiatrist of the receiving hospitals on the Boards to assist in the making of appointments, and in that way some of the very unsatisfactory appointments would be avoided. Nevertheless, many of them are doing very good work, with little training, and it is encouraging to find hospitals running case conferences for the mental welfare officers wherever it is 1268 possible. But too often the catchment area of the hospital is separated right away from the hospital. North London catchment area hospital is at Epsom, but it is at any rate able to have good relation with these officers.
There is fairly general agreement that quality and quantity are things we ought to try to improve as time goes on. Aftercare is largely non-existent. It may be due to the enormous size of the job which has to be tackled. It may be due to Government restraint on capital expenditure, because time and again the doctors with whom I have been in touch say that the local authorities are afraid to spend the money. They have not the money to spend to do the work, and even if they carried out all the plans it would be a pathetic story, because, as the noble Lord said, under 500 beds are provided, but the need is measured in tens of thousands. It is an enormous need. And as for social after-care, it just does not exist. When these people are discharged from hospital there is nobody to look after them in these areas—and nobody to help their general practitioners or to do the social care in most cases. I have always been quite sure myself—and I could give your Lordships some quotations here—and most of the hospital doctors agree that it is best done by staff based on the hospitals. If that is done, yon bring together the day hospital, the rehabilitation unit and the rest of it, with the same doctors looking after the patients right the way through.
However, that is not what the Act says. But we agreed that where this sort of arrangement was working it should be allowed to continue to work, and the more that kind of arrangement develops, the better. Time and again they have special grants for what is needed. I do not know whether it is special grants, or whether it is more enthusiasm and more drive, but something must be done if we are really to make an impression. I agree with the noble Earl that some, at any rate, of these admissions may well be due to completely inadequate after-care. Though it is not the whole story, it is a good thing to push the patients out quickly and get them back into the world, even if they have to come back again, because it is better for a patient to have had three periods 1269 of six weeks in hospital than one period of two years; for if he is in for two years he becomes institutionalised.
To sum up—and I am sorry to have been rather long—there is little need for legal revision; there is some need for administrative watchfulness, for example, over the list of approved doctors; and there is growing need for more buildings and more medical, nursing and social work staff. It is a very great problem and it is going to become worse. For example, the Platt Report says that the number of doctors should be based on the number of beds. In psychiatric work, the fewer the beds the greater the turnover, and the more doctors who can be put in charge of those beds the better the results. The psychiatric unit I know has five doctors for 80 beds, yet in the average psychiatric hospital there is less than one doctor for 80 beds. When I was a boy the ratio was one doctor for 500 or 1,000 beds, so things have come on.
To apply the Platt Report on general medicine to the mental staffing situation is just ridiculous, which serves to emphasise the noble Earl's point about having an inquiry into this whole thing and to look at this staffing situation properly. We must have these special units that we have spoken about. We must have a proper after-care side, and we must make sure that local authorities not only shoulder their responsibilities but have the means to shoulder their responsibilities, and the encouragement and "shove" that is necessary; and there, I think, we can all play a part.
§ 4.31 p.m.
§ LORD AMULREE
My Lords, I should like to join in the general welcome given to the Motion which the noble Earl has put down for debate this afternoon. I agree that the Mental Health Act has not been going for very long, but that is an even more cogent reason for talking about it now, so that we can see what is going on and talk about the difficulties we have found in administration, so that if these things are proved they can be put right before they get too fixed and settled. Broadly speaking, I think one would say, from the point of view of an acutely sick person, that the Act has worked very well. There arecertaincriticisms and certain comments I shall make later on, but 1270 in my view it has worked very well. If your Lordships will excuse me, I am not not going to follow the lines of the noble Lord, Lord Taylor, in talking about a large number of hospitals, but I should like to do what is probably wrong and argue from one particular hospital to the general workings.
In my own hospital, where I work we have a big mental observation branch for 34 men and 34 women. For a large amount of the time the 34 women's beds are occupied by people who have come in informally, not from compulsory entry at all. At the present time it is not quite that, for we have 29 beds full, of which two have come in under compulsion. That, I think, is something quite remarkable, and shows, from the mental observation point of view, that the same trend is going on. People are coming in a purely informal way. One of the difficulties is that sometimes we have to refuse people admission because of the shortage of mentally or psychiatric-trained nurses to take care of them. If you are going to be able to persuade people to come into hospital on an informal, voluntary basis you have to be able to offer them first-class treatment and care; and if you have not sufficient staff it is difficult to do that, and therefore they will not come in.
That is one respect in which I see difficulties in the way of the proper working of the Mental Health Act—the difficulty of finding staff with really first-class psychiatric training to take the place of those people now doing the work when, in due course, they retire. One of the things we have in this country is the very great tradition of psychiatric-trained nurses, or, as I think they are now more popularly called, mentally-trained nurses. That was one of the things that we were very good at indeed, and a great deal better than many other countries. I am not going to say for a moment that hospitals, from the point of view of buildings and overcrowding, were good; but there was a very good background for training in psychiatry among the nurses. That is something which I think is now in some danger of falling off, and it would be a real tragedy if it were to occur.
I was very pleased that the noble Lord, Lord Newton, said that the Government were planning to get 1.8 mental beds per 1,000 of the population, 1271 because that would encourage some of the people Who were somewhat discouraged by the thought that the running-down of the mental hospitals might be carried on to infinity and who felt that there was no future in them. But what the noble Lord said should encourage people to realise that there is a future and to make people come in for training—because one must get people with proper training to treat these patients. Except on very rare occasions, it is no good getting a nurse with a good general training and then giving her just six weeks in psychiatric training and thinking she can really cope with patients who are acutely ill mentally or have been suffering from long-term mental illness. Such illness is a very serious affair, and cannot be treated in that kind of way.
Training of these nurses must be carried out partly in the acute short-term mental hospitals and partly in long-term mental hospitals, too; because, although we can talk about improvement of treatment, improvement of care, and continuance of community care in the home, there will, I am sure, remain for a very long time, if not permanently, a certain number of people who cannot be cured. We cannot expect to cure everybody. There will be people who will need long-term care, although it need not be of a compulsory nature. They can be voluntary, informal patients. But I think they will need to be in long-term mental hospitals, and that is where the nurses of the future must undergo part of their training.
Certain reference has been made to the troubles of the elderly, and I should just like, if your Lordships will allow me, to say one or two words on this subject. There are really two types of old persons in need of mental care. There is the type with which I am dealing first, the old person who really becomes acutely or chronically psychiatrically sick; and such people need full and proper care, with nurses and staff trained for the care of the mentally sick. That means psychiatric training. There are not very many of this type of sick, but they need to be treated in mental hospitals, because there are no facilities in a general hospital to deal with people like this, whose mind is so diseased and whose behaviour is so 1272 extremely difficult. Where there are people who have become mentally confused because their disease has some physical cause, then I see no reason at all why they should go into a mental hospital, because once the physical cause has been removed, the patient will, if not recover fully, certainly quieten down.
The noble Lord, Lord Taylor, referred, I think, to patients with pneumonia. It is a common enough thing for a patient with chronic and long-standing constipation to get into a state of mental agitation and confusion, which is cured or relieved when the constipation is overcome. These are patients who are quite rightly treated in general hospitals, because they are suffering from a purely physical disease and have nothing mentally wrong with them at all. But there are those who need to go into mental hospitals, and it is now becoming very difficult to get them admitted. I am not quite sure why, but it is becoming extremely difficult. But the vast majority of old people who show mental deterioration, who become mildly or seriously confused, do not need to go into mental hospitals: they need, I think, to be taken care of in the wards of a general hospital. It may be necessary perhaps to keep them together with others with the same symptoms, because they are a little difficult for more normal patients to be with robably the staff dealing with them should include one or two nurses who have had some training of a psychiatric nature, so that they can cope with some of the little difficulties that come along.
These are the people for whom at the present time there is no provision made at all, because quite rightly, their admission to mental hospitals is not encouraged, and no extra beds have been made available for them in the general hospitals. One tends to find that geriatric departments are fuller than they should be of people suffering from mild mental confusion, who have no relatives, or whose relatives cannot take them, who do not need full treatment in the mental hospitals yet have to be in hospital. That is one of the sad things about the Hospital Plan, published recently, which we debated not long ago. It is a very good plan in many ways, but it makes no provision for these people, who will be increasing in number, I think, and will tend to occupy more and more beds in general hospitals 1273 where they do not really need to be. The mental hospitals, quite rightly, do not want to take them; and indeed, if the number of beds is to be run down, they quite obviously will not be able to take them. So these people will cause some problems in the future.
One can see again the enormous value of properly trained nurses from good psychiatric or mental hospitals. If you visit a ward where there has not previously been someone like that, and you then get a really first-class sister come in, the whole atmosphere changes at once. As one noble Lord said the other day, when we were debating pay of the nurses, one sister can have an immense effect on the ward or department of which she is in charge. Patients are quieter, more normal; they are not kept in bed; doors are not locked—indeed, not many are locked now, though a few may still be locked; the whole atmosphere improves. That is another reason why we should concentrate on seeing that the mental hospitals which remain provide first-class training for the medical and the nursing staff. There has been an enormous reservoir in the past of expert trained staff, and it would be a tragedy if that were to be allowed to run down at all at the present time.
When we debated the Health Visiting and Social Work (Training) Bill the other day, the noble Earl, Lord Feversham, mentioned that if there were not enough trained psychiatric social workers and social workers generally, trained for work in the local authority field, the Mental Health Act might not fulfil the hopes we all felt when it first came in; there I agreed with him then, and I agree again now. If we do not get these trained staff we shall find people going back into the mental hospitals sooner than they do now, and we shall be back where we were before the Act came in, except that it will not be compulsory. That is why I should like to see facilities made for training these people, partly in mental hospitals and partly in others, so that they can do the work which they are intended to do under the Mental Health Act and keep people from going into hospital.
Before I conclude, my Lords, there is one point of criticism—not really criticism—I want to make. It is a rather complicated matter, about which I did 1274 write to the noble and learned Viscount, and it deals with the difference between Section 29 and Section 25. Section 29 of the Mental Health Act deals with compulsory admission under a 72-hour order, and Section 25 deals with compulsory admission on a 28-day order. As the Act is at present worded, and quite rightly, if a patient who is to be admitted is seen by only one doctor, it cannot be longer than a 72-hour, or three-day, order. Supposing they are seen by two doctors they have to be admitted for 28 days. The way the Act is working is so that, supposing the patient wants to be seen by a general practitioner, or by a house physician in a general hospital, and he wants to call in a consultant psychiatrist, it is very difficult to get him admitted under Section 29; it has to be under Section 25. Whether it is right or wrong in the meaning of the Act, that is the way it is working out now. That, I think, is wrong, because I am informed by my psychiatric colleagues that it is very rarely—I will not say very rarely, but not often, that it is necessary to take a patient for 28 days. Of those who refuse to go in, once they are admitted under a 72-hour, or three-day, order, the majority will be prepared to stay voluntarily after 12 or 24 hours.
So, one would like to see the procedure under Section 29 made a trifle simpler, so that a good doctor wishing to call in a colleague, or the general practitioner who wants to call in a consultant psychiatrist, does not by so doing more or less condemn his patient to a 28-day order, which is the case now. It is a rather complicated matter, and I trust that I have made myself clear. That is the one real criticism I want to make at the present time. Apart from that, I must thank the noble Earl for putting down this Motion, and I close by saying that the Act appears to me to be working as well as could be expected for a thing that is quite new.
§ 4.46 p.m.
THE LORD BISHOP OF LICHFIELD
My Lords, it was with a great deal of trepidation that I sent in my name to speak in this debate, because I do not possess anything like the great and detailed knowledge of this subject that has been displayed, to such advantage to us all, in the speeches which have been 1275 made earlier in this debate, by people who have made a great study of this important matter and have such knowledge of it. But I felt that as this is such an intensely pastoral matter—because it is a pastoral matter; it is caring for individuals—there ought to be a voice from this Bench.
In these days we are often intensely concerned about the increase in crime and violence, and so on, and in these circumstances it is very easy for the preacher to thunder against the decline of Christian principle in the country; indeed, there may be a good deal of truth in it, and I know that I have done it myself on several occasions. It is therefore, I think, a wholesome corrective to someone like myself to listen to a debate like this, and to realise the way in which the Christian principle has so much permeated the national thinking, so that people realise that those who cannot always fend for themselves should not be cast off but should be cared for by the community. We have heard the way in which, through this Act, it is now being insisted that this is a duty, that we should care for them to the fullest extent and in a spirit of love and charity. For that I thank God and take courage.
It seems to me, my Lords, that this Act is fostering a spirit of co-operation, not only in the field of mental health, but in the whole field of health in this country. I think that sometimes there have been criticisms of the National Health Service; it has been said that it has tended to put the various sections of the Service into rather too watertight compartments. That may have been an unjustified criticism, but I have frequently heard it made. I think there are many ways now in which it is being overcome, perhaps by G.P.'s being able to treat their patients in hospital to a greater extent than they have been able to—I say that merely as an illustration. But here we see the way in which the hospitals and local authorities simply must work together; for if they did not it would appear that there would be chaos.
The point I would stress this afternoon is that that co-operation must be encouraged, and the whole community must be encouraged to play its part. After 1276 all, we should never dream of casting off the physically handicapped, the blind, the deaf and so on, and taking no further notice of them. In no sense, therefore, must we try to push out of sight and to forget the mentally ill. In the past, undoubtedly, in the mind of the general public, there has been a good deal of stigma attaching to mental illness. If you had to go to a general hospital and have your appendix removed, there was no disgrace about that; but if a member of your family had for a time, either voluntarily or by compulsion, to be removed to a mental institution, the family were very worried indeed about the matter, having regard to this stigma. I think that one of the most hopeful signs at the present is the way in which that attitude in the mind of the general public is gradually disappearing. I think we are improving in that way.
I noted that the noble Lord, Lord Newton, mentioned, I think rightly, the way in Which sometimes the general public can be ungenerous in this matter. There have been many illustrations of that, but I think it is passing. We should note that with hope. But I also think that the new tendency to increase the number of psychiatric wards in general hospitals as opposed to the big mental hospital away from the centre of population will ultimately help in this matter. The great mental hospital has often, willy-nilly, been some miles from the centre of a big town, perhaps away in the countryside, and there has been an atmosphere of segregation about it. So far as I can see, we do not want to segregate the mentally ill more than is possible; we want to integrate them into the community, to help them to play their part in life once more. I therefore think that this bringing of psychiatric wards more and more into the general hospitals will greatly help. For instance, if we are going more and more to have daily patients who go home at might, clearly it is desirable that they should not have to travel longer distances than necessary.
I would also plead that it should be remembered that the mentally ill ought, if possible, to be visited by their relatives. I know that there are some cases where, alas! a visit would serve no useful purpose, where perhaps the 1277 patient concerned may not recognise his relatives or, indeed, may have turned utterly against them. In circumstances as tragic as that, a visit may be a useless waste of time. But there are cases where these people ought to be visited by their relatives, but are not, because the relatives have got them away; they heave a sigh of relief and let them stay there, and do not really bother about them any more. That is a deplorable attitude, and something against which we must fight.
If segregation in this matter is passing and integration is taking its place, there are certain steps which have to be taken. Here I should like to refer to one matter in the speech of the noble Lord, Lord Taylor, which I must slay greatly worried me. He pointed out the way in which, because of the new forms of treatment, hospitals often can no longer be custodians, and he also mentioned the way in which some courts apparently fail properly to realise this. I made a note that I wished to refer to this subject, because while I am most thankful to say that when you think of the thousands of patients who are being dealt with it is obvious that the number of mistakes in this matter is quite few, yet it has to be remembered that every time a mistake is made and something deplorable happens as the result of the action of the ex-patient, the publicity is very big indeed. A great deal of attention is focused upon it, and this has a deplorable effect on the whole atmosphere of the community round about. We must never lose sight of that. It does immense damage to the very thing we are trying to encourage. When it happens the authorities concerned should not merely fob it off and say that in these enlightened days one must remember that treatment is different. That outs no ice with the general public round about.
Secondly, on the positive side, people generally must help to integrate these patients as they come back into the world again. Again, the noble Lord, Lord Taylor, spoke about the fact that there was not sufficient after-care. He made, I thought, the most important point, that hospital staffs ought to help very much in this. Again and again in the speeches this afternoon, I noticed that we came to this matter of staff. I 1278 must refer to that later, but I would say that I do not think we shall ever get enough staff to do all this work—at least, I greatly doubt it at the moment. Therefore, it behoves the general community voluntarily to do what they can to help. Here I would pay great tribute to the many voluntary organisations for what they are doing. But if we are going to set our hands to this matter voluntarily, let us remember that it is no good starting on the job for about three weeks and them getting tired of it and dropping it. That is what I aim afraid may some-times happen with voluntary effort. We must persevere.
I think it is right that I should say that the clergy are endeavouring at this time to try to train themselves to help in this matter. Well over 1,000 clergy in the Church of England are at the moment undergoing a regular course of lectures which are designed to help them a little in the psychiatric side of their work. May I make it plain that the last thing we want to do is to set ourselves up as amateur psychiatrists? That would be highly dangerous. But I think What we can do is this: by gaining a little knowledge we can play our part in trying to help patients, as they come back into the world again, to feel their feet and to integrate themselves into the community. That is our pastoral job.
Do let us remember that it is possible to recognise the symptoms of stress. In this debate naturally there has been a great deal of emphasis upon what can be done for patients in hospital and When leaving hospital. Let us remember that, above all, we must try to stop people getting ill in this way, if we can do so at all. Let us remember that there is a great deal of mental illness that can be prevented by the solving of personal or social problems. In that way we must all play our part. Again, I return to the fact that very often the trouble is the lack of people to do the work.
Here I should like to pay my tribute to the staffs of our mental hospitals. I think they are doing magnificent work for the community. They have not the glamour of the acute illness general hospital, and the work is often unpleasant and exacting. We cannot altogether be surprised if sometimes people who take on that form of nursing feel, after a little 1279 while, that they cannot stick it any longer. I am sure it makes great demands on the spiritual and mental abilities of the person concerned. Therefore I should like to say how grateful I think we should be to the many married women who come back part-time and help in our hospitals. Frankly, without them I do not know what some of our hospitals would do for staff.
May I also say, as I mentioned once before in a debate on hospitals and the National Health Service, that we must not forget the part that is played by nurses from the Commonwealth? I do not know where we should be in some of our Midlands hospitals without the great assistance that they give. But if ever there were needed a sense of vocation, it is in nursing in this particular sphere.
Let us also remember in this matter of after-care that there is much that the untrained can do. The kindly person of common sense who realises that it is his job to try to help his neighbour is a person who might be of great assistance to us in this work. Therefore, my Lords, I would end by saying that I am personally most grateful to the noble Earl, Lord Feversham, not only for his introduction of this debate in this House this afternoon, but for the great work he is doing, in season and out of season, in his particular field. I should only like to add that if there is any help the Church can give, we will give it. We are trying to do our best, and I repeat that in this pastoral work we surely should do everything we can to assist.
§ 5.1 p.m.
§ BARONESS WOOTTON OF ABINGER
My Lords, after the speeches that have been made your Lordships can be in no doubt that the Mental Health Act, 1959, marks a most remarkable step forward in the humane and civilised treatment of a very unhappy and distressed section of our community. If any of us is led to make criticisms, either of the working of the Act or possibly of some of the philosophy that lies behind it, those criticisms must be read against appreciation of its tremendous improvement in the humanity and skill of the treatment. I myself have certain doubts, which I hope your Lordships will allow me to express, on some of the potential 1280 implications, not so much of the Act itself, as of the philosophy of which I think this is an expression. But if I give voice to these doubts I should like to say at the outset that a muddled philosophy which is well-intentioned is much to be preferred to one which is coherent but of more dubious intent. As to the well-intentioned character of our present system of mental health services there can be, I think, no question at all.
One element in the philosophy which I should like to consider with your Lordships for a while is the current doctrine that mental and physical illness must be, so far as possible, assimilated. In so far as this removes the stigma from serious cases of mental illness, it is an unqualified good; in so far as it has enabled cases such as those that have been referred to constantly during this debate—cases of people in advanced stages of senility, or acute mental illness—to be treated as though they were having their appendix removed, there is nothing but gratitude to be expressed. But I think we must be careful that we do not carry this assimilation too far, and that we do not wholly overlook the fact that there is a distinction between those disorders which are expressed in bodily symptoms and those disorders which are expressed in emotional or behavioural symptoms.
Many bodily disorders do, in fact, give rise to mental symptoms—sometimes to very acute mental symptoms. Many of us have before now been delirious with high temperature and have given vent to observations that have quite surprised us when we have been told about them, on recovering later our normal temperature. But many bodily diseases do not gravely affect the personality or behaviour of the patient. Mental illness by definition does this in practically every case. This distinction is especially important, if only because in the behavioural symptoms the social elements play a very much larger part than they do in purely bodily illnesses. Here I would associate myself with what was said by the right reverend Predate, in emphasising that we must give great weight to the social environmemit in certain forms of mental illness.
One would not be so much concerned about the assimilation of bodily and mental illness if it were not for the fact 1281 that there is at the same time a tendency to widen the concept of mental disorder. This, of course, has gone very much further in the United States than in this country, though it is noticeable here. This afternoon we have been talking mainly about acute cases of mental disorder, but you will find in out-patient clinics, and still more, I think, in the consulting rooms of psychiatric consultants, a great many people whose disorders really resolve themselves into the fact that they cannot come to terms with the life of to-day. Sometimes I think we extend the categories of mental illness or mental disorder to cover cases for which it is a very dubious description. Only the other day I heard an instance of what in an earlier age would have been referred to as pure egotism described as a case of introspective neurosis. I am not sure that very much is gained by that kind of re-christening.
I should like here to pay tribute to the challenging book of the American psychiatrist Dr. Thomas Szasz which has lately been published in this country under the challenging title, The Myth of Mental Illness. I do not think many of your Lordships would go the whole way with the author of this book, in denying that mental illness exists at all; but I think that many of us could benefit from going some way with him, and in particular in calling in question what he has called the "potential dangers of rewarding disability". I should like for a moment to ask what those dangers are.
Probably the least of them is the fact that they may discourage some people from being ashamed of their obsessions, foibles and weaknesses. That is the least of the dangers, but it is not entirely negligible, especially in relation to young people. After long experience in the courts I find that I begin to deprecate the perhaps too rapid recourse to psychiatry in the case of young people who find it difficult to conform to the laws and to the moral standards of the community in which they live. I do not for one moment dispute that there are cases where psychiatrists are of enormous value in dealing with extremely difficult children, but I think we may possibly have overlooked some of what I should like to call the side-effects of treating children who cannot accept the laws of the community in which they live as though they were mentally ill. Children 1282 very quickly get to think of themselves as poor little things suffering from some disability, and the side-effect of attendance at a clinic, or of going to the doctor, fox apparently mental or moral failings are moral entirely to be discounted.
I should perhaps be less inclined to mention this point if we were blessed with greater success in the kind of psychiatric treatment which is used for delinquent children. I cannot help noticing the contrast. In my lifetime there have been enormous improvements in the treatment of certain diseases. Tuberculosis is no longer the scourge it was; the rate of infant mortality has fallen out of all recognition in half a century. But I notice that, although we multiply our child-guidance clinics and the psychiatric services attached to our courts, there is no improvement at all in the figures of child delinquency; and I am a little inclined to judge all branches of the medical profession by the same test—that is, whether they do or do not, in fact, produce results. But that, my Lords, I think is the least of the dangers: there are others which are more subtle. Here again, I am greatly indebted to the work of Dr. Szasz.
One of the consequences of treating all forms of misery as illness is that we may sometimes tend to ignore the message behind the misery or the mental symptoms. Dr. Szasz has applied this thesis very cogently to the case of soldiers who develop mental or sometimes physical symptoms in war, who are treated as psychiatric cases and, perhaps, discharged from the Army. What he is arguing is that in these cases there is no real illness in the ordinary sense; that there is merely a stringent protest against the kind of life to which the soldier is subjected, and that, in a sense, by treating him as ill we are forcing a type of conformism upon him. If this is true in the Army, it is certainly sometimes true in cases of domestic stress and personal unhappiness which lead to mental illness. We have to be a little careful that we do not enforce a kind of social conformity, by treating those who renounce some of the standards of our community as being psychiatrically disabled. Maladjustment, after all, has come to be a word which is used almost synonymously with mental disorder or disability But I think we should never 1283 use "maladjustment" in that sense, when asking ourselves "Adjustment to what?".
It is time that I tried to show the bearing of some of these more general remarks upon the actual working of the Act. The Act gives wide powers to detain certain categories of disordered persons, notably the severely subnormal, and still more notably the psychopaths. The number of persons who are compulsorily detained as psychopaths but who have not appeared before the courts is very small. I think that at the end of five months' working of the Act, out of 169 persons who were diagnosed as psychopaths under Part IV of the Act, fewer than 30 were still under compulsory powers. The number is so small, indeed, that one wonders whether it might not be safer and wiser for all persons who are detained as suffering from psychopathic disorder actually to come under court order instead of under Part IV of the Act.
The reason for this is that, if these people are persons who are violent, who break windows or who attack other people, they are obviously guilty of offences against the law, and if they are dealt with in court at least we know what they have done and Who they are. When they are detained under the procedure of Part IV of the Act, it is impossible to get any information as to the nature of the disorder, except that it is classified as psychopathic disorder. Your Lordships will remember that the definition of "psychopathic disorder" in the Act is extremely wide, and that it covers cases of persons whose conduct is seriously irresponsible or abnormally aggressive—terms of potentially enormously wide range.
§ LORD TAYLOR
My Lords, the noble Baroness says that it is impossible to get information about these cases. Impossible for the courts to get information, or for the general public to get information?
§ BARONESS WOOTTON OF ABINGER
My Lords, I mean for the public to get information, or for persons who may have some special interest in this matter to get information. The Ministry of Health will not disclose anything. I do not mean information about 1284 individual cases, which would be extremely inappropriate, but the Ministry of Health will not disclose any information even under a strict seal of confidentiality, as to the type of behaviour which has led to the diagnosis of the case as psychopathic disorder.
The Royal Medico Psychological Association has, in fact, conducted an inquiry into this very question, and I am greatly indebted to it for allowing me to see some of the particulars that have been collected. From these particulars, one sees the type of case and I think one has very little disquiet at present. These are people who are violent, who attempt suicide, who are alcoholic, and so forth. But I think we must remember—and some evidence has come to my notice—that it is possible in the course of time to extend the interpretation of this definition of "abnormally aggressive or seriously irresponsible." There are many kinds of conduct of Which virtuous people disapprove—immorality, laziness, drinking, and inability to hold down a job—which are not crimes, and I am only anxious that we should have some means of assuring ourselves that these aie not made the grounds for a diagnosis of psychopathy.
I think the second danger is the exact opposite, and that is not that people may be detained who ought not to be detained, but that people for whom treatment is urgently necessary do not get it. Your Lordships have heard many references to this aspect this afternoon, and to the difficulty of finding beds for acute cases. This we hear from all sides. I know it is a constant trouble to mental welfare officers in some areas, and it is a constant trouble to the relatives of patients, to psychiatric social workers and, sometimes, to the patients themselves. There is a chorus of opinion that the more difficult types of case are not only more difficult in themselves but are the most difficult for whom to find hospital beds. Occasionally one hears of hospitals simply putting up a barrier, and saying, very understandably, that they will not again have a patient whom they had before, because he or she caused so much trouble. One sometimes wonders whether, with the contemporary emphasis on community care, we are not in danger of giving the community just the people that they ought not to have, 1285 the hospitals taking those who could possibly fit fairly well into the community, and the community being left with the most difficult cases of all.
We know, too, that the hospitals, in their discharge policy, tend to give far too little weight to the kind of conditions into which patients axe discharged. I have myself seen cases of patients who appeared to be completely recovered, so far as the hospital was concerned—often elderly people—where account was not taken of the fact that during their illness they had perhaps lost their homes, perhaps had few relatives who could look after them, and were being thrown upon a world which was absolutely certain to make them ill again. I think there is some danger that we are likely to develop a division between the chronic and the temporary, in which the chronic are left in the community and the temporary, alone, become the charge of the hospitals.
If your Lordships will allow me, I should also like to say a few words about Part V of the Act and the philosophy that underlies the relationship of the mental health services to the penal policies of the courts, because while we are busily trying to assimilate mental disorders to bodily disorders we are at the same time drawing a sharp distinction between those behavioural disorders which are said to be due to mental disability and those for which the person who commits them is responsible. We are drawing a line, or rather I should say we are trying to draw several lines now, as our knowledge increases, between the shades of responsibility for actions which may be liable to criminal process in the courts. As we get to know more about the complexity of the human mind, so we try to make our shades of responsibility finer and more complex, and so I think we get into deeper and deeper muddles. So far as I can see, there are now at least seven grades of responsibility—and there may well be more, for I am no lawyer—which the law recognises.
If one is charged with a criminal offence, one can be found unfit to plead. If the offence is one of homicide, one can be found insane within the M'naghten Rules, or one can be found to be suffering from diminished responsibility in the terms of the Homicide Act, 1957. If one is convicted before 1286 a higher court or of any offence carrying imprisonment, one can be subsequently made the subject of a hospital or guardianship order provided one suffers from any one of a specified category of mental disorder. If one appears before a magistrates' court, one can be similarly dealt with without a conviction being recorded, but only provided the mental disorder is one of severe subnormality or mental illness, but not if one is diagnosed as a psychopath or as merely suffering from subnormality. One can again be detained as a psychopath without court proceedings, because, as I have said, one is abnormally aggressive or seriously irresponsible. Finally, one can be made the subject of a probation order, a condition of which is that mental treatment should be followed.
What I want to emphasise is that in all these cases, except possibly the last, some specific diagnosis of a degree of mental irresponsibility is required; that is to say, the law looks back to circumstances which mitigate the culpability of the person concerned, and the emphasis is upon how far his responsibility is diminished by his mental condition. Only in the case of the mental treatment condition in a probation order does the law look forward and say, without a specific diagnosis of his mental condition, that you may subject him to mental treatment if it is likely that the treatment will be beneficial and if this is the best way of dealing with him. There are hints of the forward-looking also in Part V of the Act, which suggests that hospital orders and guardianship orders must be made only if these appear to be the best way of dealing with the person who is subjected to them. But, on the whole, the approach of the Act is that we must consider degrees of culpability, and if culpability is diminished then hospital treatment or guardianship treatment is appropriate.
What I want to put to your Lordships is that we have gone half way along a very good road, but that what we have not yet had the courage to do is to say that the right criterion for treatment is not culpability but treat-ability; and that the law should look forward and discriminate between those who are proper subjects for penal treatment and those who are proper subjects for medical treatment simply in terms 1287 of which is likely to be the more successful and not by reference to the degree in which mental disorder has mitigated or failed to mitigate guilt. If we can bring ourselves to do that, then I think we may eventually manage to render to the Prison Commissioners the things which are the Prison Commissioners' and to the medical profession the things which are the medical profession's.
Those are all, perhaps, rather large questions, but I should like to end by referring to one very small one, which nevertheless looms large in the experience of those who encounter it. Here I want to refer to Part VIII of the Act. The noble and learned Viscount knows that we have had some earlier correspondence in this matter, and I mentioned to him that I should want to refer to it again. Part VIII of the Act is that Part which deals with the administration of the property of persons who are incapable of managing their own affairs as a result of their mental disorder, and which provides that the Court of Protection should look after their affairs. I should like to say at the outset that, in my experience, the Court of Protection does a marvellous job in protecting patients from the possible depredations of their greedy relatives who might wish to take advantage of their unfortunate condition. I am sure that the court does its job with the most scrupulous and detailed care, and it is very encouraging to know this. But I should like to call attention to just two points.
The first is the delay that can occur before a receiver is appointed who can take responsibility for the patient's affairs. This may be a delay of several months—four or five months' delay is possible—and during this period no payment can be made out of the patient's income to meet continuing liabilities. This can create a very serious situation. Take the case of an elderly person of small means who becomes incapable of managing his affairs and who goes into hospital. There is perhaps a good prospect of his recovery, and for that reason it is very important to keep the home going; to pay the rent and other continuing liabilities. He may have no relatives of any substantial means, and, pending the appointment of one of these relatives as a receiver, the person who applies to 1288 be a receiver must pay all these expenses out of his or her own funds. So that for four or five months a person of small means may be maintaining his brother's house, perhaps, or his sister's home entirely out of his own means pending such time as he may be appointed the receiver. Afterwards, of course, he can recoup himself, but it is a mistake to suppose that a delay of four or five months is a negligible thing in the case of people whose incomes are modest.
The other point relates to the fees which eventually have to be paid to the Court of Protection. This comes, I think, as a great shock to many people. We have a National Health Service. When we have a serious physical illness, as many of us have cause to know with gratitude, we can receive the very best medical attention in the country and not pay a penny for it. But if we should unfortunately become incapable of managing our affairs, then we have to pay, not the person who manages them, who is the relative appointed as receiver, but the Court of Protection for protecting us, as it were, against the receiver and seeing that the receiver does his job properly: and, in my judgment, the fees seem to be extraordinarily high.
I have already, I think, mentioned one case to the noble and learned Viscount, in which an elderly person with an income which lay between £400 and £500 a year became incapable. Her sister, also of small means, was appointed a receiver after some months' delay, and continued so for a period of eighteen months, until the death of the patient. During that time, the total fees that had to be paid out to the Court of Protection amounted to nearly £64. The percentage fee alone is normally fixed at, I think, 5 per cent. per annum for incomes of over £150. I think that in his correspondence with me the noble and learned Viscount said that, after all, people when they are managing their own affairs have to spend something on it; but I do not think that people with incomes of a little over £150 a year are likely to spend 5 per cent. of that income on the management of such small sums.
The noble and learned Viscount has also told us that the Regulations allow for these fees to be remitted or postponed in suitable cases, and in answer to a Question this afternoon he was good 1289 enough to give the information that they have been remitted or postponed in some 250 out of some 3,000 cases, and that in over another thousand cases it was not necessary to charge them. One only hopes that the standard by which the choice of these cases was made was adequate. But I think it is a matter of very great concern to find people of such small means quite unexpectedly running into such large expense when, if they had only managed to have a bodily illness instead of a mental one, they would not have had to pay anything at all.
My Lords, I hope that any comments and criticisms I have made on the working of the Act, or on the philosophy of the Act, will not detract from what I said at the beginning, and what I want to repeat at the end. Whatever we may think about the present situation—and I particularly wish to endorse what the noble Earl, Lord Feversham, said at the beginning—I am sure we shall all agree that no one of us would desire to go back to the situation which existed before this Act came into force. We have travelled a long way, and many wheels have practically come full circle. Two hundred years ago we used to make a practice of treating lunatics as criminals: nowadays we are much more inclined to treat criminals as lunatics. But whatever point we have come to, there can be no question that, whether we are going in a straight line or whether we are going in a circle, we are certainly going in the right direction.
§ 5.31 p.m.
My Lords, I know we are all most grateful to my noble friend Lord Feversham for putting down this Motion to-day. There are just a few aspects of the Mental Health Act about which I wish to say a few words to-night. There can be no doubt whatsoever that since the passing of the Mental Health Act there has been a tremendous improvement in the understanding of the people of this country in their knowledge of subnormality, mental subnormality, and all that is required for the health of families who suffer in this way.
In order to get a picture of the country as a whole and the way in which local authorities are dealing with the situation, I asked the National Society for Mentally Handicapped Children, of 1290 which I am honorary treasurer, to give me a survey of the way in which the local authorities are dealing with those duties which were put upon them by the Minister in this Act. It will be obvious that any survey of this kind would fill a book if it allowed for all aspects of mental health, and hence I have taken three subjects about which I wish to speak to your Lordships this evening. The first is the education of the mentally handicapped child; the second is the provision of hostels and training workshops for older children and adults, so that they can be trained to look after themselves, and in many cases go out and earn their living in industry. And the third is the provision of special care units for those children who are so mentally handicapped that they will have to go into hospital but who, owing to the overcrowding, are still on the waiting list and in the care of their families.
My Lords, it must be remembered that under the Mental Health Act, 1959, a duty is laid upon the local authorities by the Minister to provide suitable educational and training facilities for the mentally handicapped who are no longer exempted from the provisions of the compulsory and universal Education Act. Here I feel that I must stress the urgent necessity for this education. Even if a child is classified as ineducable, there is a possibility, in a great many cases, that it can become a good and happy citizen of this country. The other side—the side of the family—is equally important. One of the greatest worries with families who have a so-called ineducable child is the future of that child after their death. It is not always possible to leave the child with relations; hence everything possible must be done to ensure that, by education, the child or adult can earn a modest living when the parents are no more. It will often be the fact that .the person concerned will not be able to live by himself or herself. It is therefore essential that hostels should be provided, in which these children can live in a family atmosphere, and go from there into sheltered workshops or out into industry where, in many cases, they are very acceptable. The fact that these children will be cared for after their parents' death, and the realisation that such a child will not be on its own, or have to be put into an 1291 institution or hospital because there is no smaller community in which the child or adult can live, will give to that family a great feeling of security.
My Lords, before going into details about what local authorities are doing since the Mental Health Act was passed, may I say a few words about special care units? There are children, and unfortunately many of them, who are, or will be, quite incapable of looking after themselves in the future. There are long waiting lists for these children in our hospitals, and parents have a 24-hour day looking after them. It is vital that these people should be able to have some relaxation during the day, and for this reason special care units, attached to hospitals or training centres, must be set up in different areas to look after the children and give some respite to the family for either shopping or recreational purposes.
May I now turn to the way local authorities have implemented the duties laid upon them under this Act? I fully realise that this survey is incomplete, as it has not been possible to cover the whole country. Where I criticise, it is true that in some cases I have heard only one side of the story; and where I praise, I know that there are many not mentioned who are also very worthy of praise. But I do believe that in my words it will be shown that, with some local authorities, the problem has been fully understood and great strides made, while with others very little has been done where a very great need exists.
I propose to start with the private side of the question and to give short details of some of the local authorities which, from my information, are doing well, among many others who are doing well but which I am not able to mention. Among the smaller authorities, I should like to mention the County Borough of Bolton. They have one junior training centre, with 60 places; one adult training centre, with 45 places; plans for one adult hostel, to be started in 1963, for aged mental defectives; and two hostels in the planning stage for 1965–66. My information is that the voluntary societies in that area are well pleased with the progress made. At Kingston-upon-Hull there is a temporary day centre, which is to be replaced in August by a purpose-built centre which 1292 will accommodate 50 patients, including 15 cot cases. The new day centre has a hostel providing residential care for 27 sub-normal males, and this will also be ready in August. An adult training centre is provided, and a further hostel for about 25 adults is planned. There will also be two hostels, each with 20 beds, for sub-normal females. This, my Lords, appears to be a very good record.
At Liverpool there are three training centres, catering for about 300 children, and a new centre, called New Hall (which is in fact an industrial centre for the mentally handicapped), was opened by the present Minister of Health. About 130 are earning small amounts for work being done for private firms. A workshop is planned, and many of the other older children and adults have been transferred from the three training centres, leaving them to deal with the younger children, some of whom must be considered special care cases. The local authority provides training for almost 450. Unfortunately, there is still a long waiting list. There do not appear to be any hostels in the area or any contemplated.
I now turn to counties nearer London. I feel that I must first of all give details of the great work being done in Middlesex. The county has in operation eight junior training centres, five of which have special care units attached to them, catering in all for 762 children, and five adult training centres catering for 372 persons. Within the next two years, it is proposed to replace one junior training centre by a purpose-built centre, so making further accommodation for 32 children, and to extend another one to provide additional places for 24. They have plans to extend two adult training centres to give 105 further places and to provide a new adult training centre for 120. Ninety-six children are under oare and 89 under informal foster-care. One of the excellent provisions of the Act was that a child in foster-care no longer has to be certified, and hence the family can be kept much closer together. This is a record to be proud of.
In Buckinghamshire, the County Council has been of great assistance to the voluntary bodies. They have five junior training centres, four adult training centres, four adult hostels, one 1293 children's five-day hostel in course of building and one to be opened later. An adult training centre with workshops and hostel is being bulk by the National Society for Mentally Handicapped Children in Slough and will be taken over by the Council in five years' time. My information is that there are now sufficient places in the training centres for every mentally handicapped child in the county.
The London County Council are also doing a great job. They have nine junior training centres, providing 755 places. Although only three are purpose-built, it is proposed to have all rehoused in two or three years' time. There seems to be only one special care unit, but others are planned. For children over 16, there are seven senior training centres for girls and women and six for older boys and men, including two industrial training centres, with accommodation for 60 boys and men, where a variety of trades are taught. A third industrial centre will be opened in the autumn. There are no hostels at present, but five are at the planning stage. I am sure that there are many others in this category.
I must now turn to the other side of the picture. In Berkshire, I feel that the situation is not a happy one. The report made by the County Council shows that there is one junior training centre in Bracknell. My information is that this is an old house on two floors, which adds greatly to the difficulties of the staff in looking after the children. The centre is shared by a youth club and all the equipment has to be stored every night and brought out every morning. The gates have to be left open because of other users and the playgrounds are said to be dangerous for this reason.
There is a second junior training centre in Reading and a small care unit for severely mentally handicapped children. I understand that the Council have been sending children to training centres outside their boundaries, but attendance increased so much in 1959 that they finally decided that training centres should be provided at Abingdon as soon as possible and existing centres should be enlarged and further places provided, if future needs so require. My information is that an urgent need is there but nothing has yet been done. A letter of recommendation to the Coun- 1294 cil by the local voluntary bodies has been ignored. If we compare this with Middlesex, Buckinghamshire, London and the others I have mentioned, it will be obvious that this county are failing in their duty, and their need is no less than that in other counties.
In East Sussex there is one junior training centre in existence, which takes 35 children of all ages. A senior training centre is being temporarily planned at Shoreham but the site has not yet been chosen. Representation to the Council on the need for a senior training centre and at least one special care unit has received only excuses, such as shortage of bricks or of sites or of numbers to be trained. In the Solihull area of Warwickshire 96 children of all ages are temporarily housed in a training centre in the church hall. There is no special care unit. There is talk of a purpose-built centre in five years' time, consisting of a junior training centre, an adult training centre and a special care unit. My information is that this talk has been going on for more than five years already.
In East Suffolk, there appears to be some failure in planning. To my knowledge, there is no adult centre or special care unit. Two proposed hostels and centres combined have yet only reached the talking stage, one at Ipswich and the other at Lowestoft. These centres are at the extreme North and South of the county and it appears that the centre at Daneway House near Leiston, which it was hoped was going to be a hostel, is in future to be closed, although it has spacious grounds which would be ideal. Under the present scheme, it appears that the children around Leiston, in the centre of the county, will be 20 or 30 miles away from a training centre and hence will be debarred from education.
There are many more cases that I could quote, but I feel sure I have said enough to show that there is a wide difference in attitude taken by different councils to the problem. The local societies for mentally handicapped children are doing a wonderful job. There are now 264 local societies throughout the country which are only too keen to co-operate with the local authorities everywhere. In many cases, the cooperation is excellent, but I have had one despairing cry, which I quote:You will realise that it is difficult to collate any actual figures relating to the needs 1295 of the mentally handicapped when relations with local authorities are non-existent in this area.I fear that there are many like this.
Our one wish in the National Society is to assist in every possible way both Minister and local authorities. We have the understanding and the enthusiasm, and now all we need is co-operation throughout the country in our work. May I ask my noble and learned friend whether Her Majesty's Government will go carefully into the work of local authorities in the implementation of this Act and exhort them to expand schemes already contemplated and to continue to keep future requirements under careful review? May I also ask the views of Her Majesty's Government on hostels? I have already stated my belief in the great need for them, but there seems to be a divergent view in the country as to their requirement.
Finally, I have evidence that at least one handicapped child has been denied a place in a training centre owing to all places being taken up toy children needing special care. Special care units do not cost much, and the education of a child is so important that I feel that my case for special care units, where those who cannot be educated at all can be looked after, is definitely proved.
I have kept your Lordships for some time, and I am most grateful for your attention. I can only hope that my words may stir up a renewed effort to bring the case of the mentally handicapped more in line with other services to the sick and suffering. This Act has been a great Act. I feel that we have gone a good way along the road, but there is still so much to be done, and I think a little pressure must be put on the local authorities to see that the best possible way of dealing with the situation is attained.
§ 5.50 p.m.
§ LORD STONHAM
My Lords, I should like to add to those of other noble Lords my own words of grateful thanks to the noble Earl, Lord Feversham, for giving us the opportunity of debating this subject to-day, and also for the broad and concise tout restrained way in which he, as it were, painted the canvas and left us to fill in the details of particular aspects of the mental health services. I 1296 was particularly pleased to hear from the noble Earl—and, indeed, I warmly support what he said—about the need for first-class community services to support the hospitals, and his complaints about the totally inadequate efforts now being made towards the patient's reintegration into community life. I echo his complaints with regard to the shortage of trained staff: it is, indeed, horrifying to hear that some of the local health authorities have no psychiatric social workers in their employment. It is to these particular matters, and to what the noble Earl described as the gaps between hospitals and local authorities that I want to devote my remarks.
As we all agree, the last ten years have seen revolutionary improvements in the treatment, relief and cure of the mentally sick. This is due in part to the development of psychotherapy, but far more to the great steps forward in the field of shook treatment and the use of drugs. To-day, as we know, the average stay of new patients is only some six to eight weeks; and even the so-called chronic patients, who have spent 40 years in hospital, may now look forward to discharge. In these circumstances, the Minister of Health is quite justified in forecasting that in the next few years the number of mental hospital patients will be reduced by 50 per cent. But if we look only at these figures (and I always fight shy of percentages) I think we may get a false picture. I think there is far too great an assumption of cure. Patients are being readmitted, not once but again and again, and I think we are building up in the community a danger which has not yet been referred to in this debate—namely, that we shall have in the next ten years an accumulated total of mental patients who before long will have ceased to respond to shock treatment because they will have had it so many times.
I think that the greatest danger and difficulty of all in the mental health services is that tens of thousands of patients who thus to-day will be properly discharged, because they are no longer psychiatrically in need of hospital treatment, are usually quite unfitted themselves to deal with their own stresses. Apart from good advice, a little social 1297 work, and a brief interview with the family, few hospitals do anything to prepare a patient to stand on his own feet. He is made fit to leave the hospital, but not fit to handle his own affairs; and the stigma still exists which will make his situation in his family and in his employment even more complicated than it was before he entered hospital. If you clean out the beds of the hill streams and increase the flow of water to the plain you are likely to have a disastrous flood unless you do something in the valleys to deal with the extreme volume of water. I think that analogy cleanly illustrates the difficulties and dangers that we are in in the mental health services to-day.
Part VI of the Mental Health Act gave responsibility for after-care to the local authorities. But few of them are even aware of the size of the need that exists, let alone attempting to satisfy it. Most local authority and medical officers are experts on physical community health, but I am afraid that many of them know little or nothing of mental community health. Thus, community work is left to the all too few social workers of various kinds, who just cannot carry the burden of discharged patients in addition to the out-patients who have never been in hospital. In mental health, after-care outside is as important, in my view, and perhaps even more so, as psychotherapy and shock treatment in a hospital. I am speaking now of adult mental after-care, and not of the young people to whom the noble Lord, Lord Grenfell, referred. But after-care really does not exist.
Your Lordships will know that I have often been severely critical of the aftercare service available for ex-prisoners; but that is a shining paragon of efficiency compared to the after-care available for the mentally afflicted. Small wonder, as the noble Earl, Lord Feversham, pointed out, that nearly half of them have to be readmitted to hospital! The strain and difficulty of a mentally afflicted person in adjusting himself to society, to work and to the world on discharge from hospital can scarcely be exaggerated. Yet when they are discharged a number of these patients are homeless and without relatives they can go to. A much higher proportion are jobless and not yet capable of normal work. In the area 1298 of which I have knowledge, 25 per cent. of them do not even return to the locality whence they came; and when they do come out their sole source of income and help is the National Assistance Board. I think that this is a scandal which has only to be made public to be put right.
I am, of course, aware of the great and increasing work which is being done by voluntary bodies, and I should like to mention in some detail the work of one of these, because it has been remarkably successful and provides a pattern which I hope may be copied throughout the country. It was started three years ago in East and North London toy that remarkable sociologist, Richard Hauser. He was instrumental in setting up a unique research group, in co-operation with the London County Council and Long Grove Hospital. This hospital has nearly 1,700 beds. It is situated in Epsom and serves a population of 500,000, Who live, not at Epsom, but 25 miles away in the metropolitan boroughs of Stepney, Poplar, Bethnal Green, Shoreditch, Finsbury, Hackney and Stoke Newington. From these boroughs Long Grove Hospital alone admits and discharges 1,200 patients every year. So this is about as difficult an area for community work as could be found; because, apart from the wide range of communities, there are in some of the areas a large number of unsettled individuals of various nationalities who drift into neighbourhoods where cheap accommodation, casual work and an acceptable environment can be found.
Despite these difficulties, this small team of sociologists, psychiatrists and social workers undertook the task of investigating the sociological implications of mental illness in the area, finding ways to mitigate the difficulties and create a dynamic rehabilitation programme. Their programme was based on the belief that it was possible to help patients and their relatives to help themselves overcome the problems arising from mental sickness and prepare for their return to home, employment and society. The method employed Was to form an association of patients, inside and outside the hospital, with their relatives and friends, aided by 1299 staff and social workers in the community. To that extent (unless I misunderstood him) I do not agree with my noble friend Lord Taylor Chat the workers must be from the hospital. Of course, you have to work with the hospital, but when the catchment area is 25 miles away then, of course, the social workers must be within the community and not the hospital.
§ LORD TAYLOR
My Lords, I would at once accept my noble friend's point. It is an exceptional situation in reference to these old L.C.C. hospitals which serve North London boroughs.
§ LORD STONHAM
My noble friend would agree that the catchment area I have mentioned is not the only one which is a good distance from its hospital. The same thing occurs in various parts of the country.
The association to which I was referring is now known as the Psychiatric Rehabilitation Association, and I have the honour to be its President, although your Lordships will readily understand that my rôle is confined to that of an admiring bystander. Group or community work is fundamental to every aspect of this project, because the study of the individual patient, in isolation from his environment, no longer has any meaning. The process by which the P.R.A. (as I shall call it) works is to set up groups of patients, ex-patients, relatives, social workers, doctors and administrators, who recognise and pursue a joint purpose. Whilst, of course, there is a certain amount of group therapy and counselling in this approach, analytical exploration of individual experience is totally discouraged. The approach is thus social rather than psychiatric. Outside authoritarian leadership is avoided. The leader is found from among his equals in the group of patients. The group worker merely stimulates the desire for joint action and then rejects invitations to become leader. The initiative, in fact, emerges from the group and activates individual group members. When the group is firmly established, the function of the group worker ceases, and he is free to move on to another area.
The members first of all discuss problems of rehabilitation with all those concerned including, of course, the highest 1300 medical authorities and, most important of all, patients and their relatives. In this way, as it were, a social climate is developed in the group in which knowledge, interest and awareness are aroused. Once this interest is aroused, it permits smaller groups to be formed of a size which ensures that they are responsive to the group worker. He, in fact, acts as a "catalyst" and what each group learns or does, depends not upon him, but upon the wishes, interests and resources of the members of that group and their leader.
So far as the patients and ex-patients are concerned, group action in a catchment area and in the hospital is extremely varied. I should like to mention some of the things which these mentally sick people have done of their own volition in a short period of two years. A number of patients who emerged as leaders in their groups surveyed this hospital to discover the number of friendless or bedridden patients. They have so far made over 300 visits to infirm and lonely patients. They are now planning their own discharge and its aftermath, without undue dependence on the social workers. Twelve patients are sharing and organising accommodation for homeless ex-patients. They are arranging their own hospital activities, with a resultant increase in inter-communication between the wards. In-patients collected £70 for an "emergencies fund" to make up for the deficiencies of the National Assistance Board grants to homeless ex-patients. Out-patients and ex-patients collected £200 for the mental health appeal. There have been over 50 visits by coach of patients from Long Grove to P.R.A. meetings in the catchment area 25 miles away, with their relatives, for discussions with ex-patients who have succeeded in their rehabilitation, as it were, to exchange notes and get advice.
Many nurses, inspired by the enthusiasm of the patients, have been making voluntary home visits and attending meetings in their off-duty times. Ex-patients and relatives, because of the economic difficulties of visiting a hospital 25 miles away, have now set up their own bus service from London to Epsom. This has cut travelling costs by half, and, much more important, in 1301 my view, it has helped to build up a happy group with a common interest within which they sustain each other in difficulty and maintain a high morale. And, very remarkable indeed, ex-patients and their relatives have set up a day centre for chronic patients living at home, to give them some diversion and, equally important, to provide a respite for their relatives. These are activities of mental patients and ex-patients about which I am speaking. Altogether in this way 1,200 patients have been helped. It is one of the most inspiring and heartwarming stories of constructive self-help by the afflicted of which I have knowledge, and it embraces the whole community of 500,000 people.
Another encouraging consequence of this constructive self-assertion is that, within the hospital, members of P.R.A., of whom we now have over 600, have begun actively to break down the pattern of institutionalisation. Communication with the nursing staff has encouraged the staff and given them a new interest and purpose to their work. It has changed their attitude because they are beginning to understand the problems of rehabilitation beyond the stage of treating the immediate symptoms. It is the enthusiasm of the patients which prompts nurses to attend meetings and volunteer for home visiting in their off-duty times. This response helps to improve morale, and it produces a climate of hope and confidence. Indeed, patients even attempt to educate both nurses and doctors.
I wild give an example. One patient—I will call him "Mr. X"—after becoming apparently successfully rehabilitated, suddenly had a schizophrenic episode Which brought the doctor and the mental welfare officer hurriedly to his room to take him, on an order, to an observation ward at St. Pancras Hospital. But he dashed out of the loom, and later arrived, in a very disturbed state, at the P.R.A. centre seeking sanctuary. He was eventually coaxed into a car which took him back to the observation ward. A few days later he absconded again. Once more he returned to the P.R.A. centre, but this time to report on his survey of the observation ward. He expressed favourable views about the staff, but was saddened that they had not heard of P.R.A., and he asked for literature to 1302 take back with him. This was given to him, and he returned to the observation ward voluntarily, and without escort, to the great bewilderment of the nurses and doctors. The patient apparently was so enthusiastic in explaining the merits of our organisation that he persuaded the doctors to allow him to attend a P.R.A. meeting, accompanied by a nurse. The nurse is now a voluntary worker, and I am glad to say Chat "Mr. X" is settled in a job and sharing accommodation with another patient.
Examples like this show how a patient is able to identify himself with a group he trusts, even though he may still be very sick. The key to the whole problem is to treat the patients as equals, and to ensure that they have the right to an opinion. It is another proof that the mentally ill are not totally irresponsible, and that you cannot restore a damaged personality by removing all self-respect and responsibility. The mentally sick must be encouraged in their struggle to return to reality by working through the unwounded area of the mind.
Apart from the hospital at Epsom we have three evening centres in the catchment area—one at Stoke Newington, another at University House, Bethnal Green, and one at the Lycett Mission, in Stepney. The meetings which take place at these centres, whilst their purpose is to nurture club feelings which were born in the hospital, are not maintained through tea and Bingo. They always have the purpose of keeping alive the ex-patients' and relatives' determination to win back a place in the community. The pace is set not by the group workers but by the total group, and it varies accordingly. Many, naturally, outgrow the need of the group and leave it completely or have a casual attachment to it as a kind of insurance. Some have a keen and continuing rôle in the group in the same way that people become attached to a boys' club. But whatever their degree of interest, all the members gain from the fact that they are wanted and, above all, from the fact that they are needed. We have local civic and other leaders regularly at meetings, both at the hospital and at the centres. Discussions range from the problems of stigma to finding homes for the homeless. Films about mental health, and open days to which the public are 1303 invited, have done much to improve community relations. Employers have even joined in to help with the problems of finding employment for ex-patients.
But one of the major difficulties is that nearly 30 per cent. of patients discharged to the catchment area have either no fixed address, or no relatives at all, or none near by. One of the more recent tasks of our members has been to tour around the newsagents' notice-boards and take note of addresses where ex-patients can get accommodation, and so provide a pool of addresses. This problem of lack of accommodation seems a very simple one but is a major factor in this kind of rehabilitation, and it is one which is causing us a great deal of anxiety. Shortage of accommodation is, of course, a well-known thing, but the trouble is so much greater when it is linked with loneliness and with lack of funds.
The other day a case came to my notice of an energetic young man who, with some vigour, was able to get £3 10s. from the National Assistance Board; but, of course, the mere first few days of accommodation absorbed more than that. He had 10s. for food over three days, and would have been in desperate straits but for the emergency fund we have, and we were able to help him out. He was an energetic young man, with considerable initiative, anxious to get himself settled; but how much more desperate is the situation for older persons, with less energy and in a more demoralised condition on release from hospital! I think it is a wicked social crime that these people should be relaunched on to the world without adequate financial help from public sources. There is absolutely no sense in giving them this highly skilled, expensive treatment in mental hospitals and then releasing them virtually naked, defenceless and afraid, with little or no means, no homes, or just no one there except for voluntary bodies here and there to take any notice or do anything for them. As the noble Earl said, there is a very serious gap between mental hospitals and public authorities, and this must be filled if we are going to do any good in this way.
What do the people mainly concerned think of this experiment? From the hospital point of view it has more than 1304 proved its worth. Dr. Munro, the Physician Superintendent of Long Grove Hospital, and his staff of consultant psychiatrists are anxious that it should continue. He wrote recently:The Psychiatric Rehabilitation Association has undoubtedly played an important part in the development of relations between Long Grove Hospital and the people in the area which it serves. Without the initiative displayed by P.R.A. it is difficult to believe that we could have achieved anything like the degree of co-operation between the hospital and its community as, in fact, has been achieved.What is the point of view of the patients? It has many advantages for them. P.R.A. serves as a meeting place for the lonely; for those rejected by their families; for treatment without the feeling of stigma sometimes associated with attendance at a psychiatric outpatients' clinic; for "insurance" purposes for those susceptible to relapse—and 53 per cent. of our members have histories of relapse; for opportunities to be of service to others in appreciation of what the hospital has done for them. Group workers feel that through their experience they have developed techniques of considerable therapeutic value to patients and those in pre-breakdown conditions, and are anxious to extend their work to other hospitals.
The opinion of the London County Council is made very clear indeed by their recent decision to integrate P.R.A.'s work into their own mental health programme. Indeed, the General Secretary and the Sociologist of P.R.A. have joined them to assist in this integration, to teach the fundamentals of group work and to make themselves economically free to undertake similar work elsewhere on a voluntary basis. It is significant, as a further seal of approval, that Turkey, the United States, Germany, Norway, Austria and Ghana have sent observers to examine the work. My own hope is that now that P.R.A. has become established as an organisation of proven therapeutic value its impact will spread so that the concept of community care will begin to mean not just care in the community but care by the community.
The greatest immediate barrier to expansion is finance. There is not much difficulty in securing funds from charitable trusts for specific research projects, but there is difficulty in getting the small, 1305 regular income needed for office and administrative expenses. I say that because most of the group workers give their services anyway. I hope that the noble and learned Viscount will be able to hold out hope that the Government will be able to find a way to help in this respect; because, even looking at the matter at its lowest level, we are saving the Exchequer a great deal of money. But, my Lords, I hope that the Minister and the public will view this at the higher level, the level of the many thousands of afflicted people whom we can lead from darkness towards the light and whom we can keep in the sunshine; the people whose capacity has been underestimated and who are, many of them, in mental hospitals because they have not yet been shown the way to cope with the difficulties in their lives. By activating their minds we are helping them to live and stay outside the hospitals. By helping them to organise into a kind of trade union of mental patients we are helping them to communicate, to talk, to break through the terrible difficulties which they suffer in the isolation of loneliness, and to overcome the feeling of failure from which many have suffered throughout their lives. My Lords, there is no work more worth doing and none more worthy of support.
§ LORD TAYLOR
My Lords, before my noble friend sits down, could he say how much a year, roughly, this service costs and how much is their deficit in terms of one hospital area?
§ LORD STONHAM
My Lords, I cannot give an exact amount, but in round figures the cost is £10,000 a year in terms of one hospital area. Leaving aside grants, I should say that the administrative deficit is about £2,000 a year. Financial savings for that money are twenty-fold, and probably far more than that.
§ 6.19 p.m.
§ LORD AUCKLAND
My Lords, it is most opportune that we should be discussing the very important and very welcome Mental Health Act so soon after the new Blue Paper on the Ten-year Hospital Plan, and the whole House will be most grateful to my noble friend Lord Feversham, not only for raising the subject but for the most interesting and 1306 clear way in which he did so. I hope that I shall be acquitted if I am a little parochial in this debate, in that I shall devote many of my remarks towards the town of Epsom, which has the largest conglomeration, (if that is the word) of mental hospitals in the world. Some 7,000 patients are in mental hospitals in Epsom.
§ THE EARL OF LONGFORD
My Lords, may I interrupt the noble Lord? I have heard that said before in this House and I have often wondered about the reason. Could he tell us why there is this great gathering in his home place?
§ LORD AUCKLAND
I have been interested in that myself and I will try to find out, both for my own satisfaction and for the noble Earl's, and I will let him know.
§ LORD AUCKLAND
As a matter of fact, it seems to have worked quite well, but as the noble Lord, Lord Stonham, said just now in his admirable speech, the catchment area is extremely big, and for the purpose of administration it is in many ways much too big.
I think the Mental Health Act is undoubtedly one of the landmarks in the social history of this country. It has been praised from all sides of your Lordships' House, and quite rightly so, even though there are certain reservations. I think one of the most important reservations is in Section 136 of the Act, which deals with police apprehensions of suspected loiterers who may be of unsound mind. The noble Lord, Lord Taylor, dealt admirably with this point. I was talking only a short while ago to the deputy Medical Superintendent of West Park Hospital, which is one of the largest of the Epsom mental hospitals, and learnt that only the other day an elderly lady was found in a somewhat demented state in the Mitcham area of London and was taken into the casualty department of the West Park Hospital by the police, with no diagnosis of her case.
It makes it very difficult for the already overworked medical staff of these hospitals to cope with these situations when they receive these patients without knowing what is wrong with them. I can 1307 quite understand the difficulties here; if the police are faced with a person behaving strangely in a street or public place they must ensure, to the best -of their ability, that the person receives some treatment for any mental or physical disorder which he or she may have. But I mention .that point because it is one of the difficulties which staffs of these hospitals are facing .under the Act.
May I turn to another aspect of this problem which has been dealt with by several noble Lords, and that is care and attention by the relatives for these unfortunate people? In another .hospital of my acquaintance, a large mental hospital in Bedfordshire, there is a patient who works under the farm bailiff. He is worth probably something like £15 or £20 a week to the hospital. He occasionally has hallucinations. I used to see him quite frequently when I lived in that area, and he was a man of great charm, ability and usefulness. But his relations, who live only a few miles away, would not have anything to do with him, so the hospital had little or no alternative but to detain him. I should mention that all this happened several years ago, long before the Act was put into operation, but so far as I know this man Is still a patient in this hospital, and probably rightly so, because, as I have said, he occasionally has these outbreaks.
Consequent on that, there is this problem under the Act of whether some voluntary patients are kept long enough. I had a letter only this morning from the Medical Superintendent of another big mental hospital in Epsom, St. Ebba's, which has been the subject of some big changes recently, instancing at least one loophole of a drug addict, who might come into hospital as an informal patient, be able to leave at any time, but return to his drug, whether it is hashish or heroin, or whatever it might be, and then have to go back; he goes back and receives further treatment, and then has another addiction to this drug and again has to return. It is suggested by this Mend of mine, who is the Medical Superintendent of this hospital, and it is a view which I think is held quite widely among the medical profession, that these people should be detained for perhaps six months so that proper treatment could be given to them 1308 and they would not be in the position of shuttling between home and hospital. This is a very real problem.
If I might say a word about staffing, again I was told by the Medical Superintendent that West Park Hospital at Epsom have a very grave staffing shortage. The nurses there are to a large extent from the Commonwealth—and a remarkably good job these nurses from the Commonwealth do… I should like to pay my own tribute here to them and nurses from Spain, Italy, and many other countries. I am sure they are devoted people, but many of them speak very little, if any, English; and if they cannot speak good English it is extremely difficult, particularly if they may be faced with a violent or serious case, if they have to explain to a sister or a charge nurse What the symptoms are. Obviously it is not the fault of the nurses concerned. I should like to ask the noble and learned Viscount who is to reply—and I appreciate the fact that he probably cannot answer me now—Whether there is some standard of education required for these people, some kind of standard of knowledge of English before they come over to this country for their training; because often this can mean the difference between life and death, particularly if some drug has to be administered.
The problem of the elderly has been most persuasively mentioned by my noble friend Lord Grenfell, and others, during this debate. Again, these hospitals, particularly in Epsom, are faced with a grave problem in regard to accommodation. It is almost cruel to turn these people back to their own homes where they may not get proper treatment. Yet it is here that the staff shortage is felt at its greatest.
A fine scheme has recently been started in Epsom by West Park Hospital. It is outlined in last week's Epsom and Ewell Herald. The idea is to transfer suitable patients to work in factories, if possible local factories, and thus to serve the community. I will not go into details of this scheme now, because it is in its infancy, but it has the support of important groups and organisations in the town. It is hoped eventually to build factories in or near the town where these people can work. But of course there is one problem here—I mention this purely off my own bat. There is acute 1309 shortage of land in the Epsom area, and it may well be most expensive to build new factories for these people. However, it will be a great help in areas where there is a labour shortage to employ such people—and many of them are employable.
There have been firms in this country who are reluctant to employ people who are mentally subnormal. This is a tragic situation since they employ people who are blind, and also, in many cases, people who are deaf. There are obvious reasons why, in some cases, they cannot be employed, but many of the younger ones can be employed. I think that this scheme will help to get this going. A committee has already been set up, and it is now working actively to get something moving. Eventually, it is hoped that all the other five mental hospitals in Epsom will be brought in on the scheme. As I said earlier, we are most grateful to the noble Earl, Lord Feversham, for initiating this debate. I think it is the wish of all of us that out of it will come some positive help for these tragic, afflicted people, for the devoted people who look after them, and for the community at large.
§ 6.35 p.m.
§ THE EARL OF LONGFORD
My Lords, I should like to assure the noble Lord, Land Auckland, that I was much interested, as we all were, in his speech, and I would echo, in particular, his last words, about the service rendered, not for the first time, by the noble Earl, Lord Feversham, in initiating this debate, and for doing so in such a constructive way. The noble Earl, Lord Feverslham, will not misunderstand me if I say that I at least, and I think my distinguished colleagues here also, interpret the general sense of this debate as being most critical of what is being done at the present time. The last thing we want to do is to make this any sort of Party debate, but if we were not so anxious to avoid any flavour of Party suggestion we should perhaps voice our criticisms still more plainly. The noble and learned Viscount the Lord Chancellor is to reply, and I can assure him—and I have no doubt that my noble friend Lady Summerskill will make this abundantly plain also—that we are extremely reluctant to accept the present rate of pro- 1310 gress as in any way adequate. Of course we are grateful for much that has occurred, whoever has been responsible for it. We note the developments, but we should like to see far more done; and we feel that in many high quarters there is far too much satisfaction with far too little achievement.
I should like to echo—it is not too early in the evening, and I shall therefore not do it at any length—the emphasis laid by the noble Lord, Lord Stonham, on the need for after-care. I do not know whether I agree with his view—I think I probably do—that, feeble as is our after-care for ex-prisoners, our after-care for those who have undergone mental treatment in institutions is probably still more backward. It is a nice point of comparison on a pessimistic scale. But I look to a time when perhaps some nation-wide organisation, whatever the precise parts played by the State and voluntary /bodies, undertakes in some quite new fashion the whole problem of the aftercare of those who have been in mental homes. I say this, of course, not neglecting the services rendered by the kind of after-care bodies to which Lord Stonham referred, or, again, the excellent work done by, for example, the mental after-care association who function without any kind of official assistance. May I give one example, and then I must press on.
I have in my hand a letter received yesterday from an unknown person, but the facts given appear to be correct. This individual wrote as follows:Mr. X about ten days ago was wrongly accused of begging in the streetIt may be that he was rightly accused of it, but at any rate he was accused of begging in the street—and Mr. X, I am informed—and I know the gentleman quite well, an elderly gentleman whose powers are failing—is now in Brixton Prison. He is still much in need of clean clothing. He had tried to get taken in at several hospitals because of his feet but was not allowed to stay in. The writer"—that is, my anonymous correspondent, who is obviously simply a well-wisher and not a "poison pen" kind of person—is surprised that anyone who is an ex-mental patient, which this elderly gentleman is, as I know very well, and still affected in that way 1311 and going about in the bad state that he has been, should not be taken care of by the authorities, not just put in prison for begging. So much for the Welfare State, so-called.My Lords, that letter which comes from an anonymous correspondent is true, or nearly true. Because I rang up Brixton this morning and found out that this elderly gentleman is now in Brixton Prison, after being convicted of begging. I have seen this gentleman on a number of occasions. He is the kind of gentleman who simply needs mental after-care, possibly inside some home. Anybody less criminal, in any sort of ordinary sense, one cannot conceive. It is surprising that, even in a great city like ours, where, on the whole, the social services are as advanced as in any city in the world, there has been no body ready to take him in or to look after him; and he has now been convicted of begging. He is now a convicted criminal as the result of a total absence of mental after-care in any real sense. I will not underline the point, but to me it is shocking, and it shows what a tremendous way we have to go before we can pat ourselves on the back at all for the progress we are making.
My Lords, at this particular hour I do not want to discuss these questions before us at all widely. The Mental Health Act seems to me in itself to represent a great advance in our outlook. I do not know that one can say that its consequences haw been, or are likely to be, very great in the direct sense, so far as the mentally handicapped are concerned, with whose fortunes, as the House knows, I am especially involved. But it undoubtedly represents a great development in the outlook of the community. It seeks to remove the stigma, at any rate so far as an Act can do it, which attached—and to some extent still attaches—to those who suffer from mental disorder; and that must be reckoned a great movement in a Christian direction.
If I am asked why I think it so vital to remove the stigma, I would give a threefold answer. In the first place, the removal of the stigma is bound to diminish enormously the distress of the mentally afflicted and their relations. In the second place, it will reduce the reluctance (and I think this has already taken place) of the afflicted or their relatives to take advantage of the mental 1312 facilities provided in this country. For some years we had a lady in our house, a cook, who had a mentally handicapped child. We just could not persuade this woman—and the noble Lord, Lord Grenfell, will be familiar with this kind of case—to take full advantage of all the facilities that exist in this country. She was, in fact, foreign, and perhaps did not understand exactly how these things are looked at now; but I certainly think that the second great advantage of removing the stigma is that it will enable us to persuade these people to take advantage of what does exist.
Thirdly, the removal of the stigma should do something (there are signs of this now, though nothing like so great as one would wish) to remove the last excuse from the mind of the community for neglecting the mentally handicapped. So long as one could despise those who were suffering from a mental handicap the community could neglect them; they could feel that they were people who were lucky to be alive, or at any rate who could just be forgotten. It seems to me that that is now becoming impossible. Moreover, along with the Act itself, there have been such vital and important events as the Mental Health Year. All that, coming together, has undoubtedly proved a great blessing to the handicapped or those involved in the fortunes of the handicapped.
Nevertheless, as the noble Lord, Lord Newton, suggested at the beginning, the Act itself was not, except in rather a marginal way, concerned with services; I think the noble Lord himself used that expression. Therefore, I am not criticising the Act if I say that it would be wrong to talk as though one must expect direct benefits from the Act itself, although the Act is part of a complex of development. Be that as it may, if one had a handicapped child one would no doubt not be particularly interested in the question of the benefits which were expected either under this Act, or under an Act that has yet to be passed. I am bound to say that in the field of the mentally handicapped—and I hope the noble Lord, Lord Grenfell, will not disagree with me here (and his work for the mentally handicapped is much more intense than mine)—there has not been any revolution as a result of the Act. The position had been 1313 improving for some time, even before the Act was passed, and it has, of course, been in operation for only one and a half years. Three years ago the number of occupational centres were steadily increasing and patients were already being dealt with in the mental hospitals on an informal basis, as was explained by the noble Lord, Lord Newton. Some of the more progressive hospitals were experimenting in industrial training, and a few local authorities had senior centres. According to my records, which I think are the same as those of the noble Lord, Lord Grenfell, the position has been gradually improving since; but it would be wrong to talk as though there had been a tremendous and obvious change as a direct result of the Act itself.
We find ourselves to-day debating this subject at an interesting moment in time. Somebody might say that this debate is premature, but I do not agree. I think that this is the moment when we ought to have a debate, because it is the time when practical policy is still in the making. I understand that the local authorities have not yet all sent in their ten-year construction plans, and I am informed that the verbal proposals already submitted are too vaguely formulated to be anything like sufficiently concrete to be treated as definite intentions. According to my information (and if it is wrong I would ask the noble Lord to correct or contradict me), even if this House had before it all these local government plans, we should not even then have any clear idea of what is to take place in the next few years. The plans, where they have come in, are still fairly general. As the noble Earl, Lord Feversham, said, the Scott Committee have not yet produced their eagerly awaited Report on the training of teachers, and no single improvement Will be more far-reaching than one which affects the recruitment, training and status of the teachers.
Meanwhile, those authorities which have already done good work in the field have in the last few years continued to make progress. The noble Lord, Lord Grenfell, mentioned Middlesex, the L.C.C. and one or two others. I would certainly support him there. He mentioned certain other areas which were notoriously backward and have 1314 apparently continued to lag well behind their neighbours. This, in my opinion, is a most important question. None of us could be satisfied with what could be called an average provision if large numbers of people in certain areas were being so neglected that they had to go elsewhere or to live out their lives in misery. I hang my head in shame at the report from East Sussex, where I myself live. I do not know what to do, except to go off and commit hara-kiri as a result of that particular item of news. I have made one or two tentative inquiries there in the past, and I can only feel mortified and stimulated. The next time we have a debate I shall hope to be able to say something about it, but it is a shocking story as described by the noble Lord, and I have no reason for saying he is mistaken.
The ideals of the Act cannot have been said to be implemented in any way in regard to subnormality. I suppose, if one wants to put it quite bluntly, that the two most obvious failures are the lack of joint planning between, for example, the local authorities and hospital boards; and, secondly, a blurring of responsibility, about which I will say a word in a moment. If we think of what could be done in the way of cooperation we might look at Nottingham, or a scheme suggested in Salford; but, if we look on what has been achieved, we notice that even where there are special care units they do not meet the needs of the very young or of the adults. The workshops are slowly increasing and the subnormal population in need of them is rapidly increasing because there is, I am glad to say, far lower mortality now than there was. Therefore, we cannot claim—I am talking now particularly of the mentally handicapped—that the provision is even keeping pace with those who are in need of it.
If we were thinking of another kind of co-ordination, we could point to the lack of it when we think of what might be done in the way of co-ordination of hospital and local authority services with those of the Ministry of Labour and the representatives of industry. There ought to be far more co-operation and joint planning there. But those are points which have been made before, 1315 and I am afraid we must go on making them until much more co-operation is secured.
Perhaps, more fundamentally, the weakness to which some of us at least alluded when the Bill was becoming an Act has made itself very obvious. I refer to this blurring of the fundamental economic responsibility. It is left to the ratepayers in each area to provide, or to neglect to provide, what is necessary, and, as we said at the time, this can never be a satisfactory basis for providing for the needs of a severely afflicted minority. I myself have questioned before, and I question again, whether these words "community care" may not prove in the end a snare and a delusion. It could simply be a way of shuffling responsibilities from the Government and from those who are extremely well trained in looking after the afflicted, on to shoulders which are either too weak to bear them or which, in a sense, do not exist at all. The words "community care" suggest that the whole community is coming in to look after these afflicted people. I suppose they are really intended to refer to the local authorities—and we know that many of them are very backward. But I myself hope that new phraseology may be developed, because otherwise, in the end, the Government of the day—and I am not talking in a Party sense—may find an excuse, which I am afraid any Government is only too much inclined to look for in this field, for shirking one of their crucial responsibilities.
So we are failing in many vital respects. We have been told by the noble Lord, Lord Grenfell—we have been given painful facts—about the failure of a number of local authorities. What are the Government proposing to do about it? I must put that point clearly and sharply to the noble and learned Viscount. Suppose these facts are verified, and I have every reason to think they will be verified. Suppose a number of local authorities are failing totally in what has been declared to be their duty. Do the Government propose to let them go on failing? Do they propose to bring any financial sanctions to bear? Do they even admit that they have the power and the duty to bring those authorities into line? Those are questions which must be put 1316 to the noble and learned Viscount the Lord Chancellor. We all on this side believe that a great mistake was made when the Government declined to take mandatory powers for the purpose of making sure that the local authorities did not fail in this precise way. But that decision was taken by the Government. We were told that all would be all right when the time came. I am saying to the noble and learned Viscount that all has not been all right up to the present, and I am asking him to tell us, when he comes to reply, how he intends to make sure that things are much better in the times ahead than they have been in the short period which has elapsed since the Act was passed.
§ 6.53 p.m.
§ BARONESS SUMMERSKILL
My Lords, I join with noble Lords on both sides of the House in expressing our gratitude to the noble Earl for having initiated this debate. Of course, we all know that two years is a very short time in which to evaluate this particular measure. Nevertheless, I think every noble Lord who has spoken will agree that, a debate of this nature does give us an opportunity of commenting on the working of the Act, if not of passing judgment. I agree with my noble friend who has just spoken. Voices have been a little muted in this debate—muted, I think, because we all know that we are talking about the lot of a number in the community who suffer from an illness which is tragic in its incidence, an illness which sometimes baffles us, about a number in the community who for the most part are friendless and, indeed, have no pressure group in Parliament. For that reason we in this House, even the small number who are left after this interesting debate, have a special responsibility for these people in our midst.
I was inclined to think that the only really pessimistic note which was struck in this debate was that of my noble friend Lady Wootton of Abinger, who in the first half of her speech was, I thought, going to be tempted to call a psychiatrist a "trick cyclist", because she was inclined—in rather a cynical fashion, if I may say so—to question the approach to this illness.
§ BARONESS WOOTTON OF ABINGER
My Lords, may I point out that I was questioning the illness, not the approach to it.
§ BARONESS SUMMERSKILL
My Lords, it is most difficult in these days, I can assure the noble Lady, to divorce the two. After all, if one has an illness a civilised community should immediately try to prevent it or cure it. I will just say to the noble Lady that we have many new lessons to learn, for knowledge and wisdom are of slow growth. In this field there is a proverb which I think we can all remember:However early you rise, you cannot hasten the dawn.We have heard about psychiatry being the modern approach to illness. One should just remember, that we have passed through the demonic age, we have passed through the intramural age, and now we have reached this highly civilised age, which—who knows?—our descendants may criticise. They may criticise our approach. But it is the best we have, and what we are doing now is to try to give all our knowledge in order to help these people.
This debate gives us an opportunity of questioning our methods, of trying between us to find where we have gone wrong and where, perhaps, we can rectify our shortcomings. Inevitably, there has been repetition in this debate, and I propose simply to emphasise those aspects of the working of the Act which I think are of concern to the experts in this particular field. When the noble Earl rose in the first place he told the House, quite rightly I think, the source of his information; and when my noble friend Lord Taylor rose he said that most of his information came from superintendents of mental hospitals. Most of my information comes from working psychiatrists, general practitioners and social workers, all of whom, it will be agreed, have been concerned with the working of this Act.
I would say, in the first place, that there has been an increased volume of work arising from the earlier recognition of psychotic and psycho-neurotic disorders, and the more detailed treatment and investigation impose additional duties on the medical staff. We must recognise that the shortage of psychiatrists means that some patients may not receive adequate attention. In many institutions, both medical and nursing staff are insufficient for even custodial care, and it is estimated by some working in the field that at least 1318 1,200 extra psychiatrists should be trained in the next ten years. Therefore, being a very practical person, I would ask the noble and learned Viscount the Lord Chancellor to consider this position, and I want to make a few suggestions of a very practical kind.
I want him to remember that, although this was known many years ago—of course, it was known at the time of the Royal Commission—no effort has been made, either in the universities or in the medical schools, to encourage doctors to practise psychiatry. What one practises in the field of medicine is purely fortuitous. You may come near, let us say, a surgeon or a physician whom you admire. You may be his dresser, you may be his clerk, and you may decide as a result to become a surgeon or a physician. We all know that the work done by students in mental hospitals is very limited, and, so far as I know, there has been no effort on the part of anybody—there has in Scotland, but not in England or Wales—to direct young men or young women into the field of psychiatry. So, first of all, let us be absolutely practical and recognise that we are very short of key workers.
It has been said, of course, that there is a shortage of hospital accommodation for children and adolescents. I listened carefully to every point that the noble Earl made, and he suggested that there was not enough accommodation. I have been informed that possibly the physical accommodation could be found but that there are not enough child psychiatrists—and this, of course, is a very special field. The accommodation could be fairly limited, but provided you had enough of the necessary personnel you could get on with the job.
THE EARL OF FEVERSHAM
My Lords, I do not wish to interrupt the noble Lady, but I should be interested to know whether she is referring to a particular area as having a shortage of child psychiatrists.
§ BARONESS SUMMERSKILL
I have had a letter from the North, and I was told in London that that was the general feeling; but, of course, I could not specify any county at all. On the other hand—and I wish the noble Lord, Lord Amulree, had been here—I have been informed that the number of geriatric units is slowly increasing, with a special 1319 emphasis on the psychiatric work of the units, and everybody who has spoken has agreed that that is the right approach to the old, senile man or woman. As we know, for many years psychiatrists have been criticised for putting old people into mental hospitals just because there was nowhere else for them to go. I must say that it was probable that many of these old people urgently needed the care which could be given only in a mental hospital.
Then, of course, it is not unusual for the hospital authorities to blame the family which is unwilling to take the old person back after the hospital has done everything it can. I want to emphasise this point, because it has been raised time after time as to what the community should do and what the family should do. Of course, the noble Lord, Lord Stonham, dealt with aftercare work, which was of tremendous interest. But we must recognise that families living in overcrowded conditions cannot manage this kind of patient, and that it is virtually impossible for the ordinary housewife to undertake day and night nursing. I am very glad to say that the new approach of having geriatric clinics with psychiatric advice is now becoming established in many parts of the country.
It has been stressed time after time that the implementation of the Hospital Plan and the Mental Health Act depends on an adequate supply of social work staff in the local authorities. Every speaker here to-day, I think, has mentioned this. I understand that most people in the psychiatric and social work services are extremely apprehensive about the present working of the Mental Health Act because of the inadequate resources of the local authorities in the provision of skilled community care. It is difficult to believe that only last week in this House we had the Committee stage of the Health Visiting and Social Work (Training) Bill, that ten Amendments were put down in order to improve its condition, and that every one was rejected. These ten Amendments were framed by the social workers' organisations and by the health visitors because they know precisely what the situation is in the country to-day. I am sorry the noble Lord, Lord 1320 Newton, smiles. This is not a smiling problem.
§ LORD NEWTON
My Lords, if the noble Lady will give way and allow me to say why I was smiling, it was because the noble Lady is now saying exactly what she said to your Lordships yesterday afternoon, to which, I hope, I replied adequately.
§ BARONESS SUMMERSKILL
I think that interruption was a sheer waste of time. I thought the noble Lord had something important to say, instead of emphasising again that I said it yesterday. I said it yesterday and I said it last week; and to-day the noble Lord comes here and in, I say, a hypocritical manner, tells the House that What we need, of course, is an improved community service, with more people in our social services, more people in our local authorities. Yet when we in this House endeavoured to improve the situation last week, he rejected everything out of hand. My Lords, we really must face up to this. To come here and debate these matters and then not apply our knowledge in a practical way is not only a waste of the time of the House—that is a minor matter—it is a betrayal of those people of whom we are speaking to-day.
The MacIntosh Committee has suggested that in the care and after-care of persons suffering from mental illness there should be one or two psychiatric social workers for every 100,000 of the population; the Younghusband Report states that a great increase is urgently needed. The importance of the psychiatric social worker cannot be over-emphasised. Knowledge of mental illness, of what the variations mean to the family, enable help to be given not only to the mentally ill person but, of course, to his relatives. They are highly successful in removing suspicions and in overcoming the hostility of the patients; and, consequently, they can establish a confidential relationship and so help to prevent the need for admission to hospital and a recurrence of breakdown. The noble Earl quite rightly emphasised that what we must tackle to-day is the feet that there is such a large percentage of readmissions. Of course, much of it can stem from this. A patient comes out of hospital friendless and without accommodation, he is met by an inadequate community social service, the 1321 stress and the strain of modern life is too great for him, and soon he says that he must go back to the protection and the care of the hospital.
In the light of this it was disturbing to find that when the psychiatric social worker, whose services are so valuable in this field and yet of whom we are so short, appealed for an increase in her salary the Ministry of Health treated her as they did the nurses. Her appeal was rejected week after week, month after month, until she, like the nurses, was forced to go to the Industrial Court. There this valuable worker in the mental health service found that her worth was recognised, and the Industrial Court increased her salary by 13 per cent. My Lords, this is a squalid story. How can the noble Lord, Lord Newton, come to this House and say that we must increase the number of social workers when we know that this is the way in which the Ministry of Health have treated them?
As I have said, no one can be more helpful, because she can assess the strength of family support, or the lack of it, indeed, to the patient who has returned to the community. This, I say, is an important criterion of the success of the Act. Our medical and social approach must not be concerned solely with the needs of the patient at the expense of the family Community care, in my opinion, has failed completely if it has resulted in the disruption of family life. The mental rehabilitation of one individual cannot be regarded as an unqualified success if, in the process, other members of the family have left home. The attitude and the provisions for the mentally sick must be adjusted, therefore, to the way the family behaves, not the way it ought to behave. We must not allow the Mental Health Act to become a kind of legislative Procrustean bed. Therefore, the community service, in my opinion, and the social service, as a means of helping the individual when he returns from the hospital to the home and, of course, of helping the family, is invaluable.
The noble Earl asked me just now in what part of the country a certain condition prevailed. Well, I would say that undoubtedly problems arising from the treatment of mentally disordered patients differ in different parts of the country. It seems to me that more problems arise 1322 from inadequate community services and unsatisfying liaison between general practitioners and hospitals than from faults in the Act. I am not criticising the Act; I am criticising the fact that the services which feed it are faulty, and the liaison is faulty. This I will say: that the conditions in London and the very big towns certainly differ from the conditions and the problems in the country districts, and for this reason many general practitioners in the London area complain that they cannot make satisfactory arrangements for mentally disordered patients as easily as they used to.
When the noble Earl described that frightful case that he knew of the woman with senile dementia being kept at home (this was in London, I understand), and the relations every night had to go from the house down the street to bring the daughter-in-law back to try to calm her, it sounded rather like the demoniac age or the intramural age, not the modern age. But he is quite right. My noble friend said that from what he had heard from superintendents of very good hospitals he did not think this could happen; but he is quite right, and the case he quoted is not exceptional. The last case I saw of that kind was a spinster daughter looking after her mother with senile dementia. The reason for it is this. In the days of the 1890 Act, all the general practitioner had to do was to ring County Hall and inform the duly authorised officer that there was a mentally disordered patient to be seen, and then he could resign all further responsibility. I and my noble friend here know that world, and we might say that there was the observation ward which we did not like; nevertheless, those patients were observed, and then they were sent to the hospital, and sent to that place where it was thought they would be best looked after.
Under the 1959 Act, the admission to a psychiatric hospital becomes a medical matter, and the onus for finding a bed rests with the general practitioner. This is undoubtedly a burden on the busy practitioner who works in an area where the hospital service is inadequate and where it may be difficult for him to find a bed. With regard to the case mentioned by the noble Earl, that woman had not been neglected; the point was that her general practitioner was probably living 1323 three roads away, but he had been unable to find a place for her—and this stems from the working of this Act.
In country districts these conditions do not arise, because there is often one psychiatric hospital serving a clearly defined area. There is a relatively settled population, so that many of the patients are well known to the general practitioner and to the hospital. It seems that London still presents many problems with mental hospitals miles away from the catchment areas; we have heard that this afternoon. In London, with the high number of transitory, unknown workers and the general practitioner struggling in isolation, with little contact with the hospitals that are supposed to serve the area, we get the kind of problem which the noble Earl described. Added to this is the pressure on the community and domiciliary services, which makes it difficult to provide a good psychiatric service.
Now I want to say something about the psycopath. It will be recalled that in the course of the passage .of the Bill a great deal of discussion concerned itself with the definition of "psychopath". It was not a simple matter, as the definition of "psychopathic disorder" in the Act is of such a kind that, after having tried to define it, some of us decided we had better leave it out. The term "psychopath" was never used officially until it appeared in the present Mental Health Act. And I want your Lordships to consider this: one eminent psychiatrist, for whom I have the greatest respect, believes that the diagnosis of "psychopath" could well be dropped from the Act. In practice it is rarely used, because if it were, the hospital would almost certainly exercise its right to refuse admission to the patient.
One of the difficulties of dealing with a psychopath is that, while he can be admitted to hospital up to the age of 21, generally he is discharged when he reaches the age of 25. Those of your Lordships who read the Report of the Royal Commission will recall that the Royal Commission recommended that all psychopathic patients should be given an automatic discharge on attaining the age of 25; but the Mental Health Act gives the responsible medical officer the right to make the decision to renew the 1324 authority for detention. The point is that this decision can be challenged by the patient and the nearest relative by applying to the mental health review tribunal. With all that in view, there is very good reason for a wise doctor to avoid the use of the term "psychopath" when he is seeking the admission of a patient to hospital; otherwise, he may have the patient back again in a condition similar to his condition on admission. Here, again, we have the same story of the psychopath going in, coming out, and then being re-admitted. For this reason, the wise doctor more usually employs some general term, such as "depression", or "disturbed behaviour". It would be interesting to know how much research is being done into the problems of the psychopath. As most noble Lards who have spoken in this debate know, it is generally felt that the diagnostic criterion is a social one and the fault may be more with the patient's environment than with his heredity.
I have tried to be brief, because I am very concious of the fact that the noble Viscount has an engagement. That has an extraordinary effect upon my verbosity. It seems it stimulates the male to verbiage; so far as I am concerned, it reduces mine. Finally, I should like to say that undoubtedly the bringing of the treatment of the mentally disordered into the general hospital is a concept which can be translated into practice only very slowly. The noble Lord, Lord Amulree, said that he thought this was not mentioned in the Hospital Plan. I would say that those who are responsible for the planning of our hospitals will have this in mind. It seems to me that they have rather a free hand, but I am hoping that many authorities will re-plan their accommodation in such a way that we can expect a comprehensive picture of the mental health services, in which the general hospital and the community services play their full part. I hope we shall have many debates between now and then, because periodic reviews of this kind, in which the degree of progress achieved makes an important contribution in this field of health, are very important. The Lord Chancellor is about to follow me, and I feel that this symbolises what many of us feel: that in the field of mental health, 1325 law and medicine must combine to protect and care for the mentally disordered.
§ 7.20 p.m.
§ THE LORD CHANCELLOR (VISCOUNT KILMUIR)
My Lords, may I add my voice to the universal chorus of gratitude to my noble friend Lord Feversham, not only for introducing this Motion to your Lordships' House but for the fact that his incisive and persuasive speech is based on so wonderful a record of public service in this sphere? That makes his speeches acceptable to us all, and I should like to thank him again. I think that all who have heard every speech in this debate will have been struck not only by the variety of subjects but also by the knowledge displayed by all speakers. I am going to try to answer as many as I can of the points that have been put up in the debate, but I would say to all noble Lords, wherever they sit in the House, that if there is any point that they do not feel I have dealt with adequately, I hope that they will tell me and I will try to supplement my answer in writing.
I think my noble friend Lord Feversham would agree that it is remarkable to have a debate so long as this with practically no complaint about compulsory detention. If we look back over the years of the development of this subject, I should think that it is almost the first time. If I may, I should like to deal with the point that has been raised from two angles by my noble friends Lord Feversham and Lord Amulree about the interplay of Sections 25 and 29. As your Lordships know, the statutory position is that under Section 25 a patient may be compulsorily admitted for observation and detained up to 28 days, and application for admission for observation is made, founded on the written recommendations of two medical practitioners. Section 29 provides that in an emergency a patient may be compulsorily admitted on the recommendation of one doctor only. In that event he may be detained for up to 72 hours, and if a second recommendation is made, he may be detained up to 28 days.
It may well be that a number of patients who have been admitted compulsorily recover sufficiently in the course of a few days to be willing to remain in the hospital informally, and if 1326 such a patient has been admitted under the provisions of Clause 25 the responsible medical officer can, under Section 47, bring the compulsory powers of detention to an end at any time, if he thinks fit, after a couple of days. I think that that is some help for the worry of my noble friend Lord Amulree. But I would ask him to consider again the point made by my noble friend Lord Feversham, that it would seem undesirable to use Section 29 in other than emergency cases.
We have to remember that compulsory admission to hospital, even for a very short period, is a serious matter. Many people feel, although wrongly, that it carries a stigma with it, and compulsory powers should not be used lightly. The Act is based on the general principle that, save in exceptional circumstances, compulsion should never be used unless at least two doctors are prepared to state that they consider it necessary. It is important that this principle should be preserved, but, as I have explained already, compulsory powers can be brought to an end if the patient does not require to be kept for the 28 days.
My noble friend Lord Auckland asked me about the educational standards of nurses, and if I may give him a general answer I hope that if there is any particular point, he will write to me about it. No educational standard is laid down for unqualified nurses, though mastery of English would be expected before anyone was accepted for training as a student nurse. But we should expect hospital authorities to take note of ability to speak English before engaging any nurse.
My noble friend Lord Grenfell has referred to the provision by local authorities of services within the community. I am sure that your Lordships know as well as I the interest which my noble friend takes in these matters and the generous assistance which he gives to those immediately concerned with the welfare of the mentally sick. I think it would be right if I emphasised the question of community services, although my noble friend Lord Newton has already dealt with them. I want again to refer to the plans which the Minister of Health has called for from local authorities and which will set out the pattern within which every authority intends to develop 1327 its community services over the next ten years. This also answers the worries of the noble Earl, Lord Longford. As my noble friend Lord Grenfell advanced, not all local authorities move forward at the same pace in the development of any particular branch of their services. What I want to stress is that these plans for a ten-year period will be revised every year and, in my view, will provide the impetus for a more rapid development of the mental health service than may previously have been the case in some areas. They certainly will disclose any area where the scale on which provision is planned may be less than adequate.
I have always regarded the position of central Government and local government as essentially a partnership. We could argue about it because there is a whole political philosophy behind it. There is the view that the noble Earl, Lord Longford, takes, which I respect but do not share, that on practically every occasion the central Government ought to take mandatory powers. We will not go into that to-day, because it is far too big an argument at the end of a debate, but I do say to him that where the central Government says not only that the local authorities must produce plans but that they will review them every year, then there is a hope that the general partnership will bring it about. And if it does not, I am sure the noble Earl will see that the matter is brought out in Parliament, as he did to-day.
§ THE EARL OF LONGFORD
My Lords, I promise to interrupt the noble and learned Viscount no more, whatever answer he gives, in view of his engagement, but I should like to say that while I attach enormous importance to the speeches made by everyone here, including myself, I wonder what would happen ultimately if Sussex, where I live, continued to fall behind in the way alleged to-day. Do the Government possess power under the Act to bring them into line?
§ THE LORD CHANCELLOR
My Lords, I also live in Sussex, so the noble Earl and I are in pari delicto. I do not carry in my mind what measures could be used and I should be the last to try to deal with them from memory. But I 1328 think one can say this: that if local authorities go on ignoring the policy put by the central Government, then it would be a pretty poor central Government who would not find some way of securing that that policy is put into operation.
The noble Earl, Lord Feversham, and the noble Lords, Lord Taylor and Lord Stonham, as well as others, including the noble Earl, Lord Longford, underlined the question of after-care. It is true that we need more after-care services, and this implies a need for more trained staff and more buildings, especially hostels. Again, I think that the Minister's call for a ten-year plan will give an impetus to these developments; but a programme of this size necessarily takes a good deal of time. At present, local authorities are concentrating largely on the community care of the mentally subnormal; but after-care does exist, largely in the form of social support given by social workers, help in finding work and help in finding accommodation, often in "digs" (if I may use that term), which are often much more suitable than hostel accommodation for certain people. This is going on.
I was grateful to the right reverend Prelate the Lord Bishop of Lichfield for once more appealing for voluntary social work. It has always been an aspect of the life of this country of which we are immensely proud. I feel that we cannot too often repeat the appeal for voluntary social work, and I was glad that the right reverend Prelate did so to-day. There is also the point, which should not be forgotten, that general practitioners play a valuable part in aftercare. But I want to make clear that, although what I have said is important, it cannot be denied that much more is needed. That is our general view.
The noble Lord, Lord Taylor, asked my noble friend Lord Newton about one figure which seemed to me to be rather important, and I thought I would try to give the answer. The noble Lord will remember that he asked about the 1.8 beds per 1,000. The survey upon which the figure of 1.8 beds per 1,000 population was based was made at a time when many mental hospitals were still admitting old people who could best have been cared for in other accommodation, had it been available. In our future plans we aim to provide that alternative accommodation, and to that 1329 extent the figure of 1.8 may be an overestimate. On the other hand, as the noble Lord well knows, the number of old people in the community will increase, and there will therefore, presumably, be more old people with mental symptoms who need mental hospital care. The two factors which work in opposite directions may well, I am informed, cancel out; but it is impossible to be absolutely sure. As the noble Lord asked that question, I thought it right to answer him.
I should like to discuss for a long time the points raised by the noble Baroness, Lady Wootton of Abinger, but may I just deal with three aspects of her speech? The first is the question of the admission of difficult patients, which has been touched on from another angle by the noble Lord, Lord Taylor, and the noble Baroness, Lady Summerskill, in winding up the debate. As the noble Baroness, Lady Wootton of Abinger, said, the scale of this problem is not large; and the Mental Health Act has not substantially added to it, since even under the old legislation the number of compulsory admissions in which hospitals are under an obligation to admit was decreasing rapidly. The main source of difficulty is probably the patient who requires treatment with security conditions and will not fit into the open wards which are now general.
There is no doubt that the removal of unnecessary restrictions on psychiatric patients has had results which are therapeutically very favourable. There are, however, a small minority of patients who need security either for their own protection or for that of the public, and the Ministry of Health have emphasised that their needs must not be overlooked. If a patient requirestreatment under conditions of special security on account of dangerous, violent or criminal propensitieshe may be admitted to a special hospital, such as Broadmoor, Rampton or Moss Side. But the Minister has accepted a recommendation contained in the Report of the Working Party on the Special Hospitals that patients should be admitted there only if it is clear that no alternative course is possible. He has therefore asked the Regional Boards to ensure that provision is made for the patients who need treatment under 1330 security conditions less stringent than those which exist at the special hospitals. He has now asked them for reports as to the present condition and their future plans.
As various of your Lordships have said, psychopaths are a special class of patient who are particularly prone to difficulty. Many were being treated in ordinary psychiatric hospitals before the Act came in to effect; and this will continue. There are, however, some psychopaths whose anti-social behaviour necessitates treatment and investigation apart from other mentally disordered patients. In the present state of knowledge of the extent to which psychopaths can benefit from hospital treatment of various types, the large-scale diversion of psychiatric resources to the creation of special units for psychopaths would not be justified. The approach must be experimental, and a few units are being planned on that basis.
Now I come to the even more interesting point raised by the noble Baroness, Lady Wootton of Abinger, which I summarise as "sin or sickness?". There is no simple or final answer to this general question. There is an infinite gradation of offenders, ranging from the man who commits an offence because he has a delusion caused by an acute mental illness which obviously needs treatment, to the man who commits a carefully planned offence for personal gain and shows no kind of mental or physical illness. Whatever degree of importance one attaches to the concept of culpability (and I do not think the noble Lady attaches a great deal, judging by what she said to-day) it is the fact that nearly everyone would regard offenders as falling into different classes and as requiring to be dealt with differently. The main practical question is at what point along this range of offenders one regards the responsibility of the Prison Service as ending and that of the Health Service as beginning. Difficulties are going to arise whatever point is chosen, since there will always be individual cases where the correct disposal is doubtful, whatever rules are in force. Moving the point of division is not, therefore, in itself a solution.
In broad terms, the medical grounds on which the Mental Health Act makes it possible for an offender to be dealt with 1331 by the Health Service, rather than the penal service, are that his mental disorder is such as would have justified compulsory admission to hospital or guardianship under Part IV of the Act; that is, if he had not committed an offence. In my view, this division is, on the face of it, reasonable. It might have to be altered at some future time as a result of changes in medical knowledge or public opinion, but there certainly seems no reason for changing it now, or any reason for supposing that a change would reduce the present difficulties, which, as far as we know, have not in practice been very serious.
On the other aspect of the noble Baroness's most fascinating speech, I would say that there is no intention of suggesting that mental and physical illness can be dealt with as though they were the same. The nature of the treatment required for each, and the background against which it is given, is quite different, and full account is taken of this in the planning of the medical services. It has been and, to some extent, still is, necessary to emphasise that mental and physical illnesses have much in common, in particular that mental disorder is indeed an illness for which treatment is needed, usually without any kind of formality. It is essential that this should be widely understood in order that people suffering from mental disorder may obtain treatment for it at an early stage, without supposing that any stigma will attach to them in consequence. I repeat that because I think it is tremendously important.
The trend towards community care and the avoidance of prolonged periods of hospital care derives from actual medical practice. Psychiatrists in general have taken the view that such a reorientation is necessary, and the Minister of Health is trying to ensure that the service is planned in such a way as to provide patients with the kind of services which are generally most beneficial in individual cases, and for the doctor concerned to decide how the patient's case will best be met; and he will no doubt take into account the drawbacks as well as the merits of community care.
There is one other aspect of the matter which I thought the noble Baroness, Lady Wootton of Abinger, 1332 might care to know. I am not going through the whole of the Home Office statistics under Part V of the Act, because the noble Baroness will get them in due course when the criminal statistics are published. It is much easier to consider statistics when they are in front of you than to have to follow someone who is talking. But I thought it would help the noble Baroness if I said this. As she knows, Part V of the Act provides means for transferring to hospital persons who have appeared before a court and have been found to be mentally disordered to a degree which makes it appropriate and, indeed, necessary for them to be treated by the health rather than the penal service. The position at the moment is that it is too early to reach more than tentative conclusions about the operation of Part V which has been in force for only 20 months. Experience, combined with research over a longer period, is needed, but with the help of a grant in aid by the Home Office under Section 77 of the Criminal Justice Act, 1948, Mr. Nigel Walker, the Reader in Criminology at Oxford, is undertaking a research project into the working of this Part of the Act. I do not suppose the results will be available for a couple of years, but I think that is an important step.
Therefore, at the moment all I want to say is this. I think it might interest the noble Baroness, Lady Summerskill, and others, to know that the courts have been dealing with their part—that is, sending them to hospitals instead of to prison. That is rather interesting. During last year the higher courts—that is, the Courts of Assize and quarter sessions—made 329 hospital orders; in 64 cases the offender was suffering from psychopathic disorder only. I believe that anyone who has followed the work of the courts will think that even a 20 per cent. proportion of dealing with psychopaths by sending them to hospital is quite a new development which one would not have expected some time ago.
I was very interested in what the noble Baroness, Lady Summerskill, said about the difficulty of the psychopathic, and I thought she would be interested to know that my own profession had, at any rate, found a sufficiency of ease to deal with these cases. I was glad (because it is a responsibility of mine) that there has not been a single word of criticism of 1333 the mental health review tribunals, unless you called the fact that there may be a hammer for a small nut a criticism. But, of course, a really good hammer, like one of the steam ones which one knows, can deal with a small nut just as well as with anything else. So I am not going to worry, and I am very grateful, because it is my responsibility as Chairman of the Legal Members.
I was interested in what was said about the hospital treatment of alcoholics. The present position is that although many mental hospitals treat a few alcoholics, there are few units specialising in the condition. While there is no evidence of unmet demand for the treatment, that may be due to the absence of specialised treatment facilities, and the Minister has recently obtained the advice of the Standing Medical and Mental Health Advisory Committee on the development of facilities for treating alcoholism. As the noble Earl said, the Memorandum, based on their advice, has just been issued to hospital authorities, and briefly it suggests to Regional Boards that, as a start, they should aim for at least one specialised unit for alcoholics in each region. This could be either in mental hospitals or form part of psychiatric units at general hospitals.
There are two other points I should like to deal with. I am doing so because I promised the noble Baroness, Lady Wootton of Abinger, that I would. One concerns the position of the Court of Protection. The noble Lady referred to the fees charged by the Court of Protection for the administration of patient's estates. These fees are authorised by the Court of Protection Rules, 1960, but the present rates have been in operation since February, 1958. Under them, a fee is chargeable at the rate of 5 per cent. per annum on a person's income, provided that if the income is no more than £100 the amount charged is £1 10s. If the income is more than £100, and less than £150, the rate is 4 per cent. and, in addition to the percentage, certain fees are payable in respect of orders. As I told the noble Lady to-day, the figures I gave indicate that free use is made of the power to postpone and remit.
Now we come to the difficulty and the disagreement between the noble Lady and myself. Lady Wootton of Abinger 1334 observed that the richest among us is entitled to free medical and hospital care, and that she personally is shocked to learn that, if the illness happens to be mental, fees are still payable. I, on the other hand, do not think that one can fairly conclude that because we can all have the benefit of medical and hospital attention we should have our affairs administered for nothing if, unhappily, we become incapable of managing them ourselves. It is, of course, a question in degree of just judgment. The State owes a duty to look after the property of mental patients, and the noble Baroness recognised that, from the point of view of protecting them, they may range from poor people with perhaps less than £100 in the world to millionaires. They may be people whose affairs are absolutely simple, or people who have businesses which have to be managed during their incapacity.
I have always been most anxious to keep these fees as low as I possibly can, and your Lordships will observe that I have not made any increase since 1958. I think I must say that we are only too well aware that during that time the cost of living has risen and with it, of course, the expense of administering estates. I have no doubt that many different opinions will be held as to the contribution which the taxpayer should make to this important social service, which does so much benefit in some 28,000 cases at the present time. But I must say, as I have said before, that for my part I cannot accept the proposition that the taxpayer should foot the whole bill, as I believe the fees now charged are not unreasonable. I think the court's powers to remit and postpone are adequate and are really used to avoid hardship.
On the second point, I am very surprised that the noble Baroness, Lady Wootton of Abinger, should say that delays of three, four or five months occur in the appointment of a receiver. There could be such delays, but such cases would be most extraordinary. They could happen if there were great difficulty in obtaining essential information without which an order appointing a receiver could not be made—for example, some doubt as to the ownership of property. May I leave it this way: if the noble Baroness, Lady Wootton of Abinger, will give me some examples I shall be 1335 delighted to look into them? Frankly, I am rather surprised at the moment.
The only other point which I have in mind, and which I cannot leave, is the point of staffing because the effectiveness of the community mental health service depends very greatly on the quality and quantity of the staff available. Following the recommendations of the Working Party on social workers, the Health Visiting and Social Work Training Bill, which is likely to come up for early consideration, provides for the setting up of a Council for training in social work of mental health officers. Two-year full-time pioneer courses for training in social work, attended mainly by officers in the community services, have been running for nearly a year in London, Birmingham and Liverpool; and similar courses will be starting next September in Bristol, Coventry, Leeds and Manchester. Also next September there will be special one-year full-time courses under the aægis of the National Institute for Social Work Training for specially selected local authority officers, including mental health officers.
I do not say I will relieve Lady Summerskill's mind, but I am happy to show the trend which is, I think, at any rate the beginning of possible relief; and although, as I agree, there is a clear need for more psychiatrists in the hospital and community service, there has in recent years been a considerable increase in their numbers, which is continuing at an accelerated rate. The number of consultant psychiatrists in the Hospital Service rose from 478 at the end of 1955 to 595 at the end of 1961. Perhaps even more important, the number of senior registrars, those in the senior training grade, increased over the same period from 94 to 134, and there are now more senior registrars in psychiatry than in any other specialty, and new training posts are being created wherever possible. Obviously, from the figures the noble Baroness had in mind, there is still a great way to go, but I thought that it would be helpful to show that that is the trend we find.
I want to say again what I think my noble friend Lord Feversham emphasised earlier, because it is very important: that in the service as a whole it is true that the expected decrease in the number of beds needed for the mentally 1336 ill has caused anxieties to mental nurses. As my right honourable friend the Minister of Health has stressed on a number of occasions, their fears are groundless. The present trend is towards more intensive treatment and improved care in a smaller number of beds; and this more intensive use of beds means that although the number of admissions has increased, the average length of stay has been reduced. More patients are being admitted, but for shorter periods of treatment; and that trend inevitably implies a higher ratio of staff to beds. In addition to this, more could be done for rehabilitation of long-stay patients if greater numbers of trained staff were available. I should like the nurses to know that that danger is something which, in my view, and in the view of the Minister of Health, they need not fear.
I want to say just a word or two more to your Lordships. All Members of this House, with different views, have agreed that this is an essential service which depends, in the end, on the staff we employ in every capacity. Therefore, my Lords, I should like my last word to be one of gratitude to that staff for all they have done; and I hope that they will realise that in this, as in many other things, your Lordships' House is not untypical of the country. We are very interested in their work. We thank them for what they have done, and we wish them well in the future.
§ 7.58 p.m.
THE EARL OF FEVERSHAM
My Lords, I am sure that I express the wish and the opinion of the whole House when I convey, not only on my own behalf but also that of your Lordships, gratitude to my noble and learned friend the Lord Chancellor for the very full and well-informed replies which he has given, in that courteous manner to which we have always been accustomed, to noble Lords who have spoken in this debate. It is of great satisfaction to me personally that for the many years during which my noble and learned friend has sat on the Woolsack he has taken a very great personal interest in the conditions and situation of both the mental hospital services and the patients who form so large a part of our general medical service. I should like to take this opportunity of expressing, on behalf of those to whom he showed apprecia- 1337 tion at the conclusion of his speech, our gratitude for the continued interest that we have from him personally, in the high office he holds.
A measure of the importance of this Motion that I have had the privilege to move to-day in your Lordships' House is that we have spent over five hours in debating it. It would be quite invidious of me at this stage to single out some of the observations made by those who contributed to the debate, and if I do so it is only very shortly indeed. I would say that I was extremely glad that the noble and learned Viscount devoted a fair portion of the time of his reply to the speech of the noble Baroness, Lady Wootton of Abinger. I always find it most refreshing that the noble Baroness brings to bear not only her great experience in aspects of this subject but also that sense of proportion which I think it is very necessary all those who are operating in the psychiatric field should have and hold at the present time. I am sure that there axe many in this field who will join with me in appreciating the written word that has fallen once again from the noble Baroness, Lady Wootton of Abinger, in this respect. There is no doubt about the way in which she logically brings us to regard steps by which we have diminished responsibility and that that will lead us towards greater consideration of treatability rather than culpability; that is a situation and a problem that some future generation will have to face up to squarely if this generation does not do so.
I should also like to express my personal appreciation to the right reverend Prelate the Lord Bishop of Lichfield for his emphasis on the great value that can be given under the heading of pastoral work by lay members of a community. I myself am quite clear that we have in this field a very great opportunity to extend the value of liaison work between those who represent religious interests and those who represent medical interests. So I would thank the right reverend Prelate very greatly for his contribution to-day.
I felt that the noble Earl, Lord Longford, who generally brings to these debates a modicum of general and universal approach, rather than a Party attitude to issues of this character, was 1338 this evening inclined to be, if I may say so, a little unfair regarding the undertakings that my right honourable friend the Minister of Health has, with great vigour, instituted in his approach to local authorities.
§ THE EARL OF LONGFORD
My Lords, may I interrupt? I am ready to accept any rebuke from the noble Earl at any hour of the night, but I would just put this point to him. The noble and learned Viscount the Lord Chancellor has disappeared from the scene without answering a vital question raised by the noble Earl about a fundamental inquiry into the medical services. I can be rebuked and extinguished without anybody suffering very much, but I do hope the noble Earl himself is not going to forget that the most important question he raised to-day was the question of this inquiry, and that has not been answered.
THE EARL OF FEVERSHAM
The noble Earl, Lord Longford, has interrupted me to deal with a slightly different point from that to which I was referring. Of course, I should not have suggested the need for a further inquiry into the shortage of medical personnel and the staffing conditions of the nursing profession had I not felt that there was very great need; and I join with the noble Earl in hoping that at some future date we shall have an assurance on that point.
But in respect of my observation about the noble Earl's remarks during the course of this debate, I feel that he has not perhaps given sufficient cognisance to the improvement that has taken place, not only since the inception of this Act of 1959, but under the direction of several Ministers of Health of the Government that reigns, compared with the inaction that took place in an earlier period. And I think the noble Earl will agree with me that, although many of us may be discontented at the rate of growth, and may think it insufficient, there has nevertheless been a progression from practically zero to a condition that some find very much more satisfactory than when we first engaged upon this work.
§ THE EARL OF LONGFORD
My Lords, may I interrupt the noble Earl on that point? I am not going to defend 1339 myself, because that must be looked after otherwise. But he raised a very important point in his speech, and now seems to have retreated from it somewhat. Earlier he raised the whole question of a fundamental inquiry into the work of the mental health service, but just now he referred to a much smaller inquiry into the staffing of the service. I am anxious to know, because it is very important, whether he has abandoned the idea of a general inquiry or whether he is prepared to press that inquiry on the Lord Chancellor in all sorts of ways which are open to him.
THE EARL OF FEVERSHAM
My Lords, I wish to make myself quite clear to the noble Earl, and if he will look at my remarks I think I have been clear. I said that I wanted to have a Royal Commission or inquiry into the staffing and running of our mental health services, and particularly in the direction of those matters which were excluded from the terms of reference of the Royal Commission. I do not think I have said anything contrary to my original intention, as I think the noble Earl will find if he will be so good as to look at my remarks.
This is developing into a second speech, which is not permitted under the Standing Orders of your Lordships' House. I should like, therefore, to conclude by expressing my warmest grati- 1340 tude to so many of your Lordships who have taken part in this debate. It has covered a very wide sphere of interest. It has dealt with some of the crucial points that are worrying and concerning us, on both sides of the House, at the present time; and I sincerely hope that one of the great benefits of this debate will be that those who are responsible for administration, either under the various Regional Hospital Boards or within local authorities, will have occasion to read the replies, and particularly the replies that have fallen from the members of the Government, so that we can count this as a further step forward in the direction which I think we are all universally wishing to see. I therefore beg leave to withdraw the Motion.
§ Motion for Papers, by leave, withdrawn.