HL Deb 12 November 1969 vol 305 cc632-56

2.45 p.m.

LORD O'HAGAN rose to call attention to contemporary attitudes to mental health; and to move for Papers. The noble Lord said: My Lords, when I was thinking how to start to-day's debate, I remembered that Christ said: I came that they may have life, and may have it more abundantly. "They" include those people on the receiving end of the services that we shall be talking about this afternoon; for them life is not as abundant, as full, as it ought to be. We all know that even those who are seriously mentally ill or handicapped can be happy, can receive and give love. But the clouded mind stops its owner from joining in, from sharing properly in, the emotional, intellectual and spiritual side of life. I thought of saying that such people could not really belong. Of course, they belong to us, and from our compassion we must help as much as we can. But, my Lords, if the cloud in the mind is getting big, we cannot really belong to them: there is a great gap between our desire to give and their ability to receive.

How best we can give so that their lives may be made more abundant ought to be the mainspring of what is said to-day. That is why I have chosen the wording on the Order Paper—"attitudes". Are we prepared to co-ordinate our efforts to tackle social distress where it starts? What is our attitude? Are we prepared to pay for research, and follow it through? Or shall we just leave the hospitals to tidy away the also-rans who cannot take the technological age? So much of mental illness is an indictment of our society. Those who are not strong are put on the edge and pushed over by what we do to them; and when that fall has started, the way that we behave, is so important, whether as part of the hospital service, as relatives or in our ordinary lives. The frame of mind that we bring to bear on the problems of the people who might be us to-morrow can do so much to help or harm. As a concerned amateur, and as someone who as an undergraduate suffered from depression, I should like to touch on various points which I hope the more expert of your Lordships will expand.

First, prevention. The late Lord Feversham, then Chairman of the National Association for Mental Health, said in your Lordships' House on June 4, 1959: I have felt ever since this Bill"— what is now the Mental Health Act— 'was published that it is little more than a half-hearted attempt at promoting the preventive services where, to my mind, the future of this whole subject lies."—[OFFICIAL REPORT, Vol. 216, col. 694].

He was quite right, my Lords. Prevention really is the Cinderella of a Cinderella service. One has only to look at Seebohm to see what could be done: general prevention to stop social decay; better housing and so on. More specifically, there should be better social services on tap for those likely to be under mental strain—the new widow or widower, and so on. The principle of special help for areas with special need is now well established. Mental health comes into that, too. I say, "Hear, hear!", to Seebohm's suggestions. Voluntary bodies do wonderful jobs, but more of the community needs to know more about mental health.

The Health Education Council, under the noble Baroness, Lady Birk, last year received £223,000 from Central Government to deal with things physical. The National Association for Mental Health received £10,000. Does that sum up the Government's attitude to mental health education? The recent Report on psychiatric nursing recommended that psychiatric nurses should more often go and talk to schools, associations and other such bodies. The idea was partly to help recruiting. But, like so many constructive efforts in this field, the good done in one way works another way, too. Those who heard a psychiatric nurse talk about her work would get a much more accurate picture of her job and her patients. The stigma of mental illness is on the way out. Every psychiatric bed in a general hospital—and I am pleased to see that the number of beds is going up—is another step towards making the attitude of the community more positive. The people inside the hospital are just ill. I, like the authors of the Seebohm Report, cannot specify exactly how to combat social distress. My disconnected suggestions prove that here is a subject crying out for research. But I can say that we ought to make our social safety nets better.

I will now discuss mental hospitals in more detail. I was sad to learn that of the money recently spent on 85 major building projects under the Department of Health and Social Security, both those completed in 1967–68, and those started since then, only 3.17 per cent. of the total was spent on schemes concerned with mental health. That was a drop on the previous year. But I really want this afternoon to talk about those who work in mental and subnormality hospitals. The obvious dedication of so many of them is perhaps the main reason why the hospital service is not collapsing. Certainly the idea of the therapeutic community betokens a splendid attitude to the patients; and, of course, new treatments have helped. But I am worried about the way the staff are treated. To my embarrassment I must praise Mr. Godfrey Winn for his article in the Daily Mail on Monday. One of the points he underlined in my mind was that even a really dedicated person may choose another form of service if pay and conditions in hospitals do not give the staff a chance to eat properly, to relax, or to concentrate on nursing and their job, rather than on the chores. We must treat the nurses and the other workers right if we expect them to treat the patients right. For, my Lords, not only is a happy hospital service the best recruitment policy, it is also best for the patients.

I cannot lay down the law about the way hospitals are organised or the way they should be controlled. I hope that it is not a choice between local parochialism, fights over who does what, and remote inflexibility. But however things are organised, a ward where there are over 100 beds (and there were still 32 in mental and subnormality hospitals in 1965, with 70-plus in 200 wards) must be nearer to the ideal of a broiler house than the ideal of a therapeutic community. Wards should have only 20 to 30 beds. I wonder whether there are so many huge wards now.

Great progress has been made towards making mental illness decent. On that score alone, I am sure that general hospitals catering for psychiatric patients are a good idea. A mother or daughter can say that a relation is at St. So-and-so's which has not the stigma of being "put away in a loony bin." Physically ill patients know at first hand that mentally ill patients recover. Then I should have thought that the special nature of psycho-geriatric patients, who now occupy some 43 per cent. of mental hospital beds, are normally better catered for in a general hospital where physical ailments can be quickly attended to—though I may well be wrong here. Let us continue the practice of making mental hospitals open and gay and, if possible, ensuring that they do not smell like hospitals. On the subject of complaints, I am glad to hear of the initiatives that are being taken. But are we going to get a really independent body to investigate complaints? Are we going to have a proper inspectorate? Both these would give great reassurance all round.

And so, my Lords, we come full circle, to the patient who returns to the community. We do homage to the idea of community care. The noble Baroness, Lady Brooke, told your Lordships about the pilgrim mothers who traipse from office to office—or give up. The services that exist must be accessible. Now that the responsibility is placed back on the shoulders of the community, the community must be given the chance to do its duty. I wonder whether it is in fact given that chance. I quoted Lord Feversham's gloomy foreboding about the preventive side. The community must also help those for whom prevention is too late. Seebohm says: The widespread belief that we have community care of the mentally disturbed is, for many parts of the country, still a sad illusion, and judging by published plans will remain so for years ahead. So, my Lords, we must salute the concept of community care. Certainly, we must have more hostels and halfway houses for those returned to the world; but they will need expert staff. Certainly, too, the community must be the focal point. Yet there were only 541 trained psychiatric social workers in England and Wales in 1968. Some areas are splendid: voluntary organisations complement official bodies; there is good liaison between general practitioners and the mental hospitals and the social workers. But other areas are just too feeble-minded to buckle down to the job.

I recently went round a hospital for the subnormal. A teenage girl was sitting on a bench swaying and crying—in fact she was screaming—as I came into the ward. Naturally the nurse said, "Sh-sh!" in quite a kind way. The girl stopped shrieking and said, "Sh-sh!" in answer. That was a remarkable advance; it was the first time that even such a link had been established. I came away from that hospital with an acute dilemma made more acute. I had seen wonderful work being done. Criticism, of course, undermines the morale of those whose job is with mental illness or subnormality, and it saps the public confidence. So often in the mass media there seems to be only one sort of news—bad news. On the other hand, we have evidence of inadequate services outside the hospital and unpleasant things inside the hospitals. I must ask, how typical is that splendid place that I visited? Of the mental and subnormality hospitals, how many more Elys are there? How many half Elys? Or part Elys? Although this country's care for the mentally ill is remarkably good, there are great variations. Perhaps the answer is a unified health service.

My Lords, I have left out a great deal with regard to research. I wonder whether all this processed rubbish that we read can really be of help to mental health. The special problems of subnormality I have hardly touched on, and I hope that noble Lords will fill in the gaps. I am sorry if I have been mean to the Government, or to their predecessors. I hope, too, that this country's steady progress towards a practical but compassionate attitude to mental health will continue. Perhaps what we say to-day will help. I beg to move for Papers.

3.0 p.m.

BARONESS BROOKE OF YSTRADFELLTE

My Lords, this afternoon we are debating so serious a problem that we all have reason to be grateful to the noble Lord, Lord O'Hagan, for his Motion and for creating an opportunity for free and frank discussion on this subject. This is no subject for Party political strife. Mental ailment is a disease which, in one or other of its manifestations, might attack any one of us at any moment. I wonder how many of us are acutely conscious of these grievous disabilities and feel that we ought to be making some contribution to their alleviation. How many of your Lordships have felt it your duty to visit mental hospitals and psychiatric units in an objective way, as the noble Lord, Lord O'Hagan, has recently done himself, to see for yourselves the size of the problem and the ways in which it is being tackled?

My interest in the whole field of mental health was aroused when I was a member of a Regional Hospital Board. When asked which of the various committees interested me, I asked to serve on the mental health committee, which was then under the chairmanship of Mr. Kenneth Robinson before he became Minister of Health. He was a first-rate chairman of that committee and I was sorry when he found himself too busy to continue. I chose the mental health committee for the simple reason that at that time I knew little about mental health or its treatment, and I wanted to learn.

Before deciding to visit my first mental hospital, and feeling a little apprehensive, I asked advice from an older and much wiser member of the Board, Sir Allen Daley, who as Medical Officer of Health to the London County Council had been responsible for all the mental hospitals under the L.C.C. before the National Health Service Act 1948. He urged me to visit the newest and most up-to-date purpose-built hospital in our region first, so that I could see the open-door technique and the various newer therapies in action—occupational, physical and industrial. To reassure me he added that, thanks to the use of sedative drugs, he did not think that I should find it as disturbing an experience as one might have feared. He was absolutely right, and as a result of that day spent at Shenley, a hospital that had been built in 1934, I grasped something of the problems facing the doctors, the nurses, the administrators and the ancillary workers.

Mental health, or rather mental ill-health, is an absorbing field in which tremendous advances have been made in treatment, drugs and attitudes of approach. A hundred years ago public opinion, uninformed and insensitive, regarded the lunatic asylums, into which all abnormal or subnormal people were relegated, as objects of ridicule or complete disinterest. The idiot was a clown in society, sometimes to be teased and to provide amusement; more often repellent and therefore to be hidden away from normal human contact and observation. To-day, thanks to modern legislation, research and experience, public opinion is a little more enlightened, the worst of the stigma that has attached to the whole subject of mental health has disappeared and much more intelligent attitudes towards it are developing.

But unhappiness is still prevalent, not only among the patients and their relatives and friends but also among the staff of the hospitals caring for them; and it is to this state of unhappiness that we should be bending our minds and giving our help. It is a lamentable fact that public opinion is awakened and shocked only by revelations such as those of the state of affairs that existed in the Ely mental hospital, which came to light last March as a result of the published report of a Committee of Inquiry set up by the Secretary of State to investigate allegations of various forms of misconduct on the part of members of the staff. It always grieves me when wide publicity is concentrated wholly upon something that has gone wrong. A picture is created in people's minds that this state of affairs is widespread. Friends and relatives of patients in similar hospitals think the worst, and the morale of the staff in those hospitals sinks like a stone in a well. So much excellent work is being done; so much real, loving care is being shown to so many patients. But this receives no publicity because it is not news. We were shocked, all of us, by the headlines, and many of us read the report of the inquiry and were amazed by what we read. But how many of us did anything about it? I should be grateful if the noble Baroness, Lady Serota, could tell us, when she comes to speak, how many of the 45 recommendations at the end of the Report of the Committee of Inquiry have been acted upon. Some, I know, are far-reaching and considerable in their implications of major reorganisation and new building; but some of the simpler, more practical ones I hope we shall hear have already been carried out.

This whole subject is so immense, and so many noble Lords have put their name down to speak, that I shall not attempt to cover the field but will concentrate on one part only: the large subnormality hospitals. Why is there unhappiness in so many of these? One of the reasons, to my mind, is the geographical isolation of so many of them. Built in the last century, they were placed on land which was cheap and easy to acquire and tucked away from the normal community life of the nearest town or village. The wards were vast; many of them still are. The sanitary arrangements were inadequate by modem standards and often some distance from the wards. The patients were segregated into sexes and the care of them all was mainly custodial, behind clanging doors, always kept locked, with padded cells for the more disturbed patients. The exterior of most of these hospitals was, and still is, austere, formidable and discouraging. To-day a great deal of the older horrors has been swept away, thanks to modern treatment and the realisation that vast numbers of patients in the long-stay subnormal hospitals can be trained to take their place in society again, earning their living, or some part of it, through sheltered workshops and sympathetically managed light industrial factories, and living in hostels away from the shadow of the old asylum.

Advances have been made in attempts to break up and subdivide the terrible old dormitories where no one could hope to retain his or her own individuality. The closely packed wards of Hogarthian appearance are disappearing. Many of the patients now have their own private locker by their bedside in which they can keep their personal possessions and their clothes. But too many are still without this obvious need, simply because there is not enough room for the lockers to stand in between the beds. In some wards the space is only a few inches and there is no other furniture at all. Can the noble Baroness give us any idea as to the number of patients who are still without a personal bedside locker, with all that that can mean to a man or a woman?

Clothing is another problem. All of us are conscious about what we wear. Attractive, well-designed clothes not only say something to other people; they do something to us. In some hospitals patients are being dressed in clothes fifty years behind the times. The women are not provided with any kind of foundation garment; clothes are common property. In others, real imagination is being used and varieties of material, colour and design are available, often for personal choice if the patient is capable of using it. Clothes much be designed for constant laundering and cleaning. With the tremendous advances that have been made in man-made, "mini-care" fibres and fabrics, all hospitals should be able to provide comfortable, well-fitting, attractive clothes of reasonably good quality. To what extent, I wonder, is advice given to those hospitals where little has been done, so that they may benefit from the experience of others who have been alive and imaginative and, consequently, have produced original ideas in this field.

A conference was held on this subject of clothing for long-stay patients at the Hospital Centre in 1967. Discussions took place between nurses, administrators, supplies officers, laundry managers and manufacturers. They approached the common problem from very different points of view. I wonder what notice was taken generally of the findings of this conference. I know that there may be purchasing difficulties and that buying small quantities of appropriate sizes is very expensive. But if the pattern of purchasing were changed so that, instead of an individual supplies officer being responsible for the clothing of his own hospital, or group of hospitals, a group of hospital management committees combined together and arranged area contracts; or if the directors of Marks and Spencer were invited to tackle the problem of providing inexpensive but attractive clothes for long-stay patients, they would produce a solution forthwith. A greater variety of garments at less cost might be the result, which would be of benefit to everyone. The ideal is for every patient to have his or her own clothing. In some hospitals the patients have been encouraged to bring their clothing with them, but in many hospitals it has been quite impossible to organise individual personal clothing because the problem of storage has been allowed to become insurmountable.

Then there is the question of staffing. Many of these hospitals are so grossly understaffed that the nurses are unable to do as much psychiatric and therapy nursing as they would like. There are nowhere near enough domestic cleaners. That work has to be done, and for lack of domestic staff it is the nurses who are too often called upon to do it. In one hospital that I know the full nursing establishment was fixed in 1907 at 480. It has never been revised. But that hospital is now 60 nurses below strength, and out of the total of 480 there are more than 100 staff nurses too few. How can the existing staff cope? In the hospital to which I am referring there are 30 large wards with only 25 domestic cleaners—fewer than one per ward. Why should something not be done to pay the fares of cleaners who cannot get to these isolated hospitals except by travelling long distances every day from the nearest town?

So far as the recruitment of nurses for these hospitals is concerned, a very high percentage come from overseas. We could not get on without them and they are making a valuable contribution. But although most of them speak English, and therefore there should be no major language difficulty, the English which some of them speak is easier to understand than that spoken by others; and when their English is not clear it is bound to slow down the speed with which tuition can be given and practical work demonstrated. British staff are not coming forward in sufficient numbers, and they will not come forward until the conditions of service, the pay and the lack of suitable living accommodation, are attended to.

My Lords, if you are going to devote the major part of your working life to employment in these hospitals you must be given the chance to enjoy your time off. Facilities for social life and entertainment for the enjoyment of leisure time are often totally neglected by those who administer the Service. Many of the trained staff who are in posts are often unhappy through lack of appreciation and poor job satisfaction, for the reasons that I have given, and this leads either to apathy or to aggressiveness. The isolation from a more lively and thought-provoking community makes life difficult for the many members of the staff who have to depend upon public transport or scanty hospital transport to get away. Consequently, the staff tend to live in on themselves, surrounded by others working in the same field, and unless there is some imaginative leadership they tend to become, as I have said, apathetic or aggressive—aggressive to the patients, aggressive to themselves, aggressive to the doctors and to the hospital management committee. And who can blame them? As one enthusiast in this field said: A difficulty which surely every big organisation must experience is the problem of personalities and passive resistance. One sometimes feels that our hospital is staffed by centipedes—each member with a hundred toes all waiting to be trodden on, and of course almost any new venture could be taken as a personal criticism of someone's work". My Lords, all is not bad. In many hospitals first-class work is being done under similar physical disadvantages, but those are the places where appreciation for good work is given freely, and where there is closer relationship and better communication between staff and staff and staff and patients, and between the hospital and the community outside. This latter is an overwhelming need, and where it has been achieved the veil of mystery clothing psychiatric treatment in mental hospitals has been lifted. It is highly necessary for the hospital staff to get the people in the neighbourhood living around them to be on their side. Once such relationships and co-operation are created, support from without will flow in automatically.

Co-operation does not cost money; it is brought about by freedom to have informal meetings; freedom for members of the public to enter the hospital to help with voluntary jobs, and freedom for the hospital staff to make friends and to develop interests outside. I look forward very much to hearing the noble Baroness, Lady Swanborough, on the splendid work which has been done by the Women's Royal Voluntary Service. There are the Leagues of Hospital Friends and there are splendid schemes where young volunteers and the Red Cross are making invaluable contributions to the more human side of the life of these patients. There is much to do. If this debate to-day serves to draw attention to the needs for more voluntary work to be offered and received, it will not have been in vain.

My Lords, I should like to end what I have been trying to say on a note of warm appreciation. In the Mental Hospital Service there are many devoted and dedicated men and women, at every level, doing selfless jobs of work. May their example shine as a beacon to those others in the Service who do not yet seem to recognise the full purpose of their work; and may those hospitals which are rapidly reaching the forefront of what really good mental hospitals should be act as an encouragement to those other hospitals which up to now have been lagging behind to try to catch up to the pace of those in the lead! Encouragement, not carping criticism, should be the call that goes out from this debate.

3.18 p.m.

LORD AMULREE

My Lords, I, too, am glad that the noble Lord, Lord O'Hagan, has seen fit to put down this Motion to-day. It is a long time since we had an opportunity of talking about mental health, and many things have occurred since then. I want to confine myself to two points to-day, but there is one thing I should like to say before that. When I was talking in the debate on the gracious Speech after the Opening of Parliament, I said that in my view the report of the Central Health Services Council upon the future of the general district hospital was a very encouraging document, because it said that the time should come when the geriatric services should be closely linked with the district general hospital. To-day I should like to add that it says in the same report that the time should come soon when the psychiatric department should be part of the district general hospital. I think that is one of the most encouraging pronouncements I have seen for some time, because in the long run it must mean the end of the large mental hospital, isolated in the country, forbidding in appearance and with, I regret to say, even now some of those large wards to which the noble Lord referred and which make any form of treatment absolutely impossible.

At the present time in the treatment of mental illness the tendency is towards having small treatment centres attached to general hospitals, from which patients speedily return home with their treatment completed. It may be said that quite a number of those patients will relapse and need to go back again. I do not think that that matters at all. The fact is that they have been able to return for a short time to their family and to the community, even though they need to go back; they can have further treatment and return home again. That is one of the things with regard to mental treatment which we should encourage very much in the medical world. Some of the big mental hospitals have a large amount of ground round them. At one time they used to farm and keep pigs, and all that sort of thing. One wonders whether some of those lands, if they are not too far out in the country, could not be used for building these new little departments where treatment can be given, during which time the bigger buildings could be pulled down, modified or destroyed.

There is one point in the Mental Health Act 1959 to which I should like to refer. One of the really first-class things that that Act did was to open the doors of the locked wards in the mental hospitals, and that has been entirely to the good. One or two difficulties have sometimes arisen, but these have been overcome and do not really cause any trouble. The whole problem, as was shown in an article which I read in the Practitioner last month, comes from a tiny number of patients. It is further complicated by the fact that some mad patients are also bad. That may be the difficulty with a tiny group of patients when they are transferred to regional mental or general hospitals. If you get one or two psychopathic criminal types coming into a general ward they can do an infinite amount of damage to the patients who are there and being successfully treated. This type need some kind of further control—I am sorry to have to say it; it is a very unpleasant thing to have to say. One wonders whether it might not be an improvement on what is being done at the present time if there were some sort of closed community for them, well run and well taken care of, not oppressive at all. I read in The Times on November 1 something which I checked in an article in the Practitioner: that the danger is growing of a real use of restraints. There is a nasty thing called the geriatric chair—why it is called the geriatric chair I do not know—which is rather akin to the stocks; a patient is locked up in this chair and cannot move. Another thing is called the "safety vest"—another word for a straitjacket. These are things that I thought we had got rid of from our medical circles, once and for all. If people must be restrained and it cannot be done by any other means, it would be far better to keep them in some kind of confined locked community, rather than restrain them physically in this kind of way, which is quite repulsive.

The noble Lord referred to the need for research into mental disease, and I agree with him, because so far as one can see the amount of mental disease is not going down very much; it may be increasing. Certainly the amount of neurosis is going up, and that is an illness we do not know very much about. Going on from that, I think that one of the big problems of the future will be the care of the increasing number of senile, elderly, confused patients who need some kind of care and treatment. From a curative point of view there has not been much advance in their treatment yet, and so far as one knows—I am not an authority on the research which is being done—there is not very much possibility in the future of any radical change occurring. A great deal can be done to make them more comfortable by the use of day hospitals, which take the burden off their families, and these old people can live in the community and live at home.

A good deal more can be done by ensuring proper housing. I know that it is rather a King Charles's head of mine that most of our social ills can be alleviated by proper housing. I wonder whether any particular inquiry has been made into that with regard to these senile, confused old people. One of the troubles is that it is becoming, or was becoming until recently, more and more difficult to find accommodation for them, because they are not really suitable to be in a mental hospital. They are better in an annex in the grounds of a mental hospital, where they can be by themselves, have much more freedom and be regarded as normal people, just a little confused in the head and not needing to be taken care of too much. There were a number of such places around London to which I sent a number of patients myself, once upon a time; but when the Mental Health Act came in the hospitals said that they had now become acute mental hospitals and did not wish to take in any more elderly people who would be there all their lives with no possibility of cure. That is a pity, because I am sure it is important that places for these elderly, confused people should have some tie-up with a mental hospital, not necessarily being part of it. Certainly it is a great advantage if some members of the staff have been trained in a mental hospital, because they will not be so upset by the rather bizarre behaviour of some elderly people when by themselves.

Coming to the question of staff, I should like to echo what the noble Baroness, Lady Brooke, has said about stalling. I would say, as she did, what extremely fine work is done by the staff of these hospitals under the most appallingly bad conditions: overcrowded, understaffed. The marvel of it is that they do their work so thoroughly and well on the whole. I admit that there is the occasional lapse, as the noble Baroness said, which immediately gets pounced on by the Press, whereas nothing is said of the good work done by the 99.9 per cent. whose work must be extremely trying, even under the best conditions. One would like to say how much one admires the very high standard kept up in these hospitals, and trust that as much as possible will be done to keep up the standards and improve the conditions in which these men and women have to do their work.

3.30 p.m.

BARONESS LLEWELYN-DAVIES OF HASTOE

My Lords, as other noble Lords have said, the noble Lord, Lord O'Hagan, has done the House a very great service in initiating this debate this afternoon. Perhaps I may say to him that we do not at all feel that he is being mean to the Government in the way he raised it. As the noble Baroness, Lady Brooke of Ystradfellte, said, there is nothing Party political about this; we are all in it together. It is a problem we all have to deal with, and if I may say so—I hope without appearing in any way condescending—I thought it particularly good that one of our youngest colleagues should have spoken with such deep concern and so movingly about a subject which a great many people, after all, are only too anxious to forget because of its nature. I think the young generation to-day are wonderfully concerned with the problems of the underprivileged, and this, for me, is a great hope for the future of our deeply troubled world.

As many people have said, attitudes really do condition what actually happens, and what the noble Lord said about attitudes is absolutely right. Many of the problems which the Health Service faces to-day arise from past attitudes, and it is only in new attitudes that solutions can be found for, at any rate, some of the problems. There has really been a need for a revolution in thinking about how to deal with mental health, both by the authorities and by people generally, and I think that this debate shows that that revolution has begun.

The old approach to the subject is symbolised by those grim, remote, ghastly edifices in which most of our mental hospitals still exist, but they were built by men who sincerely believed in their mission. They believed that they should be custodial, and that their duty lay in safeguarding the public and society. The very solidity of these buildings is a tribute to their industrious faith, if I may call it that. But, of course, that solidity poses one of our major problems in following the new approach to this subject. We have had a revolution in thinking about these problems, but there has also been, as the noble Baroness said, a therapeutic revolution which is, in a way, more important. But that therapeutic revolution can basically be acted upon only if the social conditions for its implications are adequate, and this includes not merely social institutions but social attitudes.

If I may just glance at what is actually happening now, noble Lords know that in our actual services we are at the moment in a position of transition. The Royal Commission on Mental Health in 1957, which was followed by the Mental Health Act of 1959, unquestionably marked a major turning point in this whole field. In the past, barriers were created between mental hospitals and the community. Possibly this was necessary, but since 1959 we have been actively working towards creating positive links between the hospitals and the community.

When we think of the mentally ill we have to think in terms, as the noble Lord, Lord O'Hagan, said, of preventive services, of active treatment and rehabilitation. This calls for an enormous range of facilities: outpatient services; day hospitals; acute psychiatric units; after-care hostels; workshops and day centres. Noble Lords will know as well as I do the multitude of services that are needed in this new approach; and, above all, social work support. Most important, we know that where these services exist the need for in-patient beds and the average length of stay in them can be drastically reduced, and is being drastically reduced. But we are able to think in these terms partly because the changes in attitudes which the noble Lord looks for have actually happened, and also because the therapeutic revolution has made these attitudes possible.

Of course, when we talk about the therapeutic revolution it is perhaps a rather fancy phrase; all it really means is the treatment of mental disease by drugs or other medical means. This has all happened remarkably recently. In 1950, I think, insulin coma treatment and other forms of shock treatment became available, but early in the 1950s the tranquillising drugs were discovered, and this made a tremendous difference in the treatment of the more disturbed patients. This, in itself, also made a very great difference to the general atmosphere in the wards, and was able to lead to a new approach in the unlocking of doors. Those of your Lordships who are familiar with mental hospitals will know the profound change that all this has created. It is now possible to provide a much better social atmosphere and better occupational facilities for patients, and a very dramatic improvement has resulted in the patients themselves, which is one of the hopeful things about the present situation.

Noble Lords will know that from 1954 onwards the total number of patients in mental illness hospitals has steadily declined. Later, new drugs were discovered which have a beneficial effect on the depressive illnesses. For the last ten years it has been possible to treat all the functional mental illnesses with one or other form of drug therapy, and where these physical treatments have been combined with changes in the social environment —and I stress that fact—patients and their families have benefited very much. This is hopeful. It has made a breakthrough, and we have been dealing with it, as the noble Lord, Lord Amulree said, by opening psychiatric departments in general hospitals. It is known that these departments can now handle not only the more hopeful acute cases, but almost any form of mental illness, apart, as the noble Lord said, from those needing conditions of special security. It was a breakthrough in treatment, and most important it has led to a reconsideration of the actual role of the hospitals.

If I may, I should like just to explain that. What we are now doing is to plan to unite the department and the staff treating mental illness with the general hospital. In this way, not only will fewer beds be needed in the future, but the patient and his family will receive greater support. It is important to remember, however, that although fewer beds will be needed, more nurses and doctors will be needed than in the past, and this, of course, is one of our great blocks. My noble friend Lady Serota will be dealing in detail with subnormality, but I should just like to mention that there has also been a therapeutic breakthrough here, too. Sadly, there is no specific treatment for mental subnormality, but immense advances have been made in dealing with the physical conditions that go along with it.

This combination of revolutions, if I may call it that, both of treatment and ideas, means that we have to make sure that the service is directed towards the patient's rehabilitation and, as the noble Lord, Lord Amulree, said, his return to the community at the earliest possible moment, even if he does not always stay there. Nothing is so bad for patients as keeping them in hospital when they should not be there; and, on the other side, nothing is more wasteful in resources. Therefore, it follows that the mental health services of the future must be centred on the community, and not on these large, isolated hospitals. District general hospitals have far closer links with all the things we know they need —hostels, day centres, and all the rest of it—and this is now our constant aim.

There is the question whether we might possibly need separate hospitals for medium and long-stay patients, but experience in a number of areas where modern district general hospital units are in operation suggests this may not be necessary. But this is something about which we shall have to think a little further.

What I have said applies to hospitals for the mentally ill, but the same principles apply to hospitals for the subnormal. Not all severely handicapped patients can hope to leave such a hospital, and it is essential that it should be thought of by them as their home. It is their home and there must be a homelike atmosphere there.

I should like to deal for a few moments with the point raised by the noble Baroness, Lady Brooke, about clothing, because this applies to both kinds of hospital. I know that she has taken a deep interest in this subject and I must say that I agreed with every single word she said. I think we are progressing a little, and I hope she will be comforted to hear that, although no specific advice has as yet been given to hospitals, they are very much aware of the way we are thinking. In fact, a memorandum which I hope will shortly go out will say that clothing provided by the hospital should be in modern style both for men and women, and for underclothing as well as top clothing. Dry cleaning facilities should be made available to patients and consideration given to the care of modern garments by those organising laundry services. We all know what it is like to send a nylon garment to an ordinary steam laundry, and I hope that this problem will be a thing of the past. The memorandum will also suggest that a laundrette service should be available to patients in hospital, and that encouragement should be given to the purchasing and wearing of individual clothes from local stores. I noted the reference of the noble Baroness to Marks and Spencer. I think it was a very interesting suggestion, and it must apply for everyday purposes. We all know the bulk buying of hospital issues to be one of the old bugbears, and the memorandum will say that this has a devastating effect on the individual who cannot claim that he owns even the trousers he is wearing. Moreover, the sameness is humiliating to the individual. I hope your Lordships will agree, after what I have said, that we really are tackling this problem in exactly the same spirit as the noble Baroness looks at it. Of course, the geriatric patients usually wear their own clothes, but they often have to be issued with clothing and we will apply the same principles.

The noble Lord, Lord O'Hagan talked about the large isolated hospitals, as other noble Lords have done, and we accept that it is clearly essential for hospitals to be more accessible not only for the patients, but also for the staff. It is absolutely wrong that these dedicated people should be cut off from the main stream of medicine, nursing and other professional work, and cut off also in their social lives. I very much agree with what the noble Baroness said about this. I am sure it makes it easier for them to carry out their extremely difficult tasks if they have a relaxed atmosphere outside their work, and this is what we are aiming at all the time.

I know that there are some arguments in favour of specialist mental hospitals, but even if they were accepted they must still be in close contact with the community. In all this what we are aiming at is to stop these terrible communities of institutionalised patients. We are deeply aware of the necessity for this. But I must stress again that this calls for a revolution in thinking, not only from the organisations, but also from the public, and it is only through that that we shall be able to achieve what we want.

I have tried to explain broadly what our aims are, and I think noble Lords will understand that what we are really doing is gradually—I am afraid it is only gradually—proceeding towards admitting mentally ill patients to the new units in district general hospitals, returning them to their community, as speakers have said we should, but with this difference; that we want them to remain in the care of the same therapeutic team of doctors, nurses and social workers as in their psychiatric hospitals, and continue to have treatment in day hospitals and out-patient clinics.

I was very interested in the suggestion of the noble Lord, Lord Amulree, that we should use these vast grounds—where, as he said, we used to grow pigs—for some kind of unit. I should be a little afraid that they might be a little far away from the community, but it is an interesting point. Noble Lords will know that doubts were expressed at the beginning about having mentally ill patients in the district general hospitals, and the hospitals have—understandably, I think—progressed cautiously. But the advantages to the patients are now quite obvious and we shall proceed from there.

The success of all this also depends on the attitudes of the public. It is only if a caring community exists that we can make sure that the strain will not be too great, not merely on the patient but also on his family. This is a point which is so often forgotten. Many of your Lordships will know of really tragic cases where the family has had a total breakdown as an entity because of the strain of looking after a mentally disturbed patient, even if only for a short time. This is what we have to direct our efforts towards helping. The therapeutic teams will also be working in patients' homes, in day centres, and wherever they are necessary.

Noble Lords may think that I am only describing a future perfect world. It is quite true that the provision of these essential services is uneven, but this is inevitable because we are moving from one kind of pattern of care for the mentally sick to another. Local health authority services have expanded rapidly in the last few years, but I do not attempt to pretend for one moment that these services are as yet as comprehensive as they should be. Nevertheless, in the last five years local authorities have invested £24 million in building training centres, workshops and hostels. There are at present 108 local authority hostels and another 57 are being built. There are 23,000 places in training centres for adults and another 11,000 are planned. I would not say that it is a drop in the ocean, although I know that it is not adequate. The programme has a long way to go, but a great deal has been done and your Lordships will be glad to know that it is gathering momentum and is in many ways more substantial than people realise.

The noble Lord, Lord Amulree, referred to the article in the Practitioner on restrainers. The House deeply appreciates the noble Lord's experience in these matters and we all value his wonderful contributions to our debates. I was especially glad to hear that he favours the "open door" principle. Of course, it is true that this principle carries difficulties with it and I think there can be no possible doubt that there is a necessity for a small area, a small ward, which can be locked for the most disturbed patients. I do not think anybody will deny that that is the case.

LORD AMULREE

My Lords, that is the point I was trying to make. While entirely approving of the open door so far as one can possibly have it, there might be need for one tiny little place where you keep some of these unfortunate people.

BARONESS LLEWELYN-DAVIES OF HASTOE

My Lords, I realised that that was the noble Lord's point. However, I wanted, as it were, to dot the i's and cross the t's as well, because although we are passionately in favour of the open door there must be some other provision. The subject of restrainers is a distressing one. I asked the Department about this, and they told me that they are not aware of mechanical methods of restraint being used in the treatment of psychiatric patients. But body-bands and ankle-restrainers sometimes have to be used, particularly in general or geriatric hospitals, where the patient's physical condition makes it necessary. The trouble is that some of these patients, as noble Lords will know, can hurt themselves as well as other patients and staff. I am sure that we have got rid of the safety vest, the straitjacket. As to the geriatric chair, it was an horrific description in the Practitioner but there are special geriatric chairs which have been designed to enable bedfast patients to sit up. They very much welcome this; they like to sit up and have their meals. But it has to be a rather, if you like, mediæval contraption; though I do not think they are used—I hope they are not—in the form of the stocks, as the noble Lord said.

With regard to the noble Lord's second point, elderly patients present an ever-increasing problem in psychiatric hospitals—and, of course, we all know about the mental confusion which occurs among the elderly—and we wholly agree that we need more places for them. The rising proportion of elderly people in the population has led to an increasing number of psycho-geriatric patients, and it is quite true, as the noble Lord said, that many of them have been admitted to mental hospitals simply because there has been nowhere else for them to go. This is a tragic situation, and we know that geriatric homes, and so on, would be more appropriate. We are hoping to deal with this, but I would deceive the House if I did not say that it will be a long haul. It will be; but we are deeply aware of the problem. I think the noble Lord will probably agree that improved assessment will help in this way—who should be admitted where, and so on. What we are trying to do is to set up assessment centres in psycho-geriatric units and outside to try to decide where these particularly disturbed old people, or, rather, confused old people, should go. Noble Lords have expressed anxiety about the hospital side of the health services, and I hope that the developments which we have planned and the great changes of attitudes on all sides will lead to real improvement.

The noble Lord, Lord O'Hagan, talked about prevention and training. Broadly, I think that this comes down to education. Modern research is of course adding to our knowledge of the causes of some forms of mental handicap—better obstetric care; vaccines, such as for German measles; genetic counselling, and that kind of thing—but I think the National Health Education Council is doing a very important job here. My noble friend Lady Birk, who is the chairman of this body, and who we are all looking forward to hearing, will describe it in more detail than I can, but, basically, the point is that there are two things in education: first, in preventing the occurrence of mental illness; and, secondly, in developing public understanding of the nature of mental disorder and of the need for support for patients and their families.

My Lords, I have taken a little time to describe the impact of new treatments and new attitudes, and I hope your Lordships will forgive me. It is a very complicated situation, and I wanted your Lordships to know the kind of progress that we are making and, perhaps more important, what we are aiming at. All this is what we are aiming at; but, of course, there are tremendous difficulties. When the National Health Service started in 1948, 45 per cent. of all hospitals were built before 1891, and even after twenty years of the National Health Service hospitals with anything up to 2,000 patients are trying to adapt themselves. In the course of time they have got to be abandoned or remodelled—I hope they will be abandoned—but there they are, and inevitably this will be a gradual process. In the short-term, this deeply concerns us all, because they face a formidable task in adapting their management and structure to modern methods. I do not want to minimise that: it is a formidable task. But noble Lords will know that my right honourable friend the Secretary of State and my noble friend Lady Serota are deeply conscious of and concerned about this problem.

At this point, I should like to say what is perhaps more difficult for my noble friend herself to say: that in my view the new policy in this field has shown very great courage. It would be easy to try to sweep the whole question of mental illness under the carpet because it is distasteful, distressing and, indeed, frightening to many people, and the problems of inadequate staffing, housing and so on are immense. But my right honourable friend and my noble friend, together with the Department, have firmly grasped the nettle, and I think they have made significant and important moves towards improving the situation.

The truth is that some of the difficulties in the care of the mentally handicapped arise in a very significant degree from our success in other directions: getting them out of these long-stay hospitals and putting them on the community; the fact that in the past people born with severe handicaps often did not live very long whereas now they do. But one of the major difficulties lies in the present tripartite structure of our National Health Service. The new approach calls for very close co-ordination between the services in the community and the hospitals. Overlapping boundaries between hospital catchment areas and local authority areas cannot but be a major handicap. Unless we can solve this fundamental problem we shall not get a comprehensive and co-ordinated service for our mentally sick. My noble friend, with her great experience in this field, will be saying something about the Government's policy in this direction.

For myself, I should like to say again how deeply grateful we are to the noble Lord for providing this opportunity to have this debate, which has inevitably raised issues wider even than those of his original Motion. I have myself, like many noble Lords, served on the management committee of a group of mental hospitals, and the one thing which shone out among all the distressing problems we had to deal with was the dedicated devotion of the staff. I do not regret the recent publicity of bad conditions in some hospitals. I think it is important that the public should know about it. But the overwhelming majority of nurses and doctors show quite exceptional qualities in their challenging and very trying work. Their positive attitudes are fundamental if we are going to get the improvement of our mental services. No one who has ever worked with them could underestimate their magnificent contribution.

My Lords, I am afraid this has been, perhaps, a rather sombre debate so far. I say that we in the Government know what we have to do. It is a challenge—a tremendous challenge. I have tried to outline a blueprint for our mental health service, and we are trying to implement it. So far as our present knowledge of this incredibly complex subject goes, it has everything we need, but changed attitudes are essential if we are to achieve it.